What is Late-Onset Endometrial Ablation Failure (LOEAF)?

Introduction

If you are reading this section you have either undergone an endometrial ablation procedure—or you’re
considering one. Endometrial ablation (EA) is a commonly performed minimally invasive technique to treat
abnormal uterine bleeding. Although endometrial ablation works well on the majority of women, several studies now indicate that late-onset complications – often called Late-Onset Endometrial Ablation Failures (LOEAFs)– cause 25% of women who have undergone an EA to eventually require hysterectomy.  It is unknown how many more women have troublesome symptoms—but do not undergo hysterectomy.

What is a Late-Onset Endometrial Ablation Failure (LOEAF)?

In general, all methods of endometrial ablation (EA) have the potential to leave areas of endometrium (lining tissue of the uterus) behind. In some instances the lining hasn’t been destroyed—these women experience little if any relief even during the first cycle following their endometrial ablation. In other cases the procedure may have worked well for months or even years and then some lining tissue grows back.  In the latter instance women develop recurrent menstrual bleeding, severe pelvic pain and cramps or a combination of these symptoms. In still other instances an endometrial ablation may have been performed despite the presence of fibroids or polyps—which should be removed before an ablation can be successfully performed.

In our center, which treats many endometrial ablation failures, the most common complaint referred to our practice is the occurrence of cyclic (meaning approximately once a month) pelvic pain (CPP) or cramps—often, but not always accompanied by bleeding. Some women have even compared this pain to “labor pains” or “pain in my ovaries.” The pain often occurs because of a hematometra (a collection of blood within the uterine cavity) that is unable to pass through the cervix. As the pressure inside the hematometra builds up the uterus contracts in an attempt to pass it.  The resulting pain can be just above the pubic bone or in the right and left groin areas (sometimes all are involved).  When the pain of an ablation failure is to the right or left of midline (or on both sides) women frequently mistake the pain for “ovulation” pain or “pain in my ovaries.”

To summarize, late-onset endometrial ablation failures present to us in 3 separate ways.  Often there is a combination of 2 or more of these present at the same time.

  1. Some experience no relief of their menstrual bleeding following an endometrial ablation.
  2. Some women may develop cyclic pelvic pain (CPP) following an endometrial ablation—this may occurs months or years following their procedure.  The cyclic pelvic pain may or may not be accompanied by menstrual bleeding.
  3. Some women—often many years following an endometrial ablation—may require an endometrial biopsy to evaluate abnormal uterine bleeding and it cannot be performed because of the scar tissue that develops following an ablation procedure.

Why do Endometrial Ablations Fail?

In general, these methods all have the potential to leave areas of endometrium (lining tissue of the uterus) behind. In some instances the lining may not have been adequately destroyed at the time of their ablation, in which case women experience little if any relief even during the first cycle following their treatment. Another reason that endometrial ablations fail is that they may have been performed despite the presence of fibroids or large polyps—which should be removed before an ablation can be successfully performed.

In many cases the procedure may have worked well for months or even years and then endometrium may “regrow” in a portion of their uterine cavity.  These women develop recurrent menstrual bleeding.  Often the bleeding may be accompanied by severe pelvic pain.  Women typically report that while their level of bleeding is manageable, their pain has become intolerable.

In our practice, which treats many endometrial ablation failures, the most common complaint referred to us is the occurrence of severe cyclic pelvic pain (CPP)—often, but not always accompanied by bleeding. Some women have even compared this pain to “labor pain”. The pain often occurs because of a hematometra (a collection of blood within the uterine cavity) that is unable to pass through the cervix. The pressure inside the hematometra builds up as the uterus contracts in an attempt to pass it.  In this situation women experience these contractions as “cramps” or “pain.”

 

Why do hematometrae occur?

In general, hematometrae occur because blood is being produced somewhere in the uterine cavity—generally by endometrium (lining tissue) that has regrown or a fibroid that is within the uterine cavity.  The resulting blood is unable to pass easily from the cervix because of scarring that often happens in the lower portion of the uterus.  As a result the blood “backs up” within the uterus.  The uterus initially swells and then responds by contracting and “trying harder” to get rid of the blood accumulating with it.  In the process of “contracting” a woman may experience moderate to intense pain which is often similar to “labor pains”.  It doesn’t take a great deal of blood (less than a teaspoon) to “back up” before it produces symptoms of pelvic pain.

 

How can I be tested to see if I have a hematometra?

Hematometrae are generally detected on ultrasound.  Since hematometra represent menstrual blood that hasn’t been able to pass through the cervix it accumulates within the uterine cavity and is seen on ultrasound as large “black spots” within the uterine cavity.  This is very clear in all 3 figures shown below.

 

In Figure 3 you can see 2 hematometrae clearly shown as black circles.  However, notice that these circles are surrounded by a light grey “halo.”  This, so-called “echogenic halo” is the actual appearance of endometrium which is still functioning and produces the blood seen as hematometrae.

How often do these type of late-onset ablation failures occur?

As of this writing (October 2017) there are over 500,000 endometrial ablations performed in the United States per year. To the best of our knowledge this problem affects more than 25% of women within the first 5 years of their endometrial ablation (EA)—that’s a minimum of over 100,000 late-onset failures per year. We know that it can happen up to 15 years following EA but the vast majority of them occur within the first 3 years. So if you’ve managed to make it 3 years without an issue it doesn’t mean you’re entirely out of the woods. However, statistically-speaking, most issues happen within the first 3 years.

Why didn’t my doctor tell me this could happen?

The most honest answer is that in all likelihood your physician didn’t know. Most doctor don’t perform hundreds of endometrial ablations per year. In fact most physicians probably don’t perform this procedure a dozen times a year. The majority of endometrial ablation procedures (75%) work well and women manage to avoid hysterectomy. Most physicians have not attended postgraduate courses that discuss the issue of endometrial ablation failure. Additionally, there are not many articles in the medical literature that discuss late-onset endometrial ablation failure. And there are far fewer articles that discuss how to manage them!

What is the treatment of these hematometrae or areas of endometrial growth?

The treatment for hematometra and endometrial growth (or regrowth) is primarily surgical—milder forms can occasionally be treated with medications such as birth control pills, oral progestins or Depo Provera.  The more severe forms of hematometra or endometrial regrowth that cause intense pain, bleeding or both will require surgery.

The minimally invasive treatment of hematometra involves 2 steps.  First, the removal of the scar tissue found in various portions of the uterus that cause blood to be trapped.  Second, the removal of the bleeding source.  The source is typically lining tissue that has regrown—or was never removed. In some instances the source of bleeding may be a fibroid or a polyp that was never removed or grew.  Both of these steps are important.  It’s not enough to remove just the fluid or blood!  In order to prevent or reduce likelihood of recurrence the tissue that caused the blood to become entrapped must also be removed.

In most parts of the world and in the United States the treatment for a failed endometrial ablation that causes significant pain or bleeding is hysterectomy.  The hysterectomy need not be accompanied by removal of the ovaries, however.  Often women who undergo a hysterectomy for this issue can request a subtotal hysterectomy which preserves the cervix as well. 

In most parts of the world and in the United States the treatment for a failed endometrial ablation that causes significant pain or bleeding is hysterectomy.  The hysterectomy need not be accompanied by removal of the ovaries, however.  Often women who undergo a hysterectomy for this issue can request a subtotal hysterectomy which preserves the cervix as well. 

The only other surgical treatment that we advocate in ultrasound-guided reoperative hysteroscopy surgery (UGRHS).  This surgery involves a minimally invasive procedure that allows a physician to remove the scar tissue just above the cervix along with the tissue that caused the symptoms of bleeding or pain.  Typically UGRHS involves the removal of endometrial tissue.  In many cases, however, we have also removed endometrial polyps and fibroids as well.

During ultrasound-guided reoperative hysteroscopic surgery we locate and remove areas where lining tissue is growing and we explore other portions of the uterus where lining tissue has a potential to grow.  Unless existing lining tissue or relevant fibroids are removed the problem is likely to recur.

In summary here are some “take-aways” about ultrasound-guided reoperative hysteroscopic surgery (UGRHS):

  1. It is not a repeat ablation!  In fact repeat ablations should not be performed since a repeat ablation is not designed to remove the scar tissue that entraps the functioning lining tissue (endometrium).
  2. The initial part of UGRHS is removal of all adhesions (scar tissue) within the uterine cavity.
  3. Next, we resect—which is to remove and not burn—the remaining uterine lining.
  4. Finally, we explore the likely portions of the uterus that typically harbor sequestered islands of lining tissue (endometrium).
  5. When UGRHS has been completed the uterus typically looks as if it had undergone an endomyometrial resection.  You might wish to review some of our information on endomyometrial resection as it will also help you understand how this is different from an endometrial ablation.

Below I’ve placed two “before” and “after” pictures following UGRHS.

Figure 4:  This shows how the uterine cavity looks “midway” through a typical procedure.  While some of the scar tissue has already been removed in order to allow you to see this view there are numerous “pink” areas of lining tissue that have been uncovered.  These pink areas are functioning endometrial tissue which cause the bleeding.  The blue arrow is pointed a red-brown area of lining tissue.  This color indicates lining tissue in combination with trapped blood—giving it that brownish appearance.

Figure 5:  This is the same patient after all of the “pink” lining tissue and the “red-brown” tissue have been removed.  The lining is now entirely removed and the uterus has been thoroughly explored for other signs of discoloration and trapped tissue.  The “white” or pink-tan tissue you see represents uterine muscle (myometrium).

The most troubling kind of late-onset endometrial ablation failure (LOEAF)!

Of the various kinds of endometrial ablation failure listed above the most troubling is cyclic pelvic pain (CPP). With cyclic pelvic pain women often experience cyclic pain–once a month at the time of their cycle–that may last anywhere from a day or two up to 2 weeks. In advanced cases there is no “break” and women then experience continuous lower abdominal pelvic pain that radiates into the back, groin or even their thighs. If the pain is associated with menstruation both the women and physician understand the cause of the pain. However, when there is NO VAGINAL bleeding the diagnosis of a late-onset endometrial ablation failure (LOEAF) is often missed. This can lead to some unfortunate results. Here’s why.

If women experience significant pain unaccompanied by vaginal bleeding it’s not necessarily obvious to them or to their physician that their pain is even related to their endometrial ablation (which may have occurred 3-4 years earlier). The pain, which may be described as “labor-like,” frequently leads to an emergency room (ER) visit. Often, the ER doctor is not a gynecologist and there can be a significant delay in the diagnosis. At other times, the diagnosis is missed entirely!

To summarize, the most troubling endometrial ablation failure is pelvic pain which is not accompanied by bleeding. The pain can be disabling and the diagnosis is often delayed or missed.

Why is the diagnosis delayed or missed?

Often the diagnosis is delayed or missed because the wrong tests are ordered.  In other instances the correct test was ordered but was misinterpreted. For instance, in the women we’ve seen who present with “the most troubling kind of endometrial ablation failure,” many of them have had CT Scans and pelvic ultrasounds. CT Scans–which are both expensive and time consuming—are very good in the diagnosis of bowel and kidney disease or for an acute appendicitis. However, they are far less sensitive than an ordinary transvaginal ultrasound for the diagnosis of a late-onset endometrial ablation failure!  However, a common issue we encounter in managing women with LOEAFs is that a surprising number of them have undergone ultrasound examination and told that it was “normal.” This is NEVER TRUE following an EA.

Let me explain. Even if you’ve had an endometrial ablation and it’s worked perfectly, your uterine lining has been totally or partially destroyed and your ultrasound is never “normal” again! So if someone has told you that you have a normal vaginal ultrasound examination a “red flag” should go up. Often the ultrasound examination clearly displays the abnormality but the radiologist misinterprets the findings as they often don’t understand what post-ablation ultrasounds typically look like.

Does this mean I should not have had an endometrial ablation (EA)?  Was the EA a bad idea?

Provided you were properly counseled about endometrial ablation and someone explained both the immediate and late-onset complications of EA I want to categorically state that EA has saved many women from undergoing more invasive surgeries such as hysterectomy. Even “minimally invasive” procedures such as “robotic hysterectomy” are, at best, misnomers and cannot compare to endometrial ablation in terms of safety, risks and recovery. If only 75% of endometrial ablations “work” that’s still a 75% chance of avoiding a hysterectomy utilizing a very low-risk procedure with a quick recovery.

What are the major risk factors for Late-Onset Endometrial Ablation Failure (LOEAF)?

Several important factors have been identified that increase a woman’s risk for “failure” with endometrial ablation. These are as follows:

  • Age < 35 years of age
  • Submucous or intramural fibroids. Remember that endometrial ablation is NOT a treatment for fibroids. If you have fibroids inside your uterus (submucous) they should be removed at the time of your endometrial ablation or endomyometrial resection.

  • Polyps. Polyps, like fibroids, need to be removed prior to your endometrial ablation.

  • Anomalies of the uterus (a uterine septum or a bicornuate uterus). These are present a birth. Most women who have them already know about it. However, it’s important to have an ultrasound and a hysteroscopy prior to an endometrial ablation just to be sure you don’t have one. This can be done at the time of your EA. If you have a uterine septum or a bicornuate uterus you should consider another form of treatment such as endomyometrial resection.
  • Active infection. This is self-explanatory.  Elective uterine surgery should be avoided in the presence of infection.
  • Uterine cancer or atypical endometrial hyperplasia. This is also self-explanatory. Since an ablation is a “burning procedure” you don’t want to burn the “evidence”
  • Motivation. If you understand the risks and consequences of endometrial ablation and you’re simply more “comfortable” with a hysterectomy, don’t let someone “talk you into” an EA. Women who are poorly motivated to undergo EA—after they review the information—will likely not do well.

Why not have a hysterectomy in the first place?

Hysterectomy isn’t a bad choice for many women but keep in mind that in many cases it is far more aggressive than medically warranted. Importantly, some women are just simply poor operative risks for hysterectomy. This includes women who are obese (BMI > 30), diabetic, or ones who’ve had multiple abdominal surgical procedures such as appendectomy, cholecystectomy, multiple Cesarean sections, bowel surgery and gastric-bypass procedures. Other women who should avoid hysterectomy are those with bleeding disorders, women who take “blood thinners” or have a history of pulmonary disease, coronary artery disease or strokes.

Finally, it’s important to realize that even though endometrial ablation and similar procedure are far from perfect they are simple office-based procedures with a quick recovery and rapid return to a normal life style. EAs work on a sizeable majority of women and are far less risky than hysterectomy. If endometrial ablation doesn’t work you can, in most cases, have a hysterectomy.

What can be done about endometrial ablation failure?

For most women who experience late-onset endometrial ablation failure–over 100,000 per year in the U. S.–the choices include

  • Living with the problem if the symptoms are manageable.
  • Trying to control the symptoms with hormonal suppression–birth control pills, norethindrone, Depo-Provera, oral medroxyprogesterone acetate, or megestrol (Megace).
  • Subtotal hysterectomy
  • Ultrasound-Guided Reoperative Hysteroscopic Surgery (UGRHS)

What should not be done following an endometrial ablation failure?

Many physicians offer a variety of treatments following a late-onset failure. The following procedures should be avoided if you’re had an endometrial ablation that’s failed.

  • IUD insertion—Although IUDs can be inserted following EA this needs to be done by a highly trained physician and under ultrasound guidance!
  • A “repeat” ablation of one of the following types:

    • NovaSure
    • Minerva
    • ThermaChoice Balloon (unavailable after 2016)
    • Hydrothermal Ablation (HTA)
    • Microwave endometrial ablation (no longer available)
    • Cryoendometrial ablation (HerOption)