Endometrial ablation is a minimally invasive surgical procedure used to treat heavy menstrual bleeding (periods). The procedure works by ablating (destroying) the tissue in the lining of the uterus, which is called the endometrium. Because the endometrium is the tissue that causes bleeding, destroying this tissue may reduce menstrual bleeding to normal or lighter levels.

Heavy menstrual bleeding is a common problem. About one out of three patients who get their period seek treatment for heavy menstrual bleeding. A period with bleeding totaling over 1/3 cup (80 ml) is considered heavy or excessive. Signs that you may have heavy menstrual bleeding include if you regularly:

• Change your saturated pads or tampons frequently (for example, every hour for several hours in a row).
• Wear more than one pad at a time or need to use both a tampon and a pad.
• Bleed for longer than a week during your period.
• Have symptoms associated with anemia (low red blood cell count), such as tiredness or shortness of breath.
• Avoid or miss activities, work, or social events due to your menstrual bleeding.

The FDA has approved endometrial ablation devices for premenopausal patients with heavy menstrual bleeding due to benign (non-cancerous) causes for whom childbearing is complete.

The FDA has approved endometrial ablation devices that use different methods to destroy the endometrium tissue. These methods include:

• Heat energy created by one of these methods:
  • Heated gas inside a handpiece inserted into the uterus
  • Radiofrequency energy delivered by a handpiece within the uterus
  • Free flowing heated saline circulated within the uterus
  • Microwave energy delivered by a handpiece within the uterus
  • Heated fluid within a balloon on a handpiece inserted into the uterus
  • Heated water vapor circulated within the uterus
• Extreme cold created by nitrous oxide within a balloon on a handpiece inserted into the uterus

Your health care provider will discuss with you whether you are a candidate for endometrial ablation.

You are NOT a candidate for this procedure if:

• You are pregnant or want to become pregnant in the future. Pregnancies following ablation can be dangerous for both mother and fetus.
• You had an endometrial ablation procedure or endometrial resection (including endometrial ablation/resection performed immediately before the endometrial ablation procedure). Currently available devices are not designed for repeat treatment. Repeat ablation may result in serious injury such as internal burns.
• You are on medications that could thin the myometrial muscles (the muscles of the uterus), such as long-term steroid use (except for inhaler or nasal therapy for asthma).
• You have an intrauterine device (IUD) currently in place.
• You have abnormal vaginal bleeding that has not been evaluated by a health care provider.
• You have a known or suspected abdominal, pelvic or gynecological cancer.
• You have any anatomic condition (for example, history of previous classical cesarean section) or other condition that could weaken the muscular layer of the uterus.
• You have an active genital, pelvic or urinary tract infection (for example, cervicitis, vaginitis, endometritis, salpingitis or cystitis) at the time of treatment.

In most cases, endometrial ablation will be performed as an outpatient procedure. Talk to your health care provider if you have questions about where and how they perform these procedures and the type of anesthesia that is typically used. Your health care provider will advise you about whether you need someone to drive you home afterwards.

During the procedure, your health care provider may need to dilate your cervix to allow insertion of the handpiece for the endometrial ablation device into the uterus. Once the handpiece is inserted into the uterus, energy will be delivered for a few minutes to destroy the uterine lining. After the energy delivery is completed, the handpiece is removed.

After the procedure, you will be evaluated for your readiness to go home. You should also receive instructions about when to follow up with your health care provider.

The main potential benefit of the procedure is the reduction in menstrual bleeding and improvement in quality of life.

The most common side effects of endometrial ablation occur during or immediately following the procedure and include pain, cramping, nausea, and vaginal discharge/bleeding/spotting. You may also have temporary diarrhea or a headache.

While rare, the following risks (some of which could be life threatening) may occur during or immediately following the procedure:

• Deep injury to the uterus such as perforation (tear), or burn beyond the muscular layer of the uterus
• Injury to the organs in the abdomen, such as bowel or bladder perforation (tears) or burns
• Burn injury to the vagina, vulva, and skin
• Infection
• Hemorrhage (bleeding)
• Air or gas embolism (air bubble(s) in the blood vessels)
• Need for an additional surgery, including a possible hysterectomy, due to a complication during the procedure

While rare, the following risks may happen months to years after the procedure:

• New pain during menstrual cycles in patients who have previously undergone a tubal ligation (sterilization surgery). Also known as post ablation tubal sterilization syndrome (PATSS).
• Collection and retention of blood in the uterus due to narrowing of the cervix which may result in pain.

Other considerations include

• Pregnancies following ablation can be dangerous for both mother and fetus. Serious pregnancy complications may occur for both pregnant individuals and fetus in people that have had endometrial ablation. Endometrial ablation does not protect patients from future pregnancy. To avoid pregnancy, patients need to undergo a permanent sterilization procedure or continue to use reversable contraception until menopause.
• There may be difficulty in diagnosing an endometrial cancer in the future due to scarring of the endometrium
• You may experience a return of heavy menstrual bleeding which may lead to the need for further treatment, such as a drug therapy or hysterectomy
• Endometrial ablation reduces menstrual bleeding to normal or lighter levels, but you may experience amenorrhea (lack of menstrual bleeding) following treatment.

If you are considering endometrial ablation:

• Talk to your health care provider about any problems you may have.
• Discuss what treatment options may work for you, and whether you are a candidate for endometrial ablation.
• Ask your health care provider what type of endometrial ablation device they use and the risks and benefits of the procedure as compared to other treatment options.
• Ask for the endometrial ablation device patient labeling which will provide more information.
• Ask your provider about what to expect after having the procedure and when to contact them should you experience any problems.

Drug Therapies (Hormonal and Non-hormonal)

Hormone therapy is commonly available as oral contraceptive pills, patches, or injections. Hormone therapy is frequently prescribed by a health care provider before trying more invasive treatments such as endometrial ablation.

There are also several types of hormonal intrauterine devices or systems that are inserted by a health care provider into the uterus for contraception and control of bleeding.

Non-hormonal medications can be used with or without hormonal therapy. Some medications may include tranexamic acid and non-steroidal anti-inflammatories (such as ibuprofen) and are used to reduce heavy menstrual bleeding.

These therapies require repeated use to maintain their effect, and each have their own benefits and risks that you should discuss with your health care provider. These therapies have no permanent effect on fertility (ability to have children), so they are an option for patients who may want to have children in the future.

Hysterectomy

Hysterectomy is a surgery which removes the uterus and is the most invasive treatment for heavy menstrual bleeding. The procedure carries the risks associated with a major surgery, but it completely stops bleeding because the uterus, which is the cause of the bleeding, is removed. This surgery is performed in a hospital setting under general anesthesia. The recovery for hysterectomy is longer than the recovery for endometrial ablation, and pregnancy after hysterectomy is not an option because the uterus is removed.