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 (TCRE, endometrial resection) or with newer second-generation techniques such as Novasure or Microwave ablation (MEA). This procedure is an alternative for women who previously would have been offered a hysterectomy (a major operation removing the womb) and is not suitable for women still planning a family. 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 can be performed under a local or general anaesthetic, usually as a day case or outpatient 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, not settling with usual medications or with irregular 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 identifying 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 really 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.

How long will I stay in hospital?

You will usually be discharged home in a few hours after your operation or the following morning, dependent on how you feel.

Do I need to fast before the operation?

Yes, if you are having a General anaesthetic, no food, even chewing gum for at least 6 hours before your procedure.

• Morning Operation: No food or chewing gum after midnight before your procedure. You can drink water up to 6 am of the morning of your procedure. Please take your essential medications as normal with a sip of water, unless advised by nurse or doctor.
• Evening Operation: No food or chewing gum after 10 am in the morning. You can drink water up to midday.

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. Do remember to bring a list of all your medications to show the nurse at your pre-assessment (if you are having one) and also 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, usually after 10 am).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, you will need to liaise with your surgeon and cardiologist. If in any doubt, consult your surgeon or anaesthetist and certainly inform them when you see them, as it may influence your management.

What can I expect after a Hysteroscopy?

• Vaginal bleeding: Some amount of vaginal bleeding and discharge is to be expected, usually for 6-8 weeks. As long as this is not heavy, or has an offensive smell or causes you concern, this is normal.
• Avoid tampons, usually for 2 weeks after the procedure, to reduce risk of infection.
• Pain: Some women may experience slight lower abdominal discomfort. You can take your usual painkillers (such as Paracetamol or Ibuprofen) if you think it necessary.
• Nausea You may feel slightly nauseous 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.
• Returning to work: You will be able to go to work the next day or as soon as you feel able. Other issues You will be able to resume sexual intercourse when you feel comfortable. You may wish to wait for a week or so once the bleeding has eased.
• Other physical activities: You will be able to resume other activities such as sport and swimming as soon as you feel able.

Are there any risks with the procedure?

Endometrial ablation is a 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 these risks are uncommon and usually occur in less than one in a hundred cases.

When will I know the results of the procedure?

Following your operation, the findings will be discussed with you. Any necessary appointments will usually be made before you leave the hospital. The results of the biopsy take about a week 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 can be copied into this, if you so wish.

Nitu Bajekal (Consultant Gynaecologist, Feb 2009)