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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.

 

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Birth Control vs Hysterectomy in Catholic Hospitals

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I was raised Catholic but did not agree with some of Church doctrine and left the Church as a young adult. In my wildest dreams, I never imagined that I would have a hysterectomy and be castrated in a Catholic hospital (or any hospital for that matter) for a benign ovarian cyst. You can read about my Unnecessary Hysterectomy here. I suspect many other women have had healthy organs removed at this greater metropolitan Catholic hospital or some other Catholic hospital. With hysterectomy the second most common surgical procedure and the prevalence of Catholic hospitals growing, millions of women likely have had unnecessary hysterectomies at Catholic hospitals. This made me wonder, why would the Catholic Church condone (and profit from) unnecessary hysterectomies but prohibit contraception. It seems a bit hypocritical at least, unethical at worst.

A Spider Web of Contradictions in Catholic Hospitals

Catholic doctrine prohibits contraceptives. Yet, Catholic hospitals perform hysterectomies and ovary removals (castrations) for benign conditions that can typically be treated with less drastic measures such as contraceptives. Hysterectomy is permanent birth control. So is removal of ovaries. How is hysterectomy justified but not contraceptives?

In an article entitled Do Religious Restrictions Force Doctors to Commit Malpractice, the hazards of treatment at religious hospitals are discussed. In the case of a potentially fatal ectopic pregnancy, removal of the fallopian tube which negatively affects fertility complies with Catholic doctrine while an injection of methotrexate that preserves the tube and fertility does not.

According to Catholic moralists, an injection that destroys an ectopic embryo is a direct abortion, while removing the part of a woman’s reproductive system containing the embryo is not.

But the end result is the same – a pregnancy is terminated. So why not at least preserve the woman’s fertility and health-promoting hormone production by administering the drug versus removing her fallopian tube?!

Another story in the cited article involved a woman with Lupus who was pregnant with a nonviable anencephalic fetus. Although continuing the pregnancy risked the woman’s health and her very life, pregnancy termination was denied.

The above situations would be considered medical malpractice since they caused harm to the patients. And what makes even less sense is that neither of these were viable pregnancies. Catholic Church dogma caused (intentional) harm to these women.

Another treatment done in Catholic hospitals that has me scratching my head is endometrial ablation. Although it reduces fertility, pregnancy can still occur but can be dangerous to mother and unborn child. So some form of birth control is recommended after ablation if tubal ligation was not also performed. Yet according to Is the Novasure System Ethical?, Novasure ablation has been given a passing grade by the Catholic Church. With the Church’s mandate against contraceptives, I wonder how many women are prescribed contraceptives to treat their heavy bleeding BEFORE this procedure is offered. However, in defense of the article, it does state that drug therapy is typically the first-line treatment after doing a full work-up to determine the cause of the bleeding. And if that fails then D&C should be the next step which should include polyp removal if polyps are found. However, it does not mention removal of fibroids despite being a common cause of abnormal bleeding. Although the article recommends starting with conservative treatments, the high rate of unwarranted hysterectomies and ablations indicate poor compliance with these standards.

According to a study published in 2008, the long-term problems caused by ablation too often lead to hysterectomy, the rate being highest (40%) for women having the procedure before age 41. This is further discussed in Endometrial Ablation – Hysterectomy Alternative or Trap?. However, again, in defense of the above cited Novasure article, it was published in 2005, three years prior to this study on the long-term effects of ablation. And, in addition to surgical risks, the article does mention the long-term risks of accumulation of blood in the uterus and the risk of impeding diagnosis of endometrial hyperplasia or cancer. Despite this 2008 study showing the long-term harm of ablation, the use of this procedure does not appear to be declining.

According to Catholic Doors,

To obtain a hysterectomy is a mortal sin.

The ruling by the Congregation for the Doctrine of the Faith stipulates that the only time a woman is morally permitted to have a hysterectomy is when the uterus is so damaged it presents an immediate threat to her health or life. [National Catholic Reported; August 12, 1994]

In general, an hysterectomy is morally justified if the removal of the uterus is necessary for grave medical reasons. It is not justified when the purpose is direct sterilization.

Therapeutic means which induce infertility are allowed (e.g., hysterectomy), if they are not specifically intended to cause infertility (e.g., the uterus is cancerous, so the preservation of life is intended). [Humanae Vitae]

Unnecessary Hysterectomy, Ethical Principles and the Hippocratic Oath

Birth control issues aside, how do all these overused gynecological procedures comply with the three ethical principles of the Catholic Church – respect for persons, beneficence, and nonmaleficence? For that matter, how do they comply with the Hippocratic Oath to “first, do no harm?” Since they cause harm, they violate the three ethical principles of the Catholic Church as well as the Hippocratic Oath. One must question if women are getting INFORMED CONSENT in any facility, religious or secular, but that is a topic for another day.

Ascension Health defines beneficence as follows:

As a middle principle, the principle of beneficence (and nonmaleficence) is the basis for certain specific moral norms (which vary depending on how one defines “goodness”). Some of the specific norms that arise from the principle of beneficence in the Catholic tradition are: 1) never deliberately kill innocent human life (which, in the medical context, must be distinguished from foregoing disproportionate means); 2) never deliberately (directly intend) harm; 3) seek the patient’s good; 4) act out of charity and justice; 5) respect the patient’s religious beliefs and value system in accord with the principle of religious freedom; 6) always seek the higher good; that is, never neglect one good except to pursue a proportionately greater or more important good; 7) never knowingly commit or approve an objectively evil action; 8) do not treat others paternalistically but help them to pursue their goals; 9) use wisdom and prudence in all things; that is, appreciate the complexity of life and make sound judgments for the good of oneself, others, and the common good.

Why is Hysterectomy So Pervasive at Catholic Hospitals?

For Catholic hospitals with accredited Graduate Medical Education (GME) programs, resident minimum surgical requirements may very well increase the rate of unwarranted hysterectomies. But that is certainly a poor excuse for removing an organ. Even so, if they can get around the GME abortion requirements for religious reasons (Catholic hospitals will not perform abortions) they should be able to do the same for hysterectomies, 98% of which do not meet the “grave medical reasons” test.

Hysterectomies and ablations (that too often lead to hysterectomy) are big business. Hysterectomies are estimated at generating $5-16 billion annually, and so revenues may be another reason Catholic hospitals prefer gynecological procedures over medical (pharmaceutical) intervention (birth control or other). Refusing to prescribe contraceptives may increase their ablation and hysterectomy business and therefore their bottom line. So the 76% of hysterectomies that don’t meet ACOG criteria may be even higher in Catholic hospitals. And the ongoing negative health effects of these procedures further contribute to the bottom line of these “health care” conglomerates.

Could profits trump Catholic doctrine on contraceptives and Catholic ethical principles when it comes to performing destructive gynecological procedures in Catholic hospitals?   

My experience certainly proves this as all my sex organs were removed for a benign ovarian cyst, certainly not a “grave medical reason.” I can say the same for many other women with whom I’ve connected since my unwarranted hysterectomy and castration. And the overuse of ablation appears to be just as rampant. This procedure is being done on women in their 20’s and 30’s, many of whom are now considering hysterectomy or have had one to get relief from the post-ablation pelvic pain.

Just as a man’s sex organs have lifelong (non-reproductive) functions, so do a woman’s. Any procedure that disrupts their normal functioning can cause permanent adverse effects. At least medications can be stopped if the side effects outweigh the benefits.

For more information on the necessity of the uterus beyond the childbearing years, watch this video.

 

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