dysfunctional menstrual bleeding

Endometrial Ablation – Hysterectomy Alternative or Trap?

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Endometrial ablation seems to be the latest “bag of tricks” in the treatment of women’s gynecological problems. It is an increasingly common procedure used to treat heavy menstrual bleeding. The procedure is premised on the notion that if the endometrial lining is destroyed – ablated – bleeding can no longer occur. Problem solved. But is it? Does endometrial ablation work? Does it resolve the heavy menstrual bleeding and prevent the “need” for a hysterectomy as it is marketed, or does endometrial ablation cause more problems than it solves? The research is sketchy, but here is what I found.

Short-term Complications Associated with Endometrial Ablation

For any surgical procedure there are risks associated with the procedure itself. Here are the short-term complications for endometrial ablation reported in PubMed: pelvic inflammatory disease, endometritis, first-degree skin burns, hematometra, vaginitis and/or cystitis. A search of the FDA MAUDE database included complications of thermal bowel injury (one resulting in death), uterine perforation, emergent laparotomy, intensive care unit admissions, necrotizing fasciitis that resulted in vulvectomy, ureterocutaneous ostomy, and bilateral below-the-knee amputations. Additional postoperative complications include:

  1. Pregnancy after endometrial ablation
  2. Pain-related obstructed menses (hematometra, postablation tubal sterilization syndrome)
  3. Failure to control menses (repeat ablation, hysterectomy)
  4. Risk from preexisting conditions (endometrial neoplasia, cesarean section)
  5. Infection

Long Term Complications of Endometrial Ablation

Endometrial ablation to block menstruation. In order to understand the long-term risks of endometrial ablation, one must understand the hormonal interaction between the uterus and ovaries. The endometrial (uterine) lining builds and sheds in response to the hormonal actions of the ovaries. Ablation scars the lining impeding its ability to shed. But ovaries continue to send the hormonal signals necessary for menstruation and the uterus attempts to function normally by becoming engorged with blood. The problem is, the blood has nowhere to go. It is trapped behind the scar tissue caused by the ablation. This causes all sorts of problems.

Retention of blood in the uterine cavity is called hematometra. If the blood backs up into the fallopian tubes it’s called hematosalpinx.  Hematometra and hematosalpinx can cause acute and chronic pelvic pain. Some data suggest that about 10% of the women who have had endometrial ablation suffer from hematometra. The pelvic pain in women who’ve undergone both tubal sterilization and ablation has been coined postablation-tubal sterilization syndrome.

“Any bleeding from persistent or regenerating endometrium behind the scar may be obstructed and cause problems such as central hematometra, cornual hematometra, postablation tubal sterilization syndrome, retrograde menstruation, and potential delay in the diagnosis of endometrial cancer. The incidence of these complications is probably understated because most radiologists and pathologists have not been educated about the findings to make the appropriate diagnosis of cornual hematometra and postablation tubal sterilization syndrome.”  Long term complications of endometrial ablation

So although ablation can have the desired effect of reduced or even absent bleeding, it can be a double-edged sword. This relief from heavy bleeding may, in the long-term, be overshadowed by chronic, debilitating pain caused by the ongoing, monthly attempts by the uterus to build and shed the lining.

Ablation leads to hysterectomy in younger women. The younger a woman is at the time of ablation, the greater the risk of long-term problems that can then lead to hysterectomy. A 2008 study in Obstetrics & Gynecology found that 40% of women who underwent endometrial ablation before the age of 40 years, required a hysterectomy within 8 years. Similarly, 31% of ablations resulted in hysterectomy for 40-44.9 year old women, ~20% for 45-49.9 year old women and 12% of women over the age of 50 years required a hysterectomy after the endometrial ablation procedure.

Another study, reported a similar link between endometrial ablation and hystectomy. “On the basis of our findings one third of women undergoing rollerball endometrial ablation for menorrhagia (heavy menstrual bleeding) can expect to have a hysterectomy within 5 years. If the linear relationship noted during the first 5 years is extrapolated, theoretically, all women may need hysterectomy by 13 years.”

Post ablation tubal sterilization syndrome. A 1996 study of 300 women who underwent ablation found an array of pathological changes in the uterus including: hematosalpinx, endometriosis, chronic inflammation of the fallopian tubes, and acute and chronic myometritis. Eight percent of the women developed intense cyclic pain that necessitated a hysterectomy within 5-40 months post endometrial ablation.

Informed Consent That Isn’t

Recently, Hormones Matter has begun to explore the legalities of the medical informed consent, here and here. With all the adverse effects associated with endometrial ablation, especially the need for hysterectomy later, one must question whether women are informed about those risks. As I have found when investigating this topic, there are few long term studies on endometrial ablation. Many of the articles cited for this post come from paywalled journals that are not readily available to either the patients or the physicians – the costs are prohibitive for both. So it is not clear whether the physicians performing these procedures are aware of the long-term risks associated with ablation. And as one physician suggests, neither the pathologists nor radiologists responsible for diagnosing post ablation pathology are trained to recognize these complications. Without data or access to data and without training, one wonders whether it is even possible to have informed consent for a procedure like ablation.

You know the sayings “never mess with mother nature” and “you never know what you’ve got ’til it’s gone?” We need to heed those words at least when it comes to treatments that can’t be reversed or stopped! At the very least, we have to become thoroughly educated about the risks and benefits of any given medical procedure.

This post was published originally on Hormones Matter in May 2013.

 

In the ER … Again! Heavy Menstrual Bleeding

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“You really shouldn’t be doing this,” the ER doctor informs me. As if I have any control over my body and its screwed up menstrual cycles. As if I choose this hormonal fate. I want to punch him, but I can barely keep my eyes open to look at him while he talks. “You really need to figure out why you are bleeding so heavy, this isn’t normal.”

If I had enough energy to lift my limp head up off the hospital bed, I would point out the fallacy in his logic – this is not my responsibility. I have been in and out of ER’s and doctors’ offices since I was 18 years old from menstrual bleeding so heavy that I pass out or nearly pass out. It always seems to be more of an inconvenience than a concern for doctors. Oh they are concerned at first. But as soon as I explain my history of this problem, his concern, like all doctors, turns into annoyance. As soon as I tell them I don’t want to take oral contraceptives or any other type of artificial hormone, the concern quickly evaporates like the sweat dripping down my forehead in spite of my shivering body being wrapped up in blankets. Even after I explain my experiences on oral contraceptives (OC) and how the four times I have tried to take it to regulate my periods, I bleed like this every single month, not just occasionally, and that’s on top of the other side effects: extreme depression, weight gain, and epic mood swings that cause my boyfriend to nearly dump me (and who would blame him – I’d dump me if I had to deal with the monster I become on OC).

“Ok” is all I have the energy to muster as I close my eyes to prepare myself for the next cramp I can feel billowing in my lower abdomen. I let the pain wash over me as he continues oblivious to the pain I’m in.

“You need to follow up with your primary or gynecologist,” he tells me. “I’m going to give you progesterone to stop the bleeding…” he goes on to explain the difference between progesterone and estrogen. I don’t stop him to tell him I write for a women’s health ezine or that I’ve done enough research that I likely know more about women’s health and hormones than most general doctors.

A few minutes later my nurse, I’m tempted to start a new religion just so I can appoint her as a saint, walks in with my discharge papers. “Ok honey, I hope you feel better. I’m so happy it’s not an ectopic pregnancy or anything serious.” Throughout the day she has brought in warm blankets and shown more compassion than any doctor I have ever met. I am a problem they can’t fix. They aren’t Dr. House so they’d rather just pass me off to another doctor and move on to a more exotic problem. I’m just a noncompliant patient with hormone problems. God forbid I ask them to think outside the box and figure out what is causing this excessive bleeding. My nurse takes out the IV as careful as you can take out an IV and in a motherly tone says, “I’m glad everything came back normal, but sometimes not knowing is even worse. You go home and take it easy.” I fight back tears. Exhausted and hormonal, I want to hug this woman for her simple acts of kindness and compassion.

“This isn’t really anything new.” I tell her, even though she already knows my medical history. “It sucks, but I’m used to it now.”

“But it shouldn’t be like that,” she says. Like I said, this woman should be appointed as the saint of Emergency Departments.

On my way out of the ER, I stop by the hospital pharmacy and pick up the prescription for hormones that I won’t take. I head back to my office to explain to my male boss that everything was fine and try to make it sound serious enough not to sound like a hypochondriac. He smiles and Okays me to work from home the next day.

I go home to my very concerned boyfriend. I throw the bag with the “magic” pills on the counter and exasperated say, “they gave me IV fluid and hormones, but I’m not taking them.” Naturally, this causes a fight that I don’t have the energy to deal with…again.

Boyfriend: You need to take the medication they give you.

Me: It won’t help and it just messes my system up even more.

Boyfriend: [throws arms in the air … like he’s more exhausted than me at this point?!] You’re not a doctor.

Me: I’m going to bed.

Like every time before, the bleeding slowly lets up in the following days. I’m not a prophet, but I can tell you how this story will end: For the next few weeks, I will walk around like the living dead. I will force myself to eat in spite of having absolutely no appetite. The doctor will call to follow up. “Do you want to take birth control now?” she will ask and when I tell her no, “there’s really nothing more I can do for you at this point…” I know this is how everything will play out because history is simply repeating itself. Sadly I have learned to accept it. In another month, or six, or maybe even a year, I’ll be back in the ER and the cycle will repeat itself again. As I write this I’m so faint that I’m debating going back to the ER to test my blood levels again, but resignation is the only emotion I can muster. Not concern for my own health, but resignation that this is as good as it gets so why fight the system?

So, why do hormones matter? Why don’t hormones matter is a better question. Why is this story an acceptable fate for me and so many other women?

This article was first published on Hormones Matter in July 2013.