Menstrual Disorders, Fibroids & Polyps

Endomyometrial Resection (EMR)

Why We Invented EMR

In 1988, we were the first to perform successful endometrial ablations in Western New York / Rochester.  The first instrument we used involved a specialized laser-the Nd-YAG laser – that was passed through a hysteroscope placed inside the uterine cavity.  A year later—in 1989 –the FDA approved another instrument known as the gynecologic or “rollerball resectoscope”.  The method used a specialized electrode known as a “rollerball” to efficiently heat up and thermally destroyed the uterine lining.   These were the first endometrial ablation procedures performed in the United States.

ND-YAG Laser & Rollerball Resectoscope

Although these procedures worked, they did not produce predictable and reliable results.  Despite this, endometrial ablation saved many women needless hysterectomies and represented a very good start.  There were obvious shortcomings of the early endometrial ablation techniques, including the following:

  1. Endometrial ablation did not produce reliable amenorrhea (cessation of all periods).  Only 50% of women stopped having periods entirely. Although most women had significant improvement, many women had hoped for better results.  All too often, women found that their improvement was only minimal.
  2. Endometrial ablation required the use of an expensive premedication prior to the procedure—Lupron.  Lupron, was used to “thin-out” the uterine lining—and was felt to be a pre-requisite for successful of EA.  Unfortunately, it was quite expensive and produced disabling hot-flashes for many women—lasting about 4-6 weeks altogether.
  3. The depth of destruction of the uterine lining could not be judged.  It is a simple fact that we cannot predict the depth of thermal destruction caused by endometrial ablation.  There are many variables in endometrial ablation. The same instrument and surgeon can cause 2 mm of destruction in one woman and 6 mm of destruction in another using the same instrument in the same way.  In some instances deep destruction is desirable and safe and in other instances it is not.
  4. Endometrial ablation burns and destroys tissue and therefore there is no specimen available to send for analysis.  There have been cases of uterine cancer that were improperly treated with endometrial ablation.  Unfortunately, since there was no tissue to be analyzed; the evidence was destroyed.
  5. The early endometrial ablation procedures shown above were associated with some life-threatening complications generally caused by the poor technology of the time and poor physician training.

Beginning in 1995, endometrial ablation procedures became simplified by a variety of technological achievements.  As a result many physicians began offering these procedures.  Today there are 3 types of endometrial ablation procedures that are commonly used in an office-based or hospital setting and are extremely safe.  These include NovaSure, ThermaChoice (or thermal balloon) and Hydrothermal Ablation (HTA).

NovaSure, ThermaChoice Balloon, Hydrothermal Ablation
NovaSure, ThermaChoice Balloon, Hydrothermal Ablation

The “good news” about these procedures is that they offer exceptional safety compared to earlier forms of EA.  The “not-so-good news” is that the results are not improved compared to previous forms of endometrial ablation.

Here are some facts about endometrial ablation you should know.

  1. EA has a high failure rate!  By 5 years about 25% of women treated with these methods will require a hysterectomy.  One type of EA does not appear to be superior to another type.
  2. EA can be quite painful.  If EA is done in a physician’s office—unless that office is an Accredited Office Based Surgery Center–these procedures can be quite painful!  Most physicians performing endometrial ablation (EA) in their offices do not offer adequate pain control.
  3. EA procedures work poorly if you have something other than a “standard uterus”.  You can expect poorer results if

>  Your uterus is larger than ‘average’

>  Your uterus contains endometrial polyps or fibroids

>  If you have any kind of uterine anomaly (“heart-shaped” uterus)

In 1991, in an attempt to address the shortcomings of endometrial ablation, Dr. Wortman and Amy Daggett invented the technique known as endomyometrial resection or EMR.  The difference is that EMR removes a known depth of uterine lining tissue.  In general we remove about 5 mm of lining tissue together with the underlying muscle of the uterus.  In some cases we adjust the depth to something more or less depending upon the woman’s anatomy.  In other words EMR can be tailored to your particular uterus.

The purpose of removing the muscle is to insure—to the degree possible—that the basal layer of the endometrium (think of it as the “root” of the lining) is removed.  When the basal layer of endometrium is removed—rather than burned—we found that the predictability of amenorrhea (complete cessation of periods) increased from approximately 50% to nearly 88%.  After the tissue is removed it is sent to the pathology lab where it is analyzed.  Often we find conditions that were never suspected—some are benign and inconsequential while a small percentage are pre-malignant or malignant and were previously missed on a routine endometrial biopsy.  We’ve published our findings in multiple medical journals.  Click here to review some of them.

Definition

Endomyometrial Resection
Endomyometrial Resection (EMR)

Endomyometrial Resection (see image) is the systematic removal of uterine lining tissue to a known depth—not the burning of tissue! Perhaps you have a friend or relative who’s had one. After reading this article you’ll understand why we feel that EMR is a superior technique compared to the alternative procedures available today.

Endomyometrial Resection Provides Many Benefits…

  1. Women who undergo EMR are less likely to require a subsequent hysterectomy.  Since the procedure is more predictable in terms of how much tissue is removed (destroyed) the number of women who are satisfied is far higher and the number of women who will eventually require a hysterectomy is far lower. Five years after an EMR fewer than 5% of women will require a hysterectomy – compared to 25% with ablation methods!
  2. EMR produces a tissue specimen. This enables us to avoid a separate endometrial biopsy.  When possible we often combine 2 procedures into one—a diagnostic and a therapeutic procedure.  Tissue that is removed during an EMR is sent for pathology to be certain that a cancerous or pre-cancerous condition is not present.  This often precludes the need for a separate endometrial biopsy.
  3. EMR is easily combined with the removal of many fibroids and any polyps.  About 30% of the women we treat also have uterine fibroids or polyps.  Endometrial ablation cannot not adequately treat uterine fibroids or polyps.  Since the same instrumentation is used for the removal of fibroids, polyps and uterine lining these can all be done simultaneously as part of the same procedure.  This flexibility is generally not possible with endometrial ablation.

Frequent Asked Questions (FAQs) about Endomyometrial Resection

1. How many of these procedures have you done?

Between 1991- 2015, we have performed over 3,000 endomyometrial resection procedures. A third of these procedures also involve the removal of fibroids.

2. Can my doctor do an EMR?

Yes. I have personally trained 3 other physicians that are in practice in Western NY. You may wish to ask your gynecologist if he or she has experience with this procedure.

3. If this procedure is better than endometrial ablation, why don’t other doctors offer it?

EMR is a complex operation to perform and should only be done by a dedicated team that is properly trained in both hysteroscopic surgery and in ultrasound guidance.  Additionally, the team should perform a sufficient number of cases on a regular basis in order to maintain its skills. Just as you wouldn’t want your airline crew to fly “once in a while” you don’t want your surgical team to do these procedures “on occasion”. In experienced hands, such as ours, significant complications are rare and our success if very high.

4. IS THE CENTER FOR MENSTRUAL DISORDERS ACCREDITED FOR OFFICE BASED SURGERY?

Yes.  We received our first accreditation in November of 2008.   Our accreditation agency is the Accreditation Association of Ambulatory Health Care (AAAHC).  We undergo a rigorous inspection process, as required under New York State Public Health Law every 3 years.  We were last accredited in November 2014.

5. How long have you been doing office-based EMRs?

We began offering office-based EMR in early 2007 on selected patients. As of mid-2015 we have performed 1,050 office-based EMRs and we presently average 3-4 procedures per week.

6. WILL THE PROCEDURE HURT?

No. Our procedure are done with the use of sedatives and analgesics given intravenously.  We have had extensive experience in performing office-based procedures for over 30 years.  The medications used are commonly used by gastroenterologists and other specialists who perform office-based procedures.  To date we have performed well in excess of 50,000 different gynecologic procedures with the use of intravenous sedation.

7. WHAT ARE THE ADVANTAGES OF PERFORMING AN EMR IN AN OFFICE COMPARED TO A HOSPITAL SETTING?

The main advantage is that our office-based “team” has worked together since we started offering this procedure in 2007.  As with any procedure “teamwork” is essential to patient safety and good results.

There are other advantages to performing them in an office setting.   For instance, when your case is over your team is still here with you—your doctor doesn’t leave the hospital to run to the office. Keep in mind, however, that NOT ALL CASES CAN BE PERFORMED IN AN OFFICE BASED SETTING.

8. IF I DECIDE TO HAVE AN EMR WHAT CAN I EXPECT?

Procedures are booked anywhere from 1-6 weeks in advance depending on your individual circumstances and our patient load.  When your procedure is scheduled you will actually be given two appointments.  The first appointment will be for the procedure itself.  These are generally scheduled at 8:15 AM or 12:45 PM.  The procedures typically take 20-40 minutes to perform and you can expect to spend an additional 60-90 minutes recovering from your procedure.

Endomyometrial Resection (EMR)
Endomyometrial Resection (EMR)

The second appointment you will be given is one scheduled for the afternoon prior to your EMR.  During this visit a laminaria (cervical dilator) is placed in the cervix.  Since this can cause cramps in some women you may elect to be sedated for this brief procedure (2-3 minutes).  If you are uncertain whether or not you wish to be sedated, it’s best to bring someone with you so that you can be driven to and from the office. About half of our patients elect to have intravenous sedation for the laminaria insertion.

While the procedure itself takes between 20-40 minutes to perform, you can expect to spend between two-and-a-half and three hours here.

After your EMR you will likely spend much of the day of surgery at home resting.  The medications you’ve received during your procedure will still make you feel quite sleepy.  You should expect to do little other than rest in bed.  The following day you may have slight or even moderate cramps that should quickly dissipate throughout the day.  You will be able to bathe or shower following the procedure.  Within 36-48 hours after the procedure you should feel well enough to go about most, if not all, of your routine daily activities.

9. HOW LONG WILL IT TAKE TO RECOVER FROM MY EMR?  HOW LONG WILL I NEED TO TAKE OFF FROM WORK?

Most women will need 36-48 hour to recover.  Often women try to schedule their procedure late in the week and return to work on Monday morning.

10. HOW LONG WILL IT TAKE BEFORE I KNOW IF MY EMR WORKED?

The results of EMR should be noticeable within 1 month following the procedure.  However, you may not appreciate the full benefit until 3-4 months later.

11. WHAT KIND OF FOLLOW-UP CAN I EXPECT AFTER MY EMR?

You will be asked to schedule a follow-up visit 2 weeks and 4 months following the procedure.  Your visit will include a transvaginal ultrasound examination so that we can monitor the healing that occurs within your uterus.  Although you will experience a noticeable difference within one cycle after your EMR, the uterus takes at least 4-6 months to heal.

12. IF I UNDERGO AN ENDOMYOMETRIAL RESECTION (EMR) WILL IT WORK FOREVER?  WILL I EVER NEED TO HAVE THE PROCEDURE REPEATED?

The outcome of EMRs is dependent on a number of factors.  After 5 years 87% of women (including all age groups) will have either no vaginal bleeding or only slight vaginal bleeding.  The remainder will either have moderate improvement or little improvement.  The factors that increase your likelihood of success (above the average) include the following:

Age – Women over 45 years old have the best results while women under 35 have poorer results.

Expectations – If you will only be satisfied if you are 100% guaranteed to have no further periods you may be disappointed if you don’t get perfect results and you might consider opting for a hysterectomy instead.  So only choose EMR if you are prepared for the fact that this is not a perfectly predictable procedure.  While EMR is an improvement compared to endometrial ablation—it is not perfect.

Fibroids (Leiomyomas) – The coexistence of multiple and varied types of fibroids will reduce    the effectiveness of EMR.  Since fibroids are so variable in nature it’s important to review your particular case and the kind of results we feel that you may achieve with this approach.

13. WHAT ARE THE POSSIBLE COMPLICATIONS OF EMR?

There are 2 classes of complications that can result from EMR—one’s that occur during the actual procedure (immediate) and those that happen between 3 months and 10 years later (late-onset failure).

Immediate Complications from EMR are quite uncommon.  The data we are quoting is our actual data and represents the most recent information we’ve collected from 2007 through mid-2015 (1050 cases).

Infection -Infections generally manifest themselves in the form of a fever within the first 24-36 hours.  Rarely do these require hospitalization.  Most of them occur while the patient is in recovery and are treated with intravenous antibiotics. This may delay discharge by 1-3 hours.  The likelihood of infection is between 0.5% and 1.0%.

Small uterine tears – a small uterine tear also occurs in 0.5 to 1.0% of women.  Tears happen because the surgery is occurring as the uterus is filled with fluid—we actually operate “under water”.  Water is necessary to distend the uterus so that the inside is visible to our camera and ultrasound.  Occasionally the water pressure within the uterine cavity causes a small tear near the top of the uterus.   When this happens we have to stop the case because visualization is no longer possible.  Generally, these tears do not require emergency treatment.

Excessive bleeding – although bleeding does occur following EMR it has never occurred to such an extent that a hospital transfer or blood transfusion has been necessary.

Transfer to hospital – Complications occasionally require a transfer to the hospital.  This has now occurred twice in the past 1050 cases (0.2%).

Uterine perforation – A perforation is different than a tear.  In a perforation an instrument is passed unintentionally through the uterus and may cause damage to internal organs.  The likelihood of such an event is 0.2% or 2 per thousand cases.

Delayed Complications from an EMR can occur just as they occur with endometrial ablation.  There are 2 types of delayed complications.

New onset menstrual bleeding – It is not uncommon for women to experience a change in their bleeding after 6 months or even 6 years following an EMR.  The bleeding may be light or heavy.  This is most noticeable in the majority of women who have amenorrhea (no menstrual bleeding).  It can come as a shock if they begin having even light periods.  This is generally not a cause for concern, but you should notify us.  In some cases the renewed bleeding can be heavy and quite troublesome.  The treatment of new onset menstrual bleeding will vary considerably from one woman to the next.

Cyclic lower abdominal pelvic pain – this may occur with or without vaginal bleeding.  One of the problems of EMR and endometrial ablation is that tissue can regrow—especially in younger woman (under the age of 40).  When this happens the menstrual blood may find an easy path out of the uterus through the cervix—and there are few problems.  In other cases, however, there is scarring around the cervix or elsewhere in the uterus and the blood becomes trapped inside.  When it’s unable to pass easily in the form of a period it forms a small collection called a hematometra.  Hematometrae are small (about ½ to ¾ of an inch in diameter) but can be very painful as your uterus contracts in an attempt to get rid of it.

Some women describe it as an intense menstrual cramp while others describe it as feeling like  labor pains.  We estimate the incidence of this to be between 8 – 10% overall.  The incidence is lower in women over the age of 45 and greater in women under the age of 35.  The mechanism of this is nearly identical to what happens with endometrial ablation failures. Click here to read more.

Many delayed complications can be retreated while others require some form of hysterectomy.

14. HOW WILL I KNOW IF THE EMR NEEDS TO BE REPEATED OR IF I MAY REQUIRE A HYSTERECTOMY AT SOME POINT?

About 8-10% of our patients –at some point within 5 years—will have symptoms of either troublesome vaginal bleeding or pain.  Many factors go into deciding whether such cases can be observed, treated with reoperative surgery or if you would be better off with a hysterectomy.  This issue one that you should discuss with us prior to your EMR.  If you develop any of these symptoms there’s usually plenty of time to consider your options and make a thoughtful decision.

References

Wortman M., Daggett, A.: Hysteroscopic Management of Intractable Uterine Bleeding: A Review of 103 Cases. J Reprod Med 1993; 38:505-10.

Wortman M., Daggett, A: Hysteroscopic Endomyometrial Resection: A New Technique for the Management of Menorrhagia. Obstetrics and Gynecology 1994; 82:2;295-8.

Wortman, M: Hysterectomy Alternatives: Which Surgery is best? OBG Management. January 1996. Pp.27-38.

Wortman M. Instituting an Office-Based Surgery Program in the Gynecologist’s

Office. Journal of Minimally Invasive Gynecology. 2010; 17:673-83.

Wortman M. Office-Based Surgery: What you need to know. The Bulletin. Journal of the Monroe County Medical Society. April 2011. pp 18-19.

Wortman M. Should you offer your patients office-based gynecologic surgery? Contemporary Ob Gyn. December 2011; 34-41.

Wortman M. Sonographically-Guided Hysteroscopic Endomyometrial Resection. Surgical Technology International. 2012. Volume 21:163-169.

Wortman M. Ultrasound Guided Reoperative Hysteroscopy: Managing Endometrial Ablation Failures. Surg Tech International. 2012; 21:163-69.

Wortman M, Daggett A, Ball C. Operative Hysteroscopy in an Office-Based Setting: A Review of Patient Safety and Satisfaction in 414 Cases. J Minim Invasive Gynecol. 2013; 20:56-63.

Wortman M, Daggett A, Deckman A. Ultrasound-Guided Reoperative Hysteroscopy for Managing Global Endometrial Ablation Failures. J Minim Invasive Gynecol. 2014; 21:238-244

Wortman M, McCausland A, McCausland V, Cholkeri A. Late-Onset Endometrial Ablation Failure (LOEAF)—Etiology, Treatment and Prevention. J Minim Invasive Gynecol. 2015; 22: 323-331.

Riley KA, Davies MF, Harkins GJ. Characteristics of Patients Undergoing Hysterectomy for Failed Endometrial Ablation. Journal of the Society for Laparoendoscopic Surgeons. 2013; 17:503-7

Additional references to you should read before undergoing an office-based procedure.

http://www.health.ny.gov/press/releases/2009/2009-06-25_office_based_surgery_accreditation.htm
http://www.oprah.com/health/Questions-to-Ask-Before-Having-an-Office-Based-Surgery
http://www.health.ny.gov/professionals/office-based_surgery/practices/#county