Menstrual Disorders, Fibroids & Polyps

Recommendations for Women undergoing Endomyometrial Resection and all forms of endometrial ablation

The Center of Menstrual Disorders announces its official recommendations for women who have undergone endometrial ablation* and EMR

(* includes NovaSure®, Hydrothermal®, ThermaChoice®, “roller-ball”)

During the past 28 years of performing various types of endometrial ablation and endomyometrial resection (EMR) we have had the opportunity to observe and manage thousands of women with an array of menstrual disorders. Importantly, we have also developed an understanding of the fact that women who undergo endometrial ablation or EMR need to be carefully counseled prior to their procedure and –just as important—they require careful monitoring following their procedure. This is true even for women do not perceive a problem.

At the present time no major professional organization in gynecology –neither The American College of Obstetricians and Gynecologists (ACOG) nor The American Association of Gynecologic Laparoscopists (AAGL) has issued recommendations for women who have undergone any type of endometrial ablation or endomyometrial resection procedure. In order fill that void we are presenting a summary of the potential problems that may occur following these procedures and our recommendations so that you are not caught unaware.

It is now well understood that every kind of endometrial ablation (ThermaChoice, Hydrothermal Ablation and NovaSure and “rollerball procedure” as well as Endomyometrial Resection (EMR) is associated with a set of conditions known as LOEAF – late-onset endometrial ablation failure.

Late-onset endometrial ablation failure (LOEAF) is a common condition and affects between 5-40% of women depending on a variety of factors including age (the younger you are the more prone you are to develop this) and other conditions such as fibroids.

LOEAF may take on one of three forms:

  1. Women who have previously enjoyed light or absent periods may slowly develop heavier periods. This generally happens as lining tissue has a tendency to regrow—especially in younger women. In some cases it was not possible to destroy all of the uterine lining.
  2. Central HematometraWomen may develop increasingly painful periods or episodes of pain without accompanying periods known as “cyclic pelvic pain” or CPP. CPP develops as a result of 2 factors—the regrowth of uterine lining and the growth of scar tissue that prevents menstrual blood from passing easily. This combination can lead to a slight increase in cramps at the time of your expected period or it can result in incapacitating “labor-like” pains that occur above the pubic bone (suprapubic), in the right or left lower quadrants or even in the lower back.
  1. The inability of access the uterine cavity should a biopsy be required at some point in your life. This is very important to remember. If you develop post-menopausal bleeding or require assessment of the uterine cavity (for cancer screening) conventional methods of assessment such as ultrasound, sonohysterogram, diagnostic hysteroscopy and endometrial biopsy are no longer reliable. You can see why from the picture above—the uterine cavity is typically blocked by scar tissue. Future assessment required specialized skills known as sonographically-guided hysteroscopic biopsy. This is often referred to reoperative hysteroscopic surgery (RHS). You can click here to learn more.The purpose of this article is not to explain how these biopsies or treatments can be provided. However here are the “take-aways”.

Recommendations for Women Who have undergone any form of Endometrial Ablation or Endomyometrial Resection 

  1. If you have undergone any form of endometrial ablation or resection procedure you should be seen annually.
  2. At the time of your annual you should report any change in bleeding patterns or inform your provider if you’re developing cyclic pelvic pain that is worsening or new.
  3. A transvaginal ultrasound examination should be a part of your annual visit. This allows the physician to establish a “baseline” of what your uterus looks like and makes it easier to diagnose subtle changes.
  4. If you are ever seen in an emergency room for abdominal or pelvic pain please remind your emergency room physician—who is often not a gynecologist– that you had an endometrial ablation or resection and to contact our office for further guidance.

The Center for Menstrual Disorders has a world-wide reputation in the recognition and management of endometrial ablation failures. These recommendations do not reflect practice guidelines by any major professional organization such as the American College of Obstetrician and Gynecologists (ACOG) or the American Association of Gynecologic Laparoscopists (AAGL).   However, we have been managing these issues since 1989 and have published numerous articles on this subject in multiple peer-review journals.  

Wortman M. Minimally invasive surgery for menorrhagia and intractable uterine bleeding: Time to set standards. J Am Assoc Gynecol Laparosc. 1999; 6:369-73.

Wortman M, Cholkeri A, McCausland AM, McCausland VM. Late-onset endometrial ablation failure–etiology, treatment, and prevention. J Minim Invasive Gynecol 2015 Mar-Apr; 22(3):323-331.

Wortman M, Daggett A, Deckman A. Ultrasound-guided reoperative hysteroscopy for managing global endometrial ablation failures. J Minim Invasive Gynecol 2014 Mar-Apr; 21(2):238-244.

Wortman M, Cholkeri A, McCausland AM, McCausland VM. Late-onset endometrial ablation failure–etiology, treatment and prevention. J Minim Invasive Gynecol. 2015; 22(3):323-31.

Wortman M, Daggett A. Reoperative hysteroscopic surgery in the management of patients who fail endometrial ablation and resection. J Am Assoc Gynecol Laparosc 2001 May; 8(2):272-277.