Treatment options for heavy menstrual bleeding are most effective if the root cause of the bleeding is addressed by that treatment. Often women do not fully understand their treatment options, how the treatment works, the potential side effects, or if the treatment will even be effective.
Sometimes, women with fibroids are offered a procedure called endometrial ablation to address their heavy bleeding, but while the bleeding may improve for some, this is very inconsistent, and it does not address the underlying cause of the bleeding.
We are going to look at this procedure in some detail so you can get a better understanding of how it is done, what conditions it can address, and the long-term endometrial ablation side effects.
Addressing Heavy Menstrual Bleeding
Many women experience abnormal bleeding (menorrhagia) during their period each month. According to the CDC, 1 in 5 women in the United States (over 10 million) report the symptom of heavy bleeding to their doctor. This number is almost assuredly a lot higher because many women do not feel comfortable talking about their menstrual cycle or may not realize that what they are experiencing every month is not normal.
For some women, this bleeding is debilitating and prevents them from carrying out their daily activities or causes anemia and a host of associated symptoms.
What Are the Signs of Heavy Bleeding?
Normal periods should last between 4 and 5 days and consist of blood loss of between 2 to 3 tablespoons. The term “heavy bleeding” may be interpreted differently for each person so to provide a baseline to use when benchmarking abnormal menstrual flow, check the list below;
- Your menstrual flow is heavy enough that it soaks through one pad or tampon (or more) every 3 hours or less;
- You need to use two pads at a time to contain your period flow;
- You have to get up in the middle of the night and change tampons or pads;
- Your period lasts for more than 7 days;
- You pass blood clots that are the size of a quarter or larger;
- You have chronic abdominal pain during your menstrual cycle;
- Your cycle is so heavy that you can not function or carry out your regular daily routine;
- You suffer from chronic fatigue, lightheadedness/dizziness, migraine-like headaches, or chew/crave ice.
Women who seek medical treatment for heavy bleeding should be divided into two distinct categories. The first is that the bleeding is due to a structural cause in the uterus (most common) and includes the most common cause of uterine fibroids. It also includes adenomyosis, endometrial polyps, and cancer. In the other group, the heavy bleeding is due to a non-structural cause (very uncommon) and includes ovulation abnormalities, bleeding disorders, and thyroid disorders to name a few.
The mnemonic PALM-COEIN is an easy way to remember these and stands for the following:
- P: Polyp
- A: Adenomyosis
- L: Leiomyoma (i.e. fibroid)
- M: Malignancy
- C: Coagulopathy
- O: Ovulatory
- E: Endometrial
- I: Iatrogenic
- N: Not yet classified
Women who have nonstructural causes for their heavy menstrual bleeding and are not interested in future fertility should be offered endometrial ablation as a treatment option. For these women, the problem is the uterine lining, and ablating (destroying it with some form of energy, usually heat) it will usually take care of the woman’s symptoms very effectively.
The problem is when endometrial ablation is used for the much more common type of heavy bleeding (i.e. structural causes like fibroids or adenomyosis) which is not a good use of this technology. The reason for this is threefold:
- The underlying problem for these patients is not the lining, but the structural issue (e.g. fibroids, adenomyosis, endometrial polyp);
- These patients, particularly women with fibroids and adenomyosis, often have other bulk-related symptoms (e.g. pelvic pain, increased urinary frequency, painful sex) which are not addressed at all by ablation;
- A significant number of these patients; particularly if they have adenomyosis are made worse by ablation (an analogous situation is peeling off a long scab on your body to expose a raw, bleeding surface underneath).
What Is an Endometrial Ablation?
Endometrial ablation is a gynecologic procedure that ablates (destroys) the endometrium (the lining of the uterus). It is done to reduce heavy menstrual bleeding, but it will stop menstruation entirely for some women.
The procedure is performed through the vagina and cervix using one of many various techniques. The surgical tools used will depend on the technique used which may include heated fluid, extreme cold, radiofrequency, microwave energy, etc.
Some ablation procedures are done in the doctor’s office and others in the operating room. The patient’s uterine health and the size of their uterus may determine which technique will be used.
Why Do Women Undergo the Endometrial Ablation Procedure?
Women see their OB/GYN about reproductive issues and OB/GYNs have a certain skill set that they use to treat their patients. They can offer hormone-based treatments such as birth control to regulate a woman’s period and temporarily help lighten up heavy bleeding.
However, if that fails, they will often offer surgery or ablation depending on the patient’s desire to have surgery. Women that choose ablation often do so because they are trying to avoid surgery which is understandable.
As stated above, if the cause of the bleeding is due to a nonstructural cause, ablation is a good choice for these patients. On the other hand, for fibroids, this is not a good choice and uterine fibroid embolization (UFE) is a much better nonsurgical option for these patients. Unfortunately, most women do not hear about the UFE option from the Gynecologist.
Endometrial Ablation Side Effects
Any surgical procedure has associated risks and side effects and some side effects of endometrial ablation include:
- Risks associated with general anesthesia;
- Perforation of the uterine wall or nearby organs such as the bowel or bladder;
- Bleeding requiring transfusion or surgery (i.e. hysterectomy);
- Infection;
- Damage of organs from heat or extreme cold generated;
- Normally causes sterilization and any pregnancy would be dangerous.
A study was conducted by the University of Utah School of Medicine using the FDA MAUDE database (Manufacturer and User Facility Device Experience). Researchers sought out information regarding adverse events related to 4 different global endometrial ablation devices approved by the FDA in the U.S. The study reported the following reported adverse effects:
- Hemorrhage;
- Pelvic Inflammatory disease;
- First-degree skin burns;
- Development of endometriosis;
- Hematometra (blood trapped in the uterus that causes chronic abdominal pain);
- Vaginitis/Cystitis;
- Thermal bowel injury;
- Uterine perforation;
- Necrotizing fasciitis that resulted in vulvectomy;
- Bilateral below-the-knee amputations.
Long-term Side Effects from Endometrial Ablation
While this procedure may seem like it resulted in curtailing monthly bleeding, it can also lead to issues that are just as bad if not worse. The elements that make up the female reproductive system work in unison together and when one element in that system is disrupted it can create issues.
A study conducted on the long-term side effects of ablation reported that blood can get trapped behind scar tissue resulting from the procedure and cause chronic pain forever. The reason this happens is that each month the lining of the uterus builds up and sheds in response to the ovaries’ hormonal signals.
After the procedure, the ovaries continue to send these signals but the endometrial ablation has removed the ability of the uterus to shed normally so this blood has nowhere to go and becomes trapped behind scar tissue. This trapped blood is called hematometra if it is contained within the uterus and hematosalpinx if it becomes backed up and trapped in the fallopian tubes. Both conditions cause chronic pelvic pain.
Another long-term side effect of endometrial ablation is the need for a hysterectomy in the future. A study published in Obstetrics & Gynecology reported that 40% of the patients that were 40 years old or younger who had an endometrial ablation required a hysterectomy within 8 years. 31% of women in the age group 40 to 44, 19% of women 45-49, and 12% of women over 50 also required a hysterectomy after undergoing the endometrial ablation procedure.
Another study reported that their findings made a case that any woman who had an endometrial ablation using the rollerball technique would require a hysterectomy within 5 years and further stated that the data supported that any woman who underwent the procedure could need a hysterectomy within 13 years.
What Is The Endometrial Ablation Failure Rate?
According to research the failure rate of endometrial ablation is between 10% and 20% and is associated with
- Women who were 35 or younger at the time of the ablation;
- Women who had a prior tubal ligation;
- The presence of uterine fibroids (myomas);
- The presence of endometriosis or adenomyosis;
- Women with preexisting dysmenorrhea;
- Obesity.
Most patients retain some endometrial glands after the ablation and this, coupled with the uterine scar tissue caused by the procedure, often leads to delayed complications. Late-Onset Endometrial Ablation Failure (LOEAF) is a term used to define complications that occur post-procedure after the first month. The two key symptoms include:
- Persistent vaginal bleeding;
- The development of pelvic pain during menstruation (CCP).
What Is The Best Treatment for Fibroids?
Uterine fibroid embolization (UFE) is a non-surgical procedure that will eliminate fibroids and their symptoms. During UFE, the blood supply to the fibroids is cut off causing the fibroids to die off. As this occurs, the fibroids soften and shrink. UFE is done as an outpatient procedure and patients can go home the same day with just a bandaid.
Recovering from uterine fibroid embolization takes less than a week for most patients and it does not compromise the uterus or prevent future fertility.
UFE is performed by expert Interventional Radiologists like Dr. John Lipman and Dr. Mitchell Ermentrout of The Atlanta Fibroid Center and is not performed by an OB/GYN. This is the reason that many women are unaware of this treatment and are only offered surgical options like myomectomy, hysterectomy, or endometrial ablation.
If you experience abnormal heavy bleeding and other symptoms associated with uterine fibroids or adenomyosis, contact The Atlanta Fibroid Center. The team of professionals is ready to answer your questions and help you learn more about UFE and how it can help you. Set up a consultation today!
