Continued Bleeding After a Uterine Ablation

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I. WHAT IS A LATE-ONSET ENDOMETRIAL ABLATION FAILURE (LOEAF)?

Introduction

If you are reading this section you have either undergone an endometrial ablation procedure—or you're considering one. Endometrial ablation (EA) is a commonly performed minimally invasive technique to treat abnormal uterine bleeding. It is often done in conjunction with the removal of uterine polyps or fibroids. Although endometrial ablation has been practiced since 1894 it has enjoyed a resurgence since the 1980s and has been practiced widely in the United States and other developed countries since 1995.

As of this writing (2018) there are 4 FDA approved endometrial ablation devices in the United States–two others have been "retired". But here's a look at all 6 that have been available in the United States and abroad.

Although endometrial ablation works well on the majority of women, several studies now indicate that late-onset complications –often called Late-Onset Endometrial Ablation Failures (LOEAFs)– cause 25% of women who have undergone an EA to eventually require hysterectomy. It is unknown how many more women have troublesome symptoms—but do not undergo hysterectomy.

What is a Late-Onset Endometrial Ablation Failure (LOEAF)?

In general, all methods of endometrial ablation (EA) have the potential to leave areas of endometrium (lining tissue of the uterus) behind. In some instances the lining hasn't been destroyed —these women experience little if any relief even during the first cycle following their endometrial ablation. In other cases the procedure may have worked well for months or even years and then some lining tissue grows back . In the latter instance women develop recurrent menstrual bleeding, severe pelvic pain and cramps or a combination of these symptoms. In still other instances an endometrial ablation may have been performed despite the presence of fibroids or polyps —which should be removed before an ablation can be successfully performed.

In our center, which treats many endometrial ablation failures, the most common complaint referred to our practice is the occurrence of cyclic (meaning approximately once a month) pelvic pain (CPP) or cramps—often, but not always accompanied by bleeding. Some women have even compared this pain to "labor pains" or "pain in my ovaries." The pain often occurs because of a hematometra (a collection of blood within the uterine cavity) that is unable to pass through the cervix. As the pressure inside the hematometra builds up the uterus contracts in an attempt to pass it. The resulting pain can be just above the pubic bone or in the right and left groin areas (sometimes all are involved). When the pain of an ablation failure is to the right or left of midline (or on both sides) women frequently mistake the pain for "ovulation" pain or "pain in my ovaries."

To summarize, late-onset endometrial ablation failures present to us in 3 separate ways. Often there is a combination of 2 or more of these present at the same time.

1. Some experience no relief of their menstrual bleeding following an endometrial ablation.
2. Some women may develop cyclic pelvic pain (CPP) following an endometrial ablation—this may occurs months or years following their procedure. The cyclic pelvic pain may or may not be accompanied by menstrual bleeding.
3. Some women—often many years following an endometrial ablation—may require an endometrial biopsy to evaluate abnormal uterine bleeding and it cannot be performed because of the scar tissue that develops following an ablation procedure.

Why do Endometrial Ablations Fail?

In general, these methods all have the potential to leave areas of endometrium (lining tissue of the uterus) behind. In some instances the lining may not have been adequately destroyed at the time of their ablation, in which case women experience little if any relief even during the first cycle following their treatment. Another reason that endometrial ablations fail is that they may have been performed despite the presence of fibroids or large polyps—which should be removed before an ablation can be successfully performed.

In many cases the procedure may have worked well for months or even years and then endometrium may "regrow" in a portion of their uterine cavity. These women develop recurrent menstrual bleeding . Often the bleeding may be accompanied by severe pelvic pain. Women typically report that while their level of bleeding is manageable, their pain has become intolerable.

In our practice, which treats many endometrial ablation failures, the most common complaint referred to us is the occurrence of severe cyclic pelvic pain (CPP)—often, but not always accompanied by bleeding. Some women have even compared this pain to "labor pain". The pain often occurs because of a hematometra (a collection of blood within the uterine cavity) that is unable to pass through the cervix. The pressure inside the hematometra builds up as the uterus contracts in an attempt to pass it. In this situation women experience these contractions as "cramps" or "pain."

Why do hematometrae occur?

In general, hematometrae occur because blood is being produced somewhere in the uterine cavity—generally by endometrium (lining tissue) that has regrown or a fibroid that is within the uterine cavity. The resulting blood is unable to pass easily from the cervix because of scarring that often happens in the lower portion of the uterus. As a result the blood "backs up" within the uterus. The uterus initially swells and then responds by contracting and "trying harder" to get rid of the blood accumulating with it. In the process of "contracting" a woman may experience moderate to intense pain which is often similar to "labor pains". It doesn't take a great deal of blood (less than a teaspoon) to "back up" before it produces symptoms of pelvic pain.

How can I be tested to see if I have a hematometra?

Hematometrae are generally detected on ultrasound. Since hematometra represent menstrual blood that hasn't been able to pass through the cervix it accumulates within the uterine cavity and is seen on ultrasound as large "black spots" within the uterine cavity. This is very clear in all 3 figures shown below.

Figure 1

Figure 2

Figure 3

In Figure 3 you can see 2 hematometrae clearly shown as black circles. However, notice that these circles are surrounded by a light grey "halo." This, so-called "echogenic halo" is the actual appearance of endometrium which is still functioning and produces the blood seen as hematometrae.

How often do these type of late-onset ablation failures occur?

As of this writing (October 2017) there are over 500,000 endometrial ablations performed in the United States per year. To the best of our knowledge this problem affects more than 25% of women within the first 5 years of their endometrial ablation (EA)—that's a minimum of over 100,000 late-onset failures per year. We know that it can happen up to 15 years following EA but the vast majority of them occur within the first 3 years. So if you've managed to make it 3 years without an issue it doesn't mean you're entirely out of the woods. However, statistically-speaking, most issues happen within the first 3 years.

Why didn't my doctor tell me this could happen?

The most honest answer is that in all likelihood your physician didn't know . Most doctor don't perform hundreds of endometrial ablations per year. In fact most physicians probably don't perform this procedure a dozen times a year. The majority of endometrial ablation procedures (75%) work well and women manage to avoid hysterectomy. Most physicians have not attended postgraduate courses that discuss the issue of endometrial ablation failure. Additionally, there are not many articles in the medical literature that discuss late-onset endometrial ablation failure. And there are far fewer articles that discuss how to manage them!

What is the treatment of these hematometrae or areas of endometrial growth?

The treatment for hematometra and endometrial growth (or regrowth) is primarily surgical—milder forms can occasionally be treated with medications such as birth control pills, oral progestins or Depo Provera. The more severe forms of hematometra or endometrial regrowth that cause intense pain, bleeding or both will require surgery.

The minimally invasive treatment of hematometra involves 2 steps. First, the removal of the scar tissue found in various portions of the uterus that cause blood to be trapped. Second, the removal of the bleeding source. The source is typically lining tissue that has regrown—or was never removed. In some instances the source of bleeding may be a fibroid or a polyp that was never removed or grew. Both of these steps are important. It's not enough to remove just the fluid or blood! In order to prevent or reduce likelihood of recurrence the tissue that caused the blood to become entrapped must also be removed.

In most parts of the world and in the United States the treatment for a failed endometrial ablation that causes significant pain or bleeding is hysterectomy . The hysterectomy need not be accompanied by removal of the ovaries, however. Often women who undergo a hysterectomy for this issue can request a subtotal hysterectomy which preserves the cervix as well.

The only other surgical treatment that we advocate in ultrasound-guided reoperative hysteroscopy surgery (UGRHS) . This surgery involves a minimally invasive procedure that allows a physician to remove the scar tissue just above the cervix along with the tissue that caused the symptoms of bleeding or pain. Typically UGRHS involves the removal of endometrial tissue. In many cases, however, we have also removed endometrial polyps and fibroids as well.

During ultrasound-guided reoperative hysteroscopic surgery we locate and remove areas where lining tissue is growing and we explore other portions of the uterus where lining tissue has a potential to grow. Unless existing lining tissue or relevant fibroids are removed the problem is likely to recur.

In summary here are some "take-aways" about ultrasound-guided reoperative hysteroscopic surgery (UGRHS):

1. It is not a repeat ablation! In fact repeat ablations should not be performed since a repeat ablation is not designed to remove the scar tissue that entraps the functioning lining tissue (endometrium).
2. The initial part of UGRHS is removal of all adhesions (scar tissue) within the uterine cavity.
3. Next, we resect—which is to remove and not burn—the remaining uterine lining.
4. Finally, we explore the likely portions of the uterus that typically harbor sequestered islands of lining tissue (endometrium).
5. When UGRHS has been completed the uterus typically looks as if it had undergone an endomyometrial resection . You might wish to review some of our information on endomyometrial resection as it will also help you understand how this is different from an endometrial ablation.

Below I've placed two "before" and "after" pictures following UGRHS.

Figure 4: This shows how the uterine cavity looks "midway" through a typical procedure. While some of the scar tissue has already been removed in order to allow you to see this view there are numerous "pink" areas of lining tissue that have been uncovered. These pink areas are functioning endometrial tissue which cause the bleeding. The blue arrow is pointed a red-brown area of lining tissue. This color indicates lining tissue in combination with trapped blood—giving it that brownish appearance.

Figure 5: This is the same patient after all of the "pink" lining tissue and the "red-brown" tissue have been removed. The lining is now entirely removed and the uterus has been thoroughly explored for other signs of discoloration and trapped tissue. The "white" or pink-tan tissue you see represents uterine muscle (myometrium).

The most troubling kind of late-onset endometrial ablation failure (LOEAF)!

Of the various kinds of endometrial ablation failure listed above the most troubling is cyclic pelvic pain (CPP). With cyclic pelvic pain women often experience cyclic pain–once a month at the time of their cycle–that may last anywhere from a day or two up to 2 weeks. In advanced cases there is no "break" and women then experience continuous lower abdominal pelvic pain that radiates into the back, groin or even their thighs. If the pain is associated with menstruation both the women and physician understand the cause of the pain. However, when there is NO VAGINAL bleeding the diagnosis of a late-onset endometrial ablation failure (LOEAF) is often missed. This can lead to some unfortunate results. Here's why.

If women experience significant pain unaccompanied by vaginal bleeding it's not necessarily obvious to them or to their physician that their pain is even related to their endometrial ablation (which may have occurred 3-4 years earlier). The pain, which may be described as "labor-like," frequently leads to an emergency room (ER) visit. Often, the ER doctor is not a gynecologist and there can be a significant delay in the diagnosis. At other times, the diagnosis is missed entirely!

To summarize, the most troubling endometrial ablation failure is pelvic pain which is not accompanied by bleeding. The pain can be disabling and the diagnosis is often delayed or missed.

Why is the diagnosis delayed or missed?

Often the diagnosis is delayed or missed because the wrong tests are ordered. In other instances the correct test was ordered but was misinterpreted. For instance, in the women we've seen who present with "the most troubling kind of endometrial ablation failure," many of them have had CT Scans and pelvic ultrasounds. CT Scans–which are both expensive and time consuming—are very good in the diagnosis of bowel and kidney disease or for an acute appendicitis. However, they are far less sensitive than an ordinary transvaginal ultrasound for the diagnosis of a late-onset endometrial ablation failure! However, a common issue we encounter in managing women with LOEAFs is that a surprising number of them have undergone ultrasound examination and told that it was "normal." This is NEVER TRUE following an EA.

Let me explain. Even if you've had an endometrial ablation and it's worked perfectly, your uterine lining has been totally or partially destroyed and your ultrasound is never "normal" again! So if someone has told you that you have a normal vaginal ultrasound examination a "red flag" should go up. Often the ultrasound examination clearly displays the abnormality but the radiologist misinterprets the findings as they often don't understand what post-ablation ultrasounds typically look like.

Does this mean I should not have had an endometrial ablation (EA)? Was the EA a bad idea?

Provided you were properly counseled about endometrial ablation and someone explained both the immediate and late-onset complications of EA I want to categorically state that EA has saved many women from undergoing more invasive surgeries such as hysterectomy. Even "minimally invasive" procedures such as "robotic hysterectomy" are, at best, misnomers and cannot compare to endometrial ablation in terms of safety, risks and recovery. If only 75% of endometrial ablations "work" that's still a 75% chance of avoiding a hysterectomy utilizing a very low-risk procedure with a quick recovery.

What are the major risk factors for Late-Onset Endometrial Ablation Failure (LOEAF)?

Several important factors have been identified that increase a woman's risk for "failure" with endometrial ablation. These are as follows:

• Age < 35 years of age
• Submucous or intramural fibroids. Remember that endometrial ablation is NOT a treatment for fibroids. If you have fibroids inside your uterus (submucous) they should be removed at the time of your endometrial ablation or endomyometrial resection.

• Polyps. Polyps, like fibroids, need to be removed prior to your endometrial ablation.

• Anomalies of the uterus (a uterine septum or a bicornuate uterus). These are present a birth. Most women who have them already know about it. However, it's important to have an ultrasound and a hysteroscopy prior to an endometrial ablation just to be sure you don't have one. This can be done at the time of your EA. If you have a uterine septum or a bicornuate uterus you should consider another form of treatment such as endomyometrial resection .
• Active infection. This is self-explanatory. Elective uterine surgery should be avoided in the presence of infection.
• Uterine cancer or atypical endometrial hyperplasia. This is also self-explanatory. Since an ablation is a "burning procedure" you don't want to burn the "evidence"
• Motivation. If you understand the risks and consequences of endometrial ablation and you're simply more "comfortable" with a hysterectomy, don't let someone "talk you into" an EA. Women who are poorly motivated to undergo EA—after they review the information—will likely not do well.

Why not have a hysterectomy in the first place?

Hysterectomy isn't a bad choice for many women but keep in mind that in many cases it is far more aggressive than medically warranted. Importantly, some women are just simply poor operative risks for hysterectomy. This includes women who are obese (BMI > 30), diabetic, or ones who've had multiple abdominal surgical procedures such as appendectomy, cholecystectomy, multiple Cesarean sections, bowel surgery and gastric-bypass procedures. Other women who should avoid hysterectomy are those with bleeding disorders, women who take "blood thinners" or have a history of pulmonary disease, coronary artery disease or strokes.

Finally, it's important to realize that even though endometrial ablation and similar procedure are far from perfect they are simple office-based procedures with a quick recovery and rapid return to a normal life style. EAs work on a sizeable majority of women and are far less risky than hysterectomy. If endometrial ablation doesn't work you can, in most cases, have a hysterectomy.

What can be done about endometrial ablation failure?

For most women who experience late-onset endometrial ablation failure–over 100,000 per year in the U. S.–the choices include

• Living with the problem if the symptoms are manageable.
• Trying to control the symptoms with hormonal suppression–birth control pills, norethindrone, Depo-Provera, oral medroxyprogesterone acetate, or megestrol (Megace).
• Subtotal hysterectomy
• Ultrasound-Guided Reoperative Hysteroscopic Surgery (UGRHS)

What should not be done following an endometrial ablation failure?

Many physicians offer a variety of treatments following a late-onset failure. The following procedures should be avoided if you're had an endometrial ablation that's failed.

• IUD insertion—Although IUDs can be inserted following EA this needs to be done by a highly trained physician and under ultrasound guidance!
• A "repeat" ablation of one of the following types:
  • NovaSure
  • Minerva
  • ThermaChoice Balloon (unavailable after 2016)
  • Hydrothermal Ablation (HTA)
  • Microwave endometrial ablation (no longer available)
  • Cryoendometrial ablation (HerOption)

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II. TREATMENT OF ENDOMETRIAL ABLATION FAILURE: Ultrasound-Guided Reoperative Hysteroscopic Surgery

Why are we the only ones?

It's a question I often get asked from women across the country and abroad.

Let me try and explain this complex issue and why you don't find this procedure readily available around the country—at least not yet.

1. The procedure known as ultrasound-guided reoperative hysteroscopic surgery (UGRHS) requires a great deal of experience in traditional resectoscopic or hysteroscopic surgery. Many of these skills were lost with the introduction of Global Endometrial Ablation techniques (NovaSure, Hydrothermal Ablation, ThermaChoice and Minerva). To date (January 2018) we have performed nearly 3500 major operative hysteroscopic procedures of which 471 are reoperative procedures . But, it was the experience we gained–as far back as 1988–in operative hysteroscopy that provides us the skill and experience necessary to perform UGRHS.
2. Ultrasound-guided reoperative surgery also requires ultrasound expertise. Ultrasound has been incorporated into our practice since 1993. We do not employ ultrasound technicians—we perform our own ultrasound examinations. Amy Daggett—our very skilled nurse practitioner—and I have worked together since 1986 and have extensive experience in both ultrasound and ultrasound-guided surgery. Most sonographers that one finds in Ob Gyn Departments and in radiologist's office have little or no experience ultrasound-guided surgery. Between the 2 of us we perform thousands of ultrasound examinations per year and hundreds of procedures every year under ultrasound guidance.
3. We have assembled a "team" that includes an R. N, a nurse practitioner, and 3 highly trained operating room technicians that have worked together for many years.
4. Because we have a large volume of cases we are able to maintain our skills. Our practice performs nearly 200 major operative hysteroscopic procedures and at least as many "minor" hysteroscopic procedures per year .
5. Honesty and integrity. Finally, none of this matters if can't provide a service and do so with honesty and integrity. Let's face it we, as physicians, we live in glass houses. Word of mouth and the internet advertise both good and bad results—quickly. Ultrasound Guided Reoperative Hysteroscopic Surgery IS NOT FOR EVERY WOMAN THAT HAS AN ENDOMETRIAL ABLATION FAILURE. There are many women who are better off with the alternatives—including hysterectomy. What we do provide is accurate information that is tailored to your particular case. We refer many women every month for other management strategies. Ultimately our reputation is dependent on honesty and not promising what we cannot deliver.

What is Ultrasound-Guided Reoperative Hysteroscopic Surgery?

Years ago when most endometrial ablation was performed using a hysteroscope –a lit telescope that allowed one to operate inside the uterus—a select group of physicians was able to perform repeat endometrial ablation. Today, most endometrial ablations are performed blindly by what are called "Global Ablation" techniques. In the past 20 years the U. S. Food and Drug Administration (FDA) has approved 6 such devices (see above); two them are no longer available.

Ultrasound-Guided Reoperative Hysteroscopic Surgery is comprised of the following elements:

1. It is hysteroscopic surgery—surgery performed under direct vision—most of the time—through a hysteroscope or resectoscope—that is placed within the uterine cavity. The image is displayed on a television monitor.
2. Ultrasound guidance. Because it is impossible to see everything through the hysteroscope—especially in the early stages of the procedure—visualization is also provided through transabdominal ultrasound. Ultrasound allows us safely dissect through the scar tissue that often blocks entrance to the uterine cavity. Once we have entered the cavity ultrasound is employed to make sure that we don't remove too much tissue and accidentally perforate the uterus.
   If you look at our room arrangement (below) you'll see that at the far end of the room there are 2 monitors on the wall—one for the "ultrasound view" and another for the "hysteroscopic view". This allows both the surgeon and the sonographer to see "the whole picture" and guide surgery accordingly.
3. It is a resection technique identical to endomyometrial resection—not an ablation technique. No tissue is being burned or "cauterized". Instead tissue is removed. Using the same "set-up" we can remove the following:
   • Adhesions
   • Endometrium which has regrown or was never destroyed in the first place
   • Fibroids within the uterine cavity or adjacent to it
   • Polyps
   • Mild to moderate adenomyosis
   • A uterine septum

One of the advantages of a resection technique is that all of the specimen –not a portion of it—is sent to the pathology lab to be analyzed. That's an important screen for endometrial cancer, its precursors and adenomyosis.

Our Operating Room "Set Up"

Can my own doctor do this?

I know of no other physician in the United States, Europe, Canada, South and Central America who performs this procedure. There are physicians that have performed reoperative hysteroscopic surgery–I know of one physician in Hamilton, Ontario who performs this procedure, but without ultrasound guidance. In recent years I have written numerous articles in peer-reviewed journals (see below) and have been invited to speak at many international gatherings of physicians. It is my sincere hope that we can influence others around the country and in other parts of the world to adopt this technique.

How many have you done?

As of this writing (January 10, 2018) we have performed over 500 ultrasound-guided reoperative hysteroscopic surgeries over the past 25 years and we have written numerous scientific papers on this subject. Our first report in the medical literature dates back to 2001. Here is a sampling of the papers we're written just on the subject of endometrial ablation failure and its management.

Wortman M, Daggett A. Reoperative hysteroscopic surgery in the management of patients who fail endometrial ablation and resection. J. Am Assoc. Gynecol Laparosc. Vol 8 No. 2; 2001:272-277.

Wortman M. Ultrasound Guided Reoperative Hysteroscopy: Managing Endometrial Ablation Failures. Surg Tech International. 2012; 21:163-69.

Wortman M, Daggett A, Deckman A. Ultrasound-Guided Reoperative Hysteroscopy for Managing Global Endometrial Ablation Failures. J Minim Invasive Gynecol. 2014; 21:238-244.

Wortman M. The MIGS approach to fixing failed EA. Contemporary Ob/Gyn. May 2014. Pp 24-32.

Wortman M, McCausland A, McCausland V, Cholkeri A. Late-Onset Endometrial Ablation Failure (LOEAF)—Etiology, Treatment and Prevention. J Minim Invasive Gynecol. 2015; 22: 323-331. 50.

Wortman M. Diagnosis and treatment of global endometrial ablation failure. Ob Gyn News. January 6, 2017. https://www.cmdrc.com/wp-content/uploads/2017/01/Diagnosis-and-treatment-of-global-endometrial-ablation-failure-Ob.Gyn_.-News.pdf.

Wortman M. Late-onset endometrial ablation failure. Case Reports in Women's Health. 2017; 15; 11-28. https://www.cmdrc.com/wp-content/uploads/2017/08/Late-onset-endometrial-ablation-failures-COLOR.pdf.

How successful is Ultrasound-Guided Reoperative Hysteroscopic Surgery?

In our work we have found that—on average—we can alleviate symptoms to avoid hysterectomy is close to 90% of women who are judged to be candidates for ultrasound guided reoperative hysteroscopy surgery. The figure for an individual person may be greater or lesser than this number and depends on the following factors:

• Their age at the time they undergo reoperative hysteroscopic surgery
• Whether or not there are polyps or fibroids present in the uterine cavity
• Whether or not there are fibroids in other portions of the uterus (intramural fibroids)
• Their expectations.
• Their motivation to avoiding hysterectomy

So what are the benefits of UGRHS compared to hysterectomy?

The advantages of UGRHS include the following:

1. It's an office-based procedure performed with intravenous sedation.
2. Rapid return to work —most women can return to their jobs (even lifting) in 48 hours.
3. The complication rate of UGRHS is extremely low . Infection occurs about 1% of the time. Uterine perforation has occurred in 1 out of our 450 cases. This rate is FAR LESS than the incidence of complications that are associated with all forms of hysterectomy.
4. Its effectiveness in avoiding hysterectomy in approximately 85-90% of women. To be clear it's not perfect. Failures are greater in younger women—those under 35. The "ideal" age group for UGRHS is >45 years of age.

What are the disadvantages of UGRHS compared to hysterectomy?

The disadvantages of UGRHS include the following:

1. It is not perfect. It does not guarantee that you'll never require a hysterectomy. In some cases women have undergone UGRHS, had it work for a year or two (or longer) and experienced another "failure" in the form of pain or vaginal bleeding. Many of these women can be "retreated" while others choose to undergo hysterectomy.
   And while I don't believe that reoperative hysteroscopic surgery will ever be "perfect" I believe that over the years our results will continue to improve as newer techniques are incorporated in our procedure.
2. It is not convenient. Unless you live within an hour or so of Rochester, New York you will need to do some traveling. We've had some strongly motivated women who've traveled from Florida, Germany, Los Angeles and Calgary! But for many women it's simply not worth the time and the expense of time off from work, travel and hotels when they can undergo a hysterectomy in their home town. My hope is that in time there will be other centers in the United States, Europe and Canada to accommodate some of these women.

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III. OKAY, I WANT TO LEARN MORE. WHAT'S NEXT?

Here are some suggestions if you are have experienced an endometrial ablation failure and you'd like to learn more.

1. Click here to read peer-reviewed articles by Dr. Wortman. These articles cover a wide range of publications by Dr. Wortman but focus on the ones that include Reoperative Hysteroscopic Surgery for Endometrial Ablation Failures and Late-Onset Endometrial Ablation Failures.
2. Read through the remainder of this entire section.
3. Go to one of the many on-line Patient Review websites such as www.healthgrades.com or www.vitals.com. This will give you an opportunity to see how other patients judge us. You can find additional information under our Facebook Page and under our Blogs.
4. If you're still interested and live within a 2-3 hour driving radius of our office consider making a consultation appointment. These generally are 1-hour appointments. Prior to these appointments we request that you fill out a Patient Information Form and email it to contact@cmdrc.com.
5. In addition, please provide us with the following:
   • A copy of your most recent ultrasound examination report—we don't require the actual ultrasound images.
   • A copy of your operative report or some documentation of the date of your procedure and the type of endometrial ablation procedure you had. If an operative report is available please have that copied for our records.
   • A copy of any pathology report such as an endometrial biopsy that may have been performed prior to or since your endometrial ablation.
   • Don't worry if you can't locate all of this information. We can assist you in retrieving it.

Finally, if you're interested in arranging a consultation call our office and schedule one. If you live more than 2-3 hours away from our office please contact Ms. Marcia Weston or Ms. Christina Cinanni and they will help arrange for a 20-30 phone interview with me.

After we review your information and conduct a preliminary interview we'll be able to decide whether or not this is an option worth pursuing for you.

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IV. WHAT TO EXPECT

This article will summarize the method we use to treat nearly all endometrial ablation failures. As I've pointed out in other articles on this website there are basically 3 types of late-onset endometrial ablation failures:

1. Persistent or recurrent bleeding following an endometrial ablation (EA)
2. Cyclic pelvic pain – or in some cases continuous pelvic pain
3. The inability to assess the uterine lining –such as the use of hysteroscopy or endometrial biopsy—should the need arise.

In this article I will "walk you through" what you might expect once you arrive at our office.

Day #1—Consultation and Laminaria placement

Although we operate 3 days a week—Tuesday, Wednesday and Thursdays—most women coming from out of town prefer to travel to our office during the weekend and are typically seen for their initial consultation on Monday mornings. There are many exceptions to this, however. Our goal is work with your schedule.

The morning appointment: The consultation

At your initial visit we will typically set aside a one-hour consultation in the morning . It's important that you bring someone with you. Although no one is required to be there with you during your consultation we've found that another set of eyes and ears is often helpful. So hopefully you'll be traveling with a trusted family member or close friend and you might feel comfortable having them accompany you through your initial consultation.

During your consultation I'll review the medical information you've already provided. You will have already provided us with important and vital medical information so we're not "starting from scratch." After your consultation we'll perform our own ultrasound examination and physical examination. This is always done by me since I'm the one who'll be performing your surgery I won't be relying on information from other reports or images from another technician. I often take measurements that are not "standard" ultrasound measurements—such as the thickness of your uterine walls specific and critical points. These measurement are important since they inform us precisely where we need to exercise great caution during your cervical preparation and surgical procedure.

Following your consultation and your ultrasound we'll reassemble in my office and review your specific case and our particular approach for your surgery. This is very important. A textbook chapter or an article can provide generic information and "averages" but women want to know if their outcomes are expected to be "average," "below average," or "above average." After we've reviewed your current information and findings I'll be in a much better positon to offer an opinion.

This is your time to ask all of your questions that haven't been answered up to this point. Afterwards you'll be asked to have a late breakfast or early lunch, if possible. You will be returning in the afternoon for our second appointment—preparing the cervix. I will ask you to not eat any solid food for 4 hour before your afternoon appointment. You can drink clear liquids (only on this day) right up until your afternoon appointment.

The afternoon appointment: Cervical Preparation and Laminaria Placement

You'll be asked to return during the afternoon of first day—2:30 or 3:30 PM appointments are typical. One of our staff will check your vital signs including a hematocrit (mini-"blood count").
Although not everyone requires intravenous sedation for this part of the procedure most patients request it. If you would like to begin without it and see if you "need" it that's okay—we often work with women who would like to avoid sedation, if possible. If you elect to have sedation we'll insert an intravenous catheter and administer either fentanyl, midazolam or both (most women opt for both).

During this part of the procedure I will briefly repeat your ultrasound scan and insert a vaginal speculum. Following this an ultrasound probe is placed on your abdomen and the cervix is dilated and "stretches" the scar tissue that is often found in the lower portion of the uterus and upper reaches of the cervix. After dilation is accomplished—generally to 3 or 4 mm—a laminaria japonica–which is rolled up sea weed!—is inserted into the cervix and comes to rest just in the lower portion of the uterus. Once placed there the laminaria will absorb moisture over the next 12-24 hour and dilate your cervix to about 5-7 mm. This little bit of dilation is very important in most, but not all cases. Dilation is performed this way because it is slow and gentle on your cervix and prevents cervical tears during your surgery the following day. Here are some "highlights" about the "laminaria experience."

1. Most women find it uncomfortable and others find it painful—that's why we offer intravenous sedation.
2. The laminaria placement procedure takes 5 minutes.
3. You will likely experience cramps if you are not receiving sedation.
4. Those initial cramps last about 10-15 minutes.
5. However, once those cramps disappear there will be other cramps that may begin 1-6 hour later as your cervix dilates.
6. Those secondary cramps can be mild to moderate—generally not severe.
7. You will be given prescriptions for pain medication (as well as others) to manage those cramps.
8. Take them. Do not be "tough." Focus on getting sleep.
9. That night will be the roughest part of your surgical ordeal in most cases.
10. Do not eat solid food after midnight of the night prior to surgery if you have an 8:30 AM case.
11. You may drink clear liquids up until 2 hours prior to your procedure.
12. If your procedure is scheduled for 12:45 PM you may eat a light breakfast that ends before 8 AM.
13. You should take your morning medications—especially if you have hypertension!
14. If you feel that you need a medication to help you sleep the night prior to surgery don't hesitate to ask!
15. Try to arrive at our office—if possible—with a full bladder. It will help you avoid catheterization.

Day #2: Your Surgery

Hopefully you've had a decent night's sleep by the time you get here. It's not always possible. The laminaria expansion that occurred overnight may have caused you pain or restlessness. It's okay to take a pain medication or a sedative (if you've been prescribed one).

Here are some general guidelines and expectations for you day of surgery.

1. Take your morning medications. Don't skip blood pressure medications unless specifically told by us. We will review all of your medications and answer all of your questions regarding which medications to take and which you can skip.
2. Try to wear loose fitting clothes. Pajamas and sweat-pants are fine—anything that you can easily get off and back on again.
3. Try to arrive with a full bladder—if possible. I know it's mentioned above, but worth remembering.
4. Please remember that whomever is accompanying you will be asked to stay for the duration of your procedure and your postoperative course. They should expect to spend about 3 hours here.
5. After you change you can expect to have an intravenous line started along with typical monitoring equipment (such as EKG leads).
6. You will receive carefully administered intravenous sedation.
7. Your procedure will typically take about 30-45 minutes to complete.
8. When you awaken you will be joined by whomever you selected to accompany you.
9. You will be carefully monitored following your procedure.
10. Pain is very variable in the immediate postoperative period. Most women experience uncomfortable cramps which are treated as necessary. We will not allow you to have severe pain.
11. In most cases you will have bright red postoperative bleeding. This is not your "period." This bleeding is the result of removing your endometrium from the underlying muscle.
12. When you're ready for discharge you will be accompanied by our staff to your car.
13. You should expect to spend the next 3-5 hours resting at home or in your hotel room.*
14. You may also experience some increase in bleeding as you get out of bed for the first time. This is normal and should quickly subside.
15. You will probably regain your appetite later in the afternoon.
16. Start out with a light meal and avoid alcohol.
17. You should have only minimal discomfort by the end of the day.
18. Do not use tampons during the day of surgery.

Please call us if you experience any of the following

1. A feeling of "chills".
2. Temp over 100 degrees F.
3. Bleeding which requires a pad change more often than once an hour after you wake up.

If you don't feel "right" please just pick up the phone and call. We would always rather you call than not call!

Day #3: Your First Postop Day

You should feel pretty good the morning following your surgery. Most women, though not "back to normal" report some fatigue but generally are not experiencing any significant pain or soreness. Your bleeding should be improved compared to the previous day. There is no "typical bleeding pattern" from this point onwards but most women will be changing pads every 1 ½ to 2 hours for the first 24-48 hours.

You will have an appointment for your first postoperative day. Here's what you can expect.

1. We will perform an ultrasound to establish a "baseline" of what your uterus looks like 24 hours after surgery. You will have a "hematometra" – however this is an expected finding at this time and will disappear over the next few months.
2. We will review your surgery including unedited videos.* We will also review any JPEGs that have been taken during your surgery.*
3. Please provide us with a flash drive so that we can download this information for you to share with your physician (if you choose).*
4. I will review your findings and answer specific questions regarding your expectations.
5. You will be given copies of your operative report and any other notes you might wish.*
6. You can expect that your pathology report will be mailed to you within the next 7-10 days.*
7. If you are driving back to your destination please remember to stop every 2-3 hours to stretch your legs.*
8. If you are traveling by air we will have already discussed how to best manage your trip back home.*

From this point on…

Your care isn't over when you've left our office. It's important for you to maintain contact with us. Because there are so many variables in taking care of women you will be given specific instructions that are relevant to your care. In general you can expect the following:

1. Your first postoperative visit in 2 weeks following your surgery. This does not necessarily apply to our out of town patients.
2. Your second postoperative visit 3-4 months following your surgery. If you are traveling from a considerable distance we will make specific recommendations for you.
3. Bleeding –including mild vaginal discharge—should last up to 3 weeks following your surgery
4. Fairly rapid return to full activity, including exercise, within 48 hours from your surgery.
5. Return to sexual activity within 3 weeks following surgery. This is highly variable, however, and should be discussed individually.

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Source: https://www.cmdrc.com/treatment-of-endometrial-ablation-failure/