Endometrial Ablation - The Second Generation

By Hope Waltman

Excessive menstrual bleeding (menorrhagia) is a medical condition that causes women to be prisoners in their homes for several days a month and it can even cause women to have to go to the hospital for emergency treatment. 

Paul Indman, M.D., is recognized worldwide for his expertise in the treatment of excessive menstrual bleeding and the training of physicians on this medical condition.  He has a private medical practice in San Jose, California.  I interviewed Dr. Indman and asked him several questions about excessive menstrual bleeding and the Endometrial Ablation procedure.

What questions and examinations should be performed to evaluate abnormal uterine bleeding?

At the initial office consultation I ask my patient about the amount and regularity of bleeding and how it impacts her life.    I try to determine if she is ovulating, or using medication that may increase her bleeding.  It is important to evaluate her uterus.  Since many problems, such as polyps or fibroids inside of the uterus may not be detected by pelvic exam, I always do an ultrasound at the first visit.  This only takes a few minutes, and frequently finds the cause of the bleeding.  Many times I will confirm the diagnosis at another visit by looking inside the uterus with a slender telescope called a hysteroscope.  This can easily be done in the office setting.

What is Endometrial Ablation?

Endometrial Ablation is a treatment for heavy bleeding that removes or destroys the endometrium (lining of the uterus).   It is an outpatient procedure, and most women can return to normal activities within a day or two.  There are a number of methods by which this can be done.  For years I have used a slender telescope called a resectoscope.  This allows me to see inside the uterus and treat the lining so it will no longer bleed.  In addition, I can use the same instrument to remove polyps and fibroids that are inside the cavity of the uterus.  There are also a number of new devices, such as the Novasure, that allow me to quickly treat the entire lining at once.    Many women who otherwise would have had a hysterectomy or who live with heavy bleeding will be able to avoid major surgery by having an endometrial ablation. 

Is there a medical standard of training required for all physicians who perform Endometrial Ablation?

Unfortunately there is no standard physician training requirement for the Endometrial Ablation procedure.  Expertise in doing the procedure varies widely from physician to physician.

What makes Endometrial Ablation better than a D&C?

A D&C (dilation and curettage) is a blind procedure that scrapes some the surface of the lining of the endometrium.  While it can be effective in stopping acute bleeding, it rarely has any lasting effect.  In fact, there is not a single study published in the medical literature showing any long-term benefits.  You can think of a D&C as similar to mowing a lawn — it will grow back as long as you leave the roots.  Endometrial ablation treats deeper to prevent regrowth of the lining.

What is the latest generation of Endometrial Ablation technique and how does it vary with the first generation ablation?

The first successful endometrial ablation used a Nd:YAG laser.  Most of us switched to using a resectoscope, as it is faster and safer.  Both of these methods require extensive training and skill to perform safely and effectively.  Because of this, we worked on developing simpler methods that treat the entire uterine lining at one time.

The first of these methods, the Thermachoice, used a balloon placed inside the uterus and circulated hot water in the balloon.  Although most women had a decrease in bleeding, only 13% of women stopped bleeding entirely.  The HTA Hydrothermablator circulates hot water under direct vision through a hysteroscope.  Fewer women continue to bleed after this method. 

The Novasure procedure is another new endometrial ablation technique.  It is done in an outpatient setting under local anesthesia with sedation, or general anesthesia.  A sheath containing an electrode,  is inserted through the cervix.  The sheath is pulled back to expose an electrode, which expands to conform to the uterine cavity.  The electrode is activated and will automatically turn off when the treatment is complete.  The uterus is treated for approximately 90 seconds.   Most women can go home within an hour after the Novasure procedure.

What are the advantages of Endometrial Ablation?

The Novasure system is the most rapid of all the endometrial ablation techniques.  The success rate is high and it has a low complication rate.  No hormonal pretreatment is required and the procedure can be done at any time of the menstrual cycle.

What are the disadvantages of Endometrial Ablation?

Since endometrial ablation destroys the lining of the uterus, only women who have completed childbearing should consider the procedure.   For most women the effects are permanent, but some women may have recurrence of heavy bleeding or cramping.  Fortunately, it is usually possible to determine if a woman is at high risk for failure of the procedure, so she can be counseled appropriately.  Like any surgical procedure, there can be complications, but the risks are low when it is performed by an experienced gynecologist. 

Some questions that you may want to ask the doctor are:  What training has he or she had in Endometrial Ablation techniques?  What is his or her success rates with ablation?  Does he or she just do one method or is he or she familiar with a number of methods?

The Novasure Endometrial Ablation procedure is definitely worth researching before making a decision about treating excessive menstrual bleeding.