Alternatives for Hysterectomy: Endometrial Ablation - HTA, Thermachoice and Novasure.
If you are a woman who has suffered from endometriosis or severely heavy menstrual bleeding, also known as menorrhagia, there is a good chance that you have been told that your only option is a hysterectomy. For many decades, it is true that this was the only option. Many women have tried to control their symptoms with some form of hormonal contraception, or if they suffer from endometriosis, they may have had a laparoscopy.
Unfortunately, for many women, their symptoms only return. In addition, hormonal contraception can carry certain risks, especially if the woman smokes or as she ages. Progesterone-only methods often cause breakthrough bleeding, which may be the very thing the patient is trying to control. At the same time, stroke and deep vein thrombosis may be caused by contraceptives containing estrogen. However, within about the last decade, several medical breakthroughs have given new treatment options for women who suffer from these conditions.
First, what is Menorrhagia? Menorrhagia is another term for an unusually heavy and/or prolonged menstrual period. Specifically, it refers to losing 5 1/2 tablespoons or more of blood during the menstrual cycle. The Mayo Clinic states that signs and symptoms of Menorrhagia may include:
- Menstrual flow that soaks through one or more sanitary pads or tampons every hour for several consecutive hours.
- The need to use double sanitary protection to control your menstrual flow.
- The need to change sanitary protection during the night.
- Menstrual periods lasting longer than seven days.
- Menstrual flow that includes large blood clots.
- Heavy menstrual flow that interferes with your regular lifestyle.
- Tiredness, fatigue or shortness of breath (symptoms of anemia)
Some women develop Menorrhagia during the onset of puberty, many of whom have it last their entire reproductive lives. Others develop this as they approach menopause. In either case, their symptoms may be pain free or excessively painful. Women with this condition might also have additional health concerns, which might or might not be the underlying cause of the symptoms, such as endometriosis or fibroids.
What is Endometrial Ablation? Quite simply, endometrial ablation is a medical procedure which is used to remove (ablate) the endometrial lining of the uterus. (An ablation means the removal of material from the surface of the object by means of vaporization, chipping or some other erosive process.) This procedure is normally done in an outpatient setting, either in a doctor's office or hospital.
Patients who might wish to become pregnant at a later date should not have an endometrial ablation as this could result in a high-risk pregnancy. Though the majority of women become infertile after this procedure, it is still encouraged that women use some form of birth control just for this reason. Overall, approximately 90% of women who have an endometrial ablation have reduced menstrual bleeding. Of those, approximately 45% will stop having periods altogether. Some women may initially have periods after the procedure, only for those periods to completely stop within a few months.
Other women may have no periods at all for several years but may notice them returning at a much later time. Approximately 22% of women who have had this procedure will eventually chose to have a hysterectomy. Patients who have an IUD must have these removed prior to undergoing a uterine ablation. Women must also have a normal pap smear and uterine biopsy prior to having this procedure. With most forms of uterine ablations, a D and C is done immediately prior in order to both thin the lining of the uterus and often to check for uterine cancer.
In cases where a D and C is not performed (such as most in-office procedures), a hormonal medication may be given to help thin the endometrial lining. With any endometrial ablation, sex, tampons, tub baths and anything involving insertion of anything into the vagina should be avoided for a set amount of time, usually about two weeks or longer as needed. As with most procedures, a heavy discharge or flow similar to a period may last 1-2 weeks. The discharge may have an unpleasant odor and may continue even for several weeks following the procedure, even if there is no blood.
How is an Endometrial Ablation Different from a D and C? A D and C, which stands for Dilation and Curettage, is a procedure which is designed to scrape and collect the tissue inside the uterus. The dilation is the widening of the cervix in order to allow instruments into the uterus. The cuttrage involves the scraping of the walls inside the uterus. This can be done for many medical reasons, including to determine the cause of abnormal uterine bleeding, an attempt to treat heavy menstrual bleeding, a treatment for incomplete miscarriages and occasionally as a first trimester abortion. However, the procedure is not a lasting treatment of menorrhagia. As it only scrapes off the lining of the uterus, this endometrial lining often returns. For the treatment of menorrhagia, a D and C may only lighten the flow for 1-2 cycles. Often this procedure is repeated and the heavy flow will eventually return.
What are the Different Types of Endometrial Ablation? Overall, there are many different and competing endometrial ablation procedures. The three of which I will be focusing are:
- HTA System
HTA stands for Hydro ThermAblator System. This treatment relies on the circulation of heated saline, which fills the uterine cavity, in order to destroy the endometrial lining. This is an outpatient procedure in which the patient's cervix will be dilated and a small, telescopic device will be inserted into the uterus so that the physician may see the inside of the uterus. From there, a saline solution at room temperature will be used to flush and gently clean the uterus. The saline solution will gradually be heated to 90 degrees C (194 degrees F) and circulated within the uterus for ten minutes until the lining of the uterus is destroyed. Once this procedure is completed, the uterus is then rinsed with room temperature saline in order to cool both the uterus and the probe.
What to expect from the HTA: This procedure is usually done in a hospital setting though some physicians may choose to do this in their office. This can be done under general anesthesia, sedatives along with pain medications or a local anesthesia should the patient decide to be awake during the procedure. The physician may also choose to give the patient some pain medications for after the procedure. For the two weeks following the HTA, the uterus will be sloughing off this tissue, similar to having a period. Most women are able to return to normal daily actives the following day, though (as with any surgical procedure) an increase of bed rest and a restraint from doing heavily laborious activities may be beneficial for 1-2 weeks, depending upon how the patient is feeling.
The Benefits of HTA include:
- The ability to treat women with an abnormally shaped uterus.
- A 98% success rate following at a three-year follow up.
- 53% of women reporting a complete stop of their menstrual flows (amenorrhoea).
- 94% of patients reported having either a normal menstrual flow, a reduced menstrual flow or no menstrual flow.
What is Thermachoice? Thermachoice is a procedure where a soft, flexible balloon made of a silicone material (rather than latex as many women have allergic reactions) is attached to a catheter and inserted past the vagina and cervix into the uterus. The balloon is then filled with fluid and gently heated and gently circulated within the uterus for eight minutes in order to treat the uterus. Once the catheter and balloon are removed, there is nothing remaining inside the uterus. The treated endometrial tissue will shed, similar to a period, over the next 7-10 days.
Benefits of Thermachoice Include:
- There is a 96% rate of success among women who have undergone this procedure.
- 95% of women treated will return to normal levels of menstrual bleeding or lower.
- 89% of patients have a reduction of menstrual cramping.
What is Novasure? Novasure is an outpatient procedure using radio frequency to remove the endometrial lining of the uterus. During the procedure, once the cervix is dilated, a slender wand with a triangular mesh will be inserted into the uterus where it expands to the dimensions of the uterine cavity. At this point, radio frequency energy is then activated. It will immediately shut off when it senses that the treatment has been completed. This only lasts about 90 seconds. As with the other procedures, the lining will slough away for about the next 1-2 weeks.
What are the Benefits of Novasure?
- 97% of women say that they would recommend Novasure to other women.
- More than 90% reported a much lighter menstrual flow, with many women who have had their periods stop completely.
- 45% of women reported a reduction in symptoms of PMS.
- 64% reduction of women reporting pain.
- 68% of women reporting a reduction in anxiety.
- 71% reduction of women reporting a lack of self confidence.
- An almost 400% reduction of women who were reporting lack of energy.
In full disclosure: I am among the women who have undergone a Novasure procedure, approximately two months prior to writing this article.
OK, so what are the Risks of Endometrial Ablation? Though rare, any form of endometrial ablation will have certain risks. These include but are not limited to:
- Perforation of the uterus.
- Burns to the uterus beyond the endometrial lining.
- Bowl burns
There are additional risks associated with HTA and Thermachoice, due to the chance that heated fluid may escape beyond the uterine cavity and flow into other parts of the body, including the fallopian tubes.
As with any surgical procedure, there is also the risk of pulmonary edema or embolism, reactions to the anesthesia or other medications. Though extremely rare, death from general anesthesia occurs in about 1 in every 250,000 people, though this is most common in those with other, serious underlying medical conditions.
How do I know which Procedure is Right for Me? It would seem as though there are as many sites promoting their method over other methods as there are different methods of endometrial ablation. Do your research, remembering that many sites will hype their own procedures without being objective. Most important, ask your doctor. If you have an OBGYN whom you trust, ask her which procedure she would recommend and which doctor she feels would be the best, assuming she does not perform endometrial ablations.
Many women prefer a doctor who will perform these procedures in office, both for the convenience and when cost is a factor. However, as there are certain risks (which I mentioned above), it might be a good idea to find a doctor who will do this as an outpatient procedure in a local hospital. It could be beneficial to have other surgeons and emergency equipment on hand should you be the rare case where there is a serious complication.
I found a doctor who was recommended to me by the other doctors and nurses at my primary care facility, most of whom used her for their own OBGYN care. That was a strong factor regarding how I chose my doctor and procedure. Another thing to consider is that biopsies and D and Cs can also be performed under the anesthesia while at a hospital, both reducing pain and often eliminating the need for hormonal therapy prior to the procedure.
Remember, this is your body and your health. Ask questions and be certain to discuss your own medical history, including what medications and supplements you might take. Voice your concerns should any arise. Good luck to you.
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