Late-Onset Endometrial Ablation Failures
by Morris Wortman, MD FACOG
Endometrial Ablation (EA) is a widely used minimally invasive technique to manage heavy or abnormal periods. Nearly 500,000 of them are performed in the United States each year. Although EA may not be a perfect answer for everyone suffering from abnormal periods its advantages include the following:
- It can be performed in a physician’s office,
- It requires very little time off from work—compared to hysterectomy,
- It is far safer than hysterectomy
The two major endometrial ablation devices available today include NovaSure and Hydrothermal ablation (HTA). A third–the ThermaChoice–has been used in the past but has been removed from the market. Another device, the Minera System, has also been recently introduced.
Endometrial ablation, and any procedure designed to destroy the uterine lining, is capable of producing late-onset failures. These failures can occur months or years later—though most occur within the first 3 years after use. By and large these failures are manageable. HOWEVER, we find that both physicians and patients are unaware of how these failures manifest themselves.
Late-onset endometrial ablation failures (LOEAFs) manifest themselves in one of 3 ways. AND YOU NEED TO KNOW ABOUT ALL OF THEM IF YOU UNDERGO THESE PROCEDURES.
1. A change in bleeding pattern: Although endometrial ablation is effective in controlling heavy or abnormal periods often this effect is not permanent. It’s not unusual to have little or no bleeding following an EA and then–months or years later–bleeding begins to worsen. Often the bleeding is associated with increasing cramps—some women describe it as “like labor pains.”
2. Lower abdominal pain that occurs WITH OR WITHOUT MENSTRUAL BLEEDING: This complication is perhaps the most troubling of all—especially if there is no vaginal bleeding. Month or years following an EA women may experience pain above their pubic bone, off to their sides and even into their back. If there is no vaginal bleeding the woman or her physician may not make the “connection” to the previous endometrial ablation.
I have seen many women undergo needless laparoscopies, appendectomies and even removal of ovaries—and still be unimproved. Unfortunately, the diagnosis of ABLATION-RELATED CYCLIC PELVIC PAIN is missed! The pain is often the result of a hematometra—or collection of blood and uterine lining tissue within the uterine cavity. The pain is often debilitating and the cause of the pain is often delayed. The easiest method to make this diagnosis is not with CT scans or MRIs but with a simple transvaginal ultrasound!
Hematometrae often occur because a small amount of uterine lining either “grew back” or was never entirely removed. This can produce a collection of blood within the uterus with no way to escape the cervix. The result is either completely or partially trapped blood within the uterus. The pain can be intense!
Hematometrae are treated in several ways including reoperative hysteroscopic surgery and hysterectomy. However, some physicians offer women a D and C or a repeat ablation. Unfortunately these techniques typically don’t address the underlying issue and only increase frustration for the patient and her physician.
3. The inability to adequate perform a biopsy of the uterine lining if it ever becomes necessary later in life. Most women have endometrial ablations in their thirties and forties. Often, years later, they may require an endometrial biopsy or a hysteroscopy to evaluate irregular periods or even postmenopausal bleeding. Be aware that performing such an examination on a woman who’s already undergone an endometrial ablation can be challenging for physicians who have not been trained to do so. Endometrial biopsies performed following endometrial ablation procedures require special methods called reoperative hysteroscopic surgery which is done under ultrasound-guidance. Without these techniques the biopsy is often not feasible or unreliable.
In summary, endometrial ablation has been a wonderful procedure for many women and prevented hundreds of thousands of hysterectomies. However, they are associated with three separate types of late-onset ablation failures (LOEAFs) which you need to be aware of. For additional information please feel free to contact