What is an endometrial ablation?
It is now possible to see inside the womb (hysteroscopy) to investigate women having heavy periods and carry out treatment at the same time (endometrial ablation). The lining of the womb is removed either under direct vision, using diathermy (endometrial resection TCRE) or with newer second-generation techniques such as Novasure Ablation.
This procedure is an alternative for women who previously would have been offered a hysterectomy (a major operation removing the womb).
Endometrial Ablation is not suitable for women still planning a family, wanting more children or wishing to use their womb for a surrogate pregnancy in the future.
Using no cuts, a small telescope is inserted into the cavity of the womb through the vaginal route. It has a small video camera attached that allows the enlarged picture from the telescope to be seen on a television screen.
The procedure which involves removing the endometrial lining of the uterus is usually performed under a general anaesthetic, usually as a day case procedure. Treatment results are excellent with women noticing a dramatic difference in their periods within a month or so after the procedure.
Why am I having a hysteroscopy and endometrial ablation?
You may be having heavy periods that has not settled with usual medications and is affecting the quality of your life or you may be having irregular heavy bleeding. This needs investigation, especially if you are above the age of 40, usually with an ultrasound scan and blood tests first, followed by a hysteroscopy.
Usually a hysteroscopy is performed first (a telescopic examination that allows the lining of the womb to be inspected) to identify anything that might be causing your problem (e.g. a polyp or fibroid). A sample or a biopsy (removing of a few cells from the lining of the womb) is usually taken to allow further analysis by a pathologist.
Treatment can then usually be carried out at the same time. Polyps (localised thickening of the lining of the womb) or small submucous fibroids (benign growths within the lining of the uterus) can be treated at the same time as having the lining removed (endometrial ablation).
You will still need to use effective contraception after the procedure. This will be discussed in detail at the consultation. Some women choose to have a Mirena coil fitted at the same time.
Can I become pregnant if I wish after the operation?
Endometrial ablative procedures are only to be done in women who have completed their family. It is a procedure performed as an alternative to a hysterectomy. For women wishing to keep their fertility for the future, usually a hysteroscopy with removal of polyps or fibroids and fitting with a Mirena IUS is enough to control heavy periods. The coil can then be removed once you wish to try for a pregnancy.
Will I need to use contraception after the operation?
It is very important to use effective contraception even after endometrial ablation. Although pregnancy is uncommon, you are still at risk of falling pregnant and such pregnancies can be dangerous for your health, as the lining of the womb is not suitable to hold a live pregnancy. Your specialist will discuss various methods of contraception, including the Mirena IUS, which can be fitted at the time of your operation. Other methods may be sterilisation, vasectomy or hormonal methods.
Do I need to use contraception?
You must not be pregnant at the time of the procedure. You must use effective contraception or abstain from sex in the menstrual cycle of the procedure. Even though you will have a urine pregnancy test before your procedure, this does not always pick up very early pregnancies and if there is any doubt, your procedure will be cancelled on the day and rescheduled.
How long will I stay in hospital?
You will usually be discharged home immediately if under local anaesthetic or in a few hours after your operation, dependent on how you feel.
Do I need to fast before the operation?
Yes, if you are having a general anaesthetic, no food, not even chewing gum should be consumed for at least 6 hours before your procedure. You can drink water up to 2 hours before your procedure. The hospital will advise you as to the timing of your procedure and guide you.
Do I need to stop my medications before my procedure?
You normally should not stop any of your essential medications. Please take your usual essential medications with a tiny sip of water at the regular time, unless advised not to by the nurse or doctor. Do remember to bring a list of all your medications to show the nurse at your pre-assessment (if you are having one) and let your admitting nurse and anaesthetist know all the medications you are on. This is because your medications may influence your anaesthetic and surgery. You should also inform the nurse and anaesthetist of any allergies that you have to foods, metals, drugs etc. Some important notes on certain conditions are listed below.
DIABETES (insulin or tablet)
In general, you should not take your insulin injection or your tablet, when you are fasting. For example, if your operation is in the morning, DO NOT TAKE your morning dose or injection as you will be fasting overnight, but do take the previous dose as normal. If your operation is in the evening, take your doses as normal in the morning, but stop injection/tablets if you are taking any at lunchtime (you will fast for 6 hours).You can resume your normal regime, once you are eating and drinking normally. If in any doubt, consult your surgeon or anaesthetist.
ASPIRIN, WARFARIN, CLOPIDOGREL, CLEXANE or any blood thinning agent
You will need to stop most blood thinning agents such as Aspirin or Clopidogrel at least 1-2 weeks before your procedure. This is to avoid excessive bleeding at your operation. If you are on Warfarin or Clexane or any of the above blood thinners, you will need to liaise with your surgeon and if needed, your cardiologist. If in any doubt, consult your surgeon or anaesthetist and certainly inform them when you see them, as it may influence your management.
Are there any risks with the procedure?
Endometrial Ablation is a very safe procedure, but like any other operation, comes with some small risks. There may be a risk of infection, heavy bleeding or perforation (damage to womb) but are uncommon and usually occur in less than one in a hundred cases. Sometimes, the procedure may have to be abandoned because of difficult access or you may have to return for a repeat procedure.
What can I expect after a Hysteroscopy?
Nausea – You may feel slightly nauseated or groggy just as you are coming out of your anaesthetic. This will pass soon and if needed, medication will be given to you to make you feel better. You will be able to resume normal activities soon.
Vaginal bleeding – Some amount of vaginal bleeding and discharge is to be expected, usually for 2-6 weeks. If this is heavy, or has an offensive smell or causes you concern, seek medical advice. You may need to wear a sanitary towel for a few weeks. Avoid tampons and sex, usually for 2 weeks after the procedure, to reduce risk of infection.
Pain – Some women may experience some lower abdominal discomfort. You can take your usual painkillers (such as Paracetamol or Ibuprofen) if you think it necessary.
Some women feel a bit feverish after an ablation, usually due to the prostaglandin chemicals released from the lining. Taking antiprostaglandins such as ibuprofen three times a day after meals, if not allergic for a couple of days usually settles it. It is usually not a sign of infection.
Other issues
Mobilise as normal, but do not do any heavy lifting until you feel fully recovered.
Work: You will be able to resume normal activities soon. You should be able to go to work the next day or as soon as you feel able.
Sex: You will be able to resume sexual intercourse when you feel comfortable. If you are bleeding, wait for this to stop. If you are not bleeding, go ahead when you feel comfortable. It is usual to take a couple of weeks.
Other physical activities: You will be able to resume other activities such as sport and swimming as soon as you feel able, usually in a week but take longer if you need to.
Driving: Avoid for 24 hours after a general anaesthetic.
When will I know the results of the Endometrial Ablation?
Following your procedure, the findings and their implications will be discussed with you. Plans will be made for any further treatment and any necessary appointments will usually be made before you leave the hospital. The results of the biopsy take about a week or two to come back. You will usually be seen in clinic for a follow up or have the results communicated to you. If you need further surgery or other treatment, this will be discussed in detail with you, usually in the clinic. Your GP will be sent a letter with the findings from your procedure, and any results. You will be copied into this.
Dr Nitu Bajekal December 2019
