Endometrial Ablation

The aim of the leaflet is to provide information so that an informed decision can be made about whether you would like to have an endometrial ablation procedure, and provides information about the endometrial ablation procedure, including how it works, the potential benefits and risks of the procedure, pain management options and after care advice.

What is Endometrial ablation?

Endometrial ablation is a procedure which can help to reduce heavy or long periods.

How does endometrial ablation work?

Endometrial ablation uses heat to remove, or thin down, the lining of the womb (the ‘endometrium’). When the womb lining heals, it forms scar tissue, which then usually reduces or stops bleeding, however, endometrial ablation is not guaranteed to stop menstrual bleeding completely.

Endometrial ablation is performed as a day-case procedure under general anaesthesia or as an out-patient procedure with local anaesthesia and /or inhalation pain relief. Day case means that there is no overnight stay in hospital. You can discuss which option you prefer with your healthcare professional.

How do I preparation for the endometrial ablation procedure?

You will be given instructions before the procedure, which include taking pain relief, or fasting for a period of time before coming for the procedure, depending on whether you are having a general or a local anaesthetic.

Hysteroscopy and endometrial biopsy

You will usually have had a hysteroscopy examination, with endometrial biopsy a few weeks before your endometrial ablation procedure, to check that your womb lining tissue, as well as the shape and size of your womb are suitable for the ablation procedure.

During the endometrial ablation procedure

If you are having the procedure in the out-patient setting, local anaesthetic is injected into your cervix (neck of the womb) to numb it to allow dilatation (stretching) of the cervix. This is done by passing a speculum into the vagina to see your cervix. Local anaesthetic injection is not needed if the procedure is being done under a general anaesthetic, but your cervix still needs to be stretched. Measurements of the length of your womb cavity and cervical canal are also taken during this time.

Once your cervix has been stretched, a check hysteroscopy examination is done before the ablation device is placed into your womb, ready for the ablation procedure.

Once the device is correctly in place, measurements are taken of the size of your womb cavity. The measurements are needed to calculate the correct power to be used for the ablation procedure. A check is then done to make sure there is no leakage from your cervix before heating of your womb lining takes place. It can take 5 – 10 minutes to get the device ready but the actual ablation procedure takes no more than 2 minutes. When the ablation device is placed inside your womb, you may feel period-like cramps.

During the actual ‘burning’ of the womb lining, it is likely that cramping will be more severe, but the procedure is quickly completed. You may also use the gas inhalation at any time during the procedure as it will be available to you from the start of the procedure.

What are my pain management options?

Awake with pain relief

You will be advised to take simple pain relief medicines at home about an hour before your procedure. You can take tablets such as paracetamol, ibuprofen or codeine depending on whether you have an allergy to any of these medicines.

You can take more than 1 type of pain medicines, but be careful if you are driving as codeine can make you drowsy. Simple pain medicines taken by mouth can help reduce pain during and after the procedure.

Breathing in gas

You can choose to breathe in Entonox (also known as ‘gas and air’), which helps reduce pain and anxiety. This gas is commonly used in labour.

Penthrox is also available in our clinic. This may not be suitable if you have certain medical conditions so the team treating you on the day will assess the situation and discuss it with you.

Local anaesthesia

If your cervix needs to be stretched to allow the ablation device to pass through, local anaesthesia may be used. Local anaesthesia is usually injected into the cervix using a small needle, similar to that used at the dentist.

Local anaesthesia numbs the cervix to allow painless dilation, but it cannot numb the inside of the womb and cannot numb the womb during the ‘burning’ stage of the endometrial ablation.

General anaesthesia

You can choose to be asleep during the procedure and so experience no pain. However, you will still feel period-type cramps after the procedure, but you can have pain medication to ease the pain.

The anaesthetist on the day of the procedure will discuss the options and the risks with you.

Choosing and changing pain management

Before the procedure

You can discuss your pain management options with your doctor and decide what works best for you. Options may depend on how you have tolerated the first hysteroscopy with biopsy procedure.

During the procedure

If you feel that you need a different type of pain management you can change your mind and tell the team looking after you.

If you choose not to continue with the out-patient procedure, then arrangements will be made for your admission at a different time for the procedure to be done as a day-case.

Expected pain (outpatient procedure only)

If the Endometrial ablation procedure is done when you are awake, you will feel some abdominal pain/cramps during and immediately after the procedure. It is recommended to take pain relief 30 to 60 minutes before your appointment.

If the pain is too much or you find the procedure distressing, let a member of team know, and they will stop the procedure immediately. There will always be two nurses present with you during the ablation procedure.

If you have severe pain after the procedure, you may be kept in the hospital for stronger pain medicines and observation.

Common side effects and risks

Feeling faint (outpatient procedure only)

This can happen during or immediately after the procedure. You may feel cold, clammy, and possibly sick. This is often due to a drop in your blood pressure.

These feelings usually settle after resting, lying down and drinking water. Anti-sickness tablets or injections are available and there is also a rest area in the clinic.

Unable to complete the procedure

Sometimes the procedure cannot be completed due to the unexpected shape and size of the womb, or pain. Rarely, equipment problems can also stop completion of the procedure. If this happens, a repeat procedure or a different management plan will be discussed with you.

However, it may mean that you need to return on another day for further treatment.

Vaginal bleeding

You will experience some bleeding immediately after the procedure. This will get lighter after 1 or 2 days. However, there may be a blood-stained vaginal discharge for up to 2 weeks. You may also get a light ‘period’ bleed if your next period is due quite soon after the ablation procedure. This is normal and does not mean that the ablation procedure has not worked.

Abdominal cramps

You should expect period-like cramps for the first 1-2 days after the treatment. A hot water bottle together with simple pain medicines can help to ease the cramping.

Pain

You should continue to use simple pain medication after the procedure, especially for the first 24 hours. One in five people report some continuing pain for about two weeks after the procedure.

Infection of the womb and bladder

Infections of the burnt lining of the womb can cause a smelly vaginal discharge, abdominal pain and fever. Urinary tract (bladder) infections can cause a burning feeling when passing urine and the need to pass urine more often. In these cases, a few days of treatment with antibiotics is required.

Adhesion formation

Scar tissue (adhesions) forms after the womb lining is treated. If you have abnormal bleeding in the future, it can be harder to diagnose problems inside the womb as hysteroscopy examination can be more difficult due to the scarring.

Continuing or new menstrual symptoms

Up to one in five people may continue to have bleeding symptoms or get new abnormal bleeding symptoms and/or period pain.

Up to one in six people who have had an endometrial ablation procedure will have a hysterectomy within two years after the procedure due to menstrual symptoms.

Uncommon risks

Uterine perforation

A hole can be made through the wall of the womb while placing the ablation device. The procedure must be stopped if this happens. The hole usually heals by itself, but a laparoscopy (keyhole) procedure may need to be done to check on the perforation. In this case you will be admitted to the gynaecology ward for observation and then a decision regarding a laparoscopy.

Antibiotics are also given to prevent infection of the womb and pelvis. Once the perforation has healed, it may be possible to plan another ablation procedure some weeks later.

Blood infections and pelvic abscess

Bacteria from the vagina or from an infection of the womb lining can enter the blood circulation and cause fever, chills, nausea and other symptoms. Hospital admission for treatment with intravenous fluids (through a drip in the arm) and antibiotics is needed.

Further tests such as ultrasound scan may be needed to check for a pelvic abscess (pus in the pelvis) or damage to internal organs.

Recovery and further advice

Your recovery will depend on several factors, including:

• Your overall health and fitness before the operation.
• The reason for your endometrial ablation.
• The specific type of endometrial ablation you undergo.
• Whether there were any complications during the ablation procedure.

Factors that can delay your recovery

Recovery from an endometrial ablation may take longer if:

• There were health issues present before your operation; for instance, diabetes mellitus may slow the healing and increase the chances of an infection.
• You smoke – smoking increases the risk of chest infections during recovery and can delay the healing process.
• You are overweight at the time of your operation – being overweight may delay recovery from anaesthesia increase the chances of complications such as a chest infection and venous thrombosis (blood clots in your legs or lungs).

When to seek medical advice after endometrial ablation

If you experience any of the following, it is important to seek medical advice from your GP, the hospital where you had the procedure or NHS services:

• Pain or discomfort when passing urine or passing urine more frequently: These symptoms could indicate a urinary tract infection, which requires antibiotics for treatment.
• Heavy or prolonged bleeding, especially if you feel unwell and have a fever: This may be due to an infection in the womb and a course of antibiotics is needed.
• Lower abdominal pain which does not ease, particularly if accompanied by fever: This could be a sign of a more serious complication and may need a hospital admission for further tests and treatment.

Returning to your routine activities

Around the house

You may feel tired in the first few days after treatment, so it may be useful to have support for jobs around the house and for childcare. Most people will feel well enough to start household activities within a few days.

Driving

Avoid driving for 24 hours following general anaesthesia, or until you no longer feel drowsy from your pain medicines.

Returning to work

It is usual to rest for a day or two before resuming vigorous activities. Typically, it takes
2-5 days before feeling ready to return to work, depending on the nature of your job.

Resuming sexual activity

It is recommended to wait until vaginal bleeding or discharge has stopped and you feel physically and emotionally comfortable and ready.

Exercise and activity

Engaging in light exercise and activities, such as gentle walks the day after your procedure is generally safe. However, it is wise to avoid heavy exercise for a couple of days to allow your body time to recover.

Important considerations

Suitability

Endometrial ablation is suitable for those who do not wish to become pregnant in the future. Removing the womb lining increases the risks of complicated pregnancy.

Risks to report

Report any significant bleeding, especially if it occurs years later after reaching age of menopause-age 51 in UK. This is considered postmenopausal bleeding and requires investigation.

Pregnancy after endometrial ablation can be risky, leading to miscarriages, pre-term birth, stillbirth and a condition called placenta accreta which is when the placenta does not separate from the uterus wall and can be life-threatening. Using effective contraception is strongly recommended.

Endometrial ablation is a safe and effective way to treat heavy periods. By understanding the procedure, pain management options, potential risks and what to expect, you can make an informed choice with your healthcare provider. Always follow your healthcare provider’s advice and ask any questions you may have to ensure you feel comfortable and informed about the procedure.

Informed consent

This leaflet is provided to supplement verbal information that will be given to you by your healthcare provider (Doctor/ Surgeon/Nurse) as part of the consent process prior to your procedure. Information sharing between you and the clinician is essential to ensure that your decision to consent is fully informed.

Please ask questions if you don’t fully understand or have any concerns about what is proposed. You have a right to be involved in these decisions and should feel supported to do so. Please take the time to consider what is important to you to ensure the information you receive is specific and individualised.

Further information

For further information, guidance, and support, you can refer to the following sources: