**If you have questions or need a physician referral, please contact HERS at 888.750.HERS (4377) or 610.667.7757.**

Endometrial Ablation

The inside lining of the uterus is the endometrium. The endometrium proliferates (thickens) by building up and continuing to thicken until menstruation begins. During menstruation, the endometrial lining is shed.

Endometrial ablation is a surgical procedure that burns the endometrium. The goal of ablation is to permanently scar the endometrium to prevent it from proliferating. The scarring prevents it from building up so there is nothing to shed during menstruation.

Although the endometrium is permanently scarred, the uterus still tries to function normally. The natural engorgement of blood continues to occur in preparation for menstruation. But there is no lining to build up because the endometrium has been burned and scarred, so the uterus remains engorged with blood and there is nowhere for the blood to go, a condition called hematometra.

Continuous engorgement may initially cause a feeling of fullness or heaviness in the uterus and pelvis, but after a few months of this abnormally induced amenorrhea (suppression of menstruation), many women experience constant, debilitating pain.

Because the normal menstrual flow is blocked, the blood may also be forced into the fallopian tubes, causing additional pain.

In addition to the common occurrence of severe, ongoing pain, the risks of ablation include: possible perforation of the uterus, bowel, or bladder, infection, hemorrhage, endometriosis, worsening endometrial hyperplasia (excessive thickening of the endometrium), thermal injuries to the uterus, bladder, and bowel, fluid overload, and death.

For ablations that use heat to burn the endometrium, a doctor begins by administering a significant amount of fluid intravenously. The amount of fluid must be closely monitored, and every woman is unique in terms of how much her body will tolerate. The surgeon then applies heat to the endometrium. In the process, an indeterminate amount of the fluid evaporates. Some of the fluid is absorbed into the woman's body. The exact amount of evaporation and absorption cannot be measured precisely, and women have died from fluid overload of the heart and lungs.

The first method of ablation doctors used to burn and scar the inside of the uterus was electrocautery. Later, rollerball ablation was developed, which involves heating a metal ball and applying it to the endometrium. Rollerball was followed by cryo-ablation, which involves burning by freezing, which was developed to eliminate some of the damage caused by electrocautery and rollerball ablation. And when the damaging effects of cryo-ablation were recognized, thermal balloon ablation was developed, which involves filling a balloon with a heated substance and inserting it into the uterus. The idea is that a heated balloon will burn the endometrial tissue more slowly, and thus be safer. The most recent experiment with burning and scarring the inside of the uterus is microwave ablation.

Regardless of the method used to burn and scar the inside of the uterus, all forms of endometrial ablation damage the uterus. Whether it is done slowly or quickly, by heating or freezing, it is still damaging.

You cannot unscar the uterus. There is no remedy for the problems caused by ablation. The symptoms often worsen with each menstrual cycle because of the unreleased engorgement of menstrual blood in the uterus. By the end of the first or second year following ablation, when women seek treatment for the unrelenting problems caused by the procedure, they are usually told that hysterectomy is the only way to get relief from their pain.

The Food and Drug Administration (FDA) has an online Manufacturer And User Facility Device Experience Database (MAUDE) where a small percentage of the actual adverse events are reported for endometrial ablation. Multiple medical journal articles also report significant adverse events, which often lead to hysterectomy. As many as 34% of women undergo a hysterectomy within 5 years of ablation to relieve the symptoms caused by the procedure.

Some women continue to experience bleeding after ablation because areas of the endometrium are burned unevenly, allowing some of the endometrial tissue to grow. But because of the scarring, there is no way of knowing if the bleeding is caused by the ablation or by endometrial hyperplasia, particularly if hyperplasia was diagnosed prior to the ablation. At that point women are likely to be told that the only remedy is a hysterectomy.

Because ablation is often recommended for "abnormal" bleeding, it is helpful to first determine what is normal for you.

Menstruation usually lasts from two to ten days. The first day most women experience light spotting or light flow. The second and third days are usually heavier, and then the flow generally tapers off until it stops entirely.

The amount of bleeding, the length of flow, and the number of days in the menstrual cycle can vary considerably. A normal amount of blood flow and a normal length of menstrual cycle is whatever is normal for you.

Variations in menstruation are often familial, what is common among the women in your family. Some variables in the length of the menstrual cycle and the amount of bleeding may be influenced by diet, exercise, stress, travel, environmental factors, weight loss/gain, or illness.

If a panty liner is usually all that is needed during menstruation and then uncharacteristically the amount of blood flow increases and you need to use two super pads and a super tampon, that is a significant departure from the amount of bleeding that is normal for you. If bleeding becomes so heavy that it is unmanageable, or if you are unable to work or leave home during menstruation because of the heavy flow, you may want to ask a family doctor or gynecologist for a written order to get a pelvic and transvaginal ultrasound to evaluate the pelvis. An ultrasound may reveal the cause of heavy bleeding.

The medical term for cyclical heavy or excessive bleeding is menorrhagia (men-or-raja). Menorrhagia occurs when the time between menstrual periods remains fairly consistent, but bleeding is heavier than usual.

Menometarorrhagia (men-o-met-ah-raja) is the medical term for irregular, unpredictable excessive bleeding, or continuous bleeding. Menometarorrhagia can be caused by stress, illness, travel, or climate change, but it is most commonly caused by endometrial hyperplasia, polyps, thyroid imbalance, Von Willebrand's Disease, or adenomyosis.

For more information about hyperplasia, polyps, or adenomyosis, click on the corresponding links on the HERS Foundation's website Home page.

Many women are led to believe that they will be improved by endometrial ablation because it is an alternative to hysterectomy and the doctor will be using the newest, latest ablation technique with state-of-the-art technology. No matter how talented the surgeon may be, and regardless what techniques or devices are used, the result is the same-ablation permanently scars the uterus, preventing it from functioning normally.

When excessive bleeding is caused by a fibroid, some doctors recommend a procedure call ExAblate. ExAblate burns the fibroid itself, not the entire endometrium. But it has been shown to burn other tissue as well, causing pain and injury that can radiate throughout the pelvis, buttocks, and lower extremities. An endometrial ablation adverse event report on FDA's MAUDE makes the point very clearly: "Treatment was stopped when the pt [patient] complained of pain radiating to the left leg and catheter tip. In recovery the lady complained of a sensation of numbness in the left buttock. On closer exam she was found to have decreased sensation throughout the peri-anal and perineal region as well as the posterior left thigh. She had leaked some faecal matter..."

It is common for the bleeding to return after the procedure is performed. Also, ExAblate creates adhesions that are thicker and larger than the kind of scar made by cutting, so burning the fibroid may make it more difficult, if not impossible, to perform a myomectomy. For more information about adhesions and myomectomy (surgical removal of fibroids, leaving the uterus intact), click on the Adhesions and Fibroids links on the HERS Foundation's website Home page.

The uterus and ovaries have many important lifelong functions. The most consistent problems women report after hysterectomy (surgical removal of the uterus), whether the ovaries are retained or not, include a 25–pound average weight gain in the first year following the surgery, a loss of sexual feeling, a loss of vitality, joint pain, back pain, profound fatigue, and personality change. For more information, visit http://hersfoundation.com/anatomy/ to watch the short video “Female Anatomy: the Functions of the Female Organs.”

Questions? Fill out the HERS contact form.

HERS Foundation
www.hersfoundation.org
www.uterinearteryembolization.org
610.667.7757
HERS@hersfoundation.org