Exploring endometrial ablation as a treatment option for women with abnormal uterine bleeding
As a double board-certified gynecologist in OB-GYN and urogynecology, I’ve spent my entire career working with medical innovations that improve women’s quality of life. Over the years, I have noticed trends in how women talk (or rather, don’t talk) about their menstrual health.
Specifically, abnormal uterine bleeding (AUB) affects 1 in 5 women, yet it can take some women years to discuss their symptoms with me, let alone seek treatment. In fact, most of the women I treat for AUB end up surprised, first by the efficacy of treatment and the difference it makes in their lives, and secondly at themselves for having waited so long to seek it out. The realization that women are still hesitant to talk about their periods with their doctors puts the onus doubly on physicians to ensure they’re informed of all their options.
One treatment that’s remained both relevant and important for women struggling with AUB is global endometrial ablation (GEA), a minimally invasive procedure involving the removal of the uterine lining via radiofrequency, heat or cryotherapy. Endometrial ablation is an important option to offer patients for several reasons, but a primary advantage is that it fills a gap left open for those patients who do not want to be treated with hormone therapy (or do not respond) but want to avoid the costs, potential complications and recovery time associated with major surgery via a hysterectomy. Importantly, candidates for this procedure must be finished with childbearing, as the removal of the uterine lining would make any resulting pregnancy extremely dangerous.
If your patient fits these qualifiers, endometrial ablation can be an effective solution for heavy periods that requires minimal recovery time. These procedures can often be performed in-office, which my patients see as a huge time and money saver and are therefore less likely to put off scheduling. For the appropriate patient, discovering she can regain some control over her life that quickly, safely and conveniently is nothing short of empowering.
GEA has been an option for quite some time. I’ve been performing ablations on patients for more than 20 years, and the procedure itself has evolved quite a bit since when I initially started performing them in the late 1990s. The early days of endometrial ablation would be more accurately categorized as an endometrial resection, as they were performed manually with a resectoscope — not the easiest tool to use — and layers of endometrium were often missed. This was also a more time-consuming process that posed greater risk to the patient, as it lacked sophisticated fluid management and visualization components while resecting the endometrium manually.
For these reasons, the resectoscope was soon taken over by non-resectoscopic GEA, specifically when the NovaSure endometrial ablation system was approved in 2001. This innovation simplified endometrial ablation dramatically, as it used radiofrequency energy to uniformly destroy the lining in the uterine cavity, instead of requiring manual manipulation.
When consulting patients about treatment options for AUB, they are usually most concerned with finding a treatment that offers long-term effectiveness. Research has proven GEA to be among the most efficacious options for women who are finished with childbearing, but do not want to deal with the cost and recovery time associated with hysterectomy. Further, endometrial ablation is a one-time procedure, making it a good alternative for women who want to reduce or eliminate bleeding without the rigidity of taking a pill everyday or having an intrauterine device replaced every 5 years.
Of course, it’s not a procedure for everyone. As mentioned, pregnancy is contraindicated following the procedure — but women are still able to conceive — so some form of birth control is required post-ablation. Women who are already on birth control without side effects to normalize their period are likely to stick with that treatment plan. Additionally, it is possible that the uterine lining rebuilds after an ablation, necessitating a hysterectomy for some women. But for most women finished having children, yet still some years before menopause, endometrial ablation is a viable option at least worth considering. In an era where patients are becoming more involved decision-makers in their health care journey, it is of paramount importance that we continue to educate women about their conditions and the treatment options available to them, along with the associated risks of each option.
When it comes to AUB, a condition constantly belittled and undertreated despite its prevalence, we could all use a reminder to keep this top of mind. – by Lori Warren, MD, FACOG, FPMRS
CDC.gov. Heavy menstrual bleeding. https://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html.
Laberge P, et al. J Obstet Gynaecol Can. 2015 Apr;37(4):362-379.