Endometrial ablation and endometrial resection are two types of surgical procedures that remove a woman’s endometrium (the lining of the uterus) through different techniques to prevent excessive bleeding during menstruation. In most cases, these procedures significantly reduce or stop blood flow.

Endometrial ablation is performed by a physician using one of several methods to destroy the lining of the uterus. It may be removed using one of the following elements:  

• Electricity
• Laser
• Heat
• Cold
• Microwaves
• Radiofrequency energy

Endometrial resection is similar to ablation as it also involves the removal of the endometrial lining. However, the physician removes the lining with an electrosurgical wire loop.

For most women, ablation and resection are effective treatments that may provide an alternative to a hysterectomy (surgical removal of the uterus) when the indication is due to excessive bleeding. Although the procedures do not remove the uterus, they will prevent women from having children in the future. 

Ablation and resection are not treatment options for some women, such as those who are pregnant, have endometrial cancer, have an unresolved genital or urinary tract infection or who have had a Caesarean section. In addition, they may not be used with women who have large uterine fibroids or cancer.

Endometrial ablation and endometrial resection are procedures to remove the endometrium, which is the lining of the uterus. These procedures are used to treat chronic, abnormally heavy or prolonged menstrual periods, a condition known as dysfunctional uterine bleeding (DUB). Types of DUB include menorrhagia and metrorrhagia.

DUB is generally diagnosed when abnormal bleeding interferes with everyday activities and no other physical cause for the bleeding can be identified. One in five women experience heavy bleeding during childbearing years, according to the American College of Obstetricians and Gynecologists. It most often affects women between the ages of 40 and 50 years, when hormone fluctuations occur as a woman nears menopause. The loss of too much blood can result in anemia, a condition in which the blood is deficient in red blood cells, hemoglobin or total volume. Anemia can cause jaundice (yellowing of the skin and whites of the eyes), fatigue and low energy. In severe cases of anemia, the patient may require a blood transfusion.

In many cases, hormone drugs such as birth control pills or a levonorgestrel-releasing IUD can help reduce the bleeding. If hormonal therapy fails, surgery – in the form of a hysterectomy (surgical removal of the uterus), or endometrial ablation or resection – may be necessary. Endometrial ablation and resection are used to remove or destroy the endometrium, the functional layer of the uterine wall that grows during the month and then sheds as the menstrual flow at the end of the cycle. Ablation and resection can stop or dramatically decrease the flow of blood during menstruation and may prevent a hysterectomy.

Endometrial resection is a surgical procedure that removes the endometrial lining with an electrosurgical wire loop. Resection can be used in women who have heavy bleeding but do not have any other underlying uterine problems. Resection appears to have a higher success rate in reducing bleeding in older women than younger women.

Endometrial ablation differs from resection in the manner in which the lining is removed. Several different methods may be used for endometrial ablation, including laser, electrocautery instrument and thermal balloon to remove or destroy the uterus lining. Ablation can be performed with the following elements:

• Electricity
• Laser
• Heat
• Cold
• Microwaves
• Radiofrequency energy

In each of these procedures, the uterine lining is destroyed to reduce excessive bleeding. The uterus is preserved, but a woman is generally not able to become pregnant. In addition, she is likely to experience little or no menstrual flow. In some cases, menstrual flow will resume at a later time, although typically not in the form of heavy bleeding associated with DUB.

In recent years, endometrial ablation and endometrial resection increasingly have replaced hysterectomies as the procedure of choice in treating women with DUB. Ablation and resection cost less, do not require incisions, require shorter hospital stays and have lower mortality rates than hysterectomies. However, ablation and resection are not effective for women who have underlying uterine problems such as large fibroids, polyps or endometrial cancer.

Endometrial ablation and resection should not be used on pregnant women. Other conditions that prevent the procedure include having an IUD in place, active genital or urinary tract infections or a history of classical Caesarean section, according to the Food and Drug Administration (FDA).

There may be additional restrictions depending on the type of procedure. For example, microwave ablation should be not used in a patient who has pelvic inflammatory disease, a history of dilation and curettage or a myometrium (outer uterine layer) thinner than 10 millimeters anywhere in the uterus, according to the FDA. A gynecologist can provide additional details about whether endometrial ablation and resection may be an appropriate treatment option.

Endometrial ablation and resection are both typically performed as hysteroscopic procedures. This means the physician uses an endoscopic instrument called a hysteroscope to visually examine the uterus before removing the endometrium. Ablation and resection procedures differ slightly from one another:

• Endometrial ablation (EMA). The physician uses a hysteroscope to view the uterine lining. The lining is then cauterized with either an electrosurgical tip called a “rollerball” (similar to a tool used to smooth wallpaper) or with a laser.
  
  The Food and Drug Administration (FDA) has approved several other forms of ablation therapy. They include:
  
• • Hydrothermal ablation. This method uses heat to destroy the lining of the uterus. A computer-controlled device directs a hot saline solution to target and destroy the innermost layer of the endometrium. The procedure starts with the physician inserting a hysteroscope and tubing through the vagina into the uterus. Saline (salt water) is heated to 194 degrees Fahrenheit (90 degrees Celsius), and a pump circulates the fluid through the HTA system and uterus for 10 minutes. This destroys the endometrium. Hydrothermal ablation is the therapy of choice for women who have a uterus that is abnormally shaped.
    
    
  • Cryoablation therapy. This method uses cold to destroy the uterine lining. A thin probe attached to a cooling unit freezes and destroys the uterine lining. The probe is inserted through the cervix into the uterus, and the tip of the probe is cooled to -4 degrees Fahrenheit (-20 degrees Celsius) before it is applied to the uterine lining. Cryoablation is often the primary choice of procedure for women seeking surgery that requires minimal anesthesia and no hospital time.
    
    
  • Radiofrequency ablation. Uses radiofrequency energy to destroy the lining of the uterus via a handheld catheter. The heat is delivered in about 90 seconds, significantly less time than is necessary for other endometrial ablation treatments. This technique does not require premedication, making it the procedure of choice for women who wish to avoid such medications. However, it can only be used in women who have normal uterine cavities.
    
    
  • Microwave ablation. Approved in 2003, this variation delivers microwave energy through a slender tube inserted in the uterus. The microwaves create heat that destroys the endometrium within minutes. It is the therapy of choice in women who have fibroids of less than 3 centimeters.
    
    
  Other types of ablation under development include techniques using phototherapy (light).
  
  
• Endometrial resection (EMR). The physician uses a hysteroscope to view the uterine cavity and removes the lining with an electrosurgical wire loop. In addition to removing the uterine lining, a quarter-inch of the uterus’ underlying muscle is removed.

All of these methods require significant technical expertise and should be performed only by experienced physicians.

A newer form of ablation that is considered easier to perform has recently emerged. Blind endometrial ablation – also known as uterine balloon therapy – is a procedure in which a soft, flexible balloon attached to a thin probe is inserted through the vagina and into the uterus. Sterile, hot fluid is used to expand the balloon to fit the contours of the uterus. The fluid then is heated to 189 degrees Fahrenheit (87 degrees Celsius). After about eight minutes, the heat destroys the uterine lining. The fluid is then withdrawn, causing the balloon to deflate before the device is removed.

Advantages of balloon therapy include the fact that no visualization is necessary, the instrument is smaller than instruments used in some other procedures, and less specialized skill is required. Balloon therapy can be performed on an outpatient basis, and recovery time is less than one day. However, balloon therapy also has drawbacks. It cannot be used if the uterus is abnormally shaped or has polyps or fibroids. In addition, balloon therapy is not always as effective as hysteroscopic techniques.

Patients should follow all preparatory steps recommended by their physician. This may include dietary restrictions and changes in medication regimens. Patients who are to undergo hysteroscopic endometrial ablation and endometrial resection may be required to take preoperative medications to thin the uterus for several weeks before the procedure.

Endometrial ablation and resection are performed as an outpatient procedure. Patients are placed under either general or regional anesthesia, which means they may or may not be asleep during the procedure. During the procedure, a physician inserts a lighted telescope called a hysteroscope into the uterus. The uterus is filled with a clear fluid so that its contours may be visualized on a monitor.

Depending on the procedure, the cells of the uterine lining are destroyed with a laser, electrical energy, heat or cold, or a balloon that is placed in the uterus and filled with hot water. These surgeries usually take less than an hour, sometimes only a few minutes.

Recovery typically takes a day or two. Following the procedure, the uterine wall will heal through scarring, which further reduces or prevents uterine bleeding. Many women experience symptoms such as cramping or a watery, pink discharge following the procedure. This may last for up to two weeks and pain medication may be prescribed, if necessary. Women may be advised to avoid strenuous activity for a 24-hour period. They may also be advised to refrain from sexual intercourse for one to two weeks, until the discharge has stopped.

Women who have ablation and resection still have all of their reproductive organs. As a result, they will need to continue to have regular Pap smears and pelvic examinations. Although ablation and resection destroy the uterine lining, there remains a very small chance that pregnancy could occur. Such pregnancies can be dangerous for the mother and the fetus. As a result, women who have these procedures must continue to use contraception.

Women who undergo endometrial ablation and resection should take progesterone to reduce the risk of developing uterine cancer. Because ablation has been performed for only about two decades, the long-term effects of the procedure are largely unknown.

In rare cases, ablation will not be wholly successful, and women will need to undergo a hysterectomy to stop abnormal bleeding.

Complications associated with endometrial ablation and resection are rare, but they do occur. The most common risks include:

• Perforation of the uterus.
  
  
• Fluid overload. This is a result of the fluid that is pumped into the uterus to keep it open. Because this fluid is kept under pressure during the procedure, it may escape into the blood vessels of the uterus on rare occasions. This can alter the balance of electrolytes in the bloodstream, a potentially life-threatening condition.
  
  
• Blood loss.
  
  
• Burning of internal structures.

In rare cases, patients who have endometrial ablation may develop endometrial carcinoma in functional endometrial tissue that was missed or buried during the procedure. The risk is small in women who have not had a history of endometrial hyperplasia or carcinoma.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions about endometrial ablation or resection:

1. What is the difference between endometrial ablation and resection?
   
   
2. Which procedure is best for me?
   
   
3. Are there other less invasive treatment options to stop my heavy bleeding?
   
   
4. If I want to have a baby, is there time to do so safely before having this procedure?
   
   
5. Is it possible to have a safe pregnancy after ablation or resection?
   
   
6. What are the risks of the different procedures? Is there much pain?
   
   
7. Will I no longer have my period? Does it cause early menopause?
   
   
8. What conditions rule out ablation and resection?
   
   
9. What is the recovery time? Will I have any restrictions?
   
   
10. Will this procedure prevent a hysterectomy in the future?