Procedure Descriptions

 

Endometrial Ablation Procedures

Endometrial Ablation

Dr. Madejski is happy to offer in office ablation of the uterine lining. This procedure is an alternative to a hysterectomy that is done for abnormal uterine bleeding. In the past, a woman would have to go to a hospital and receive anesthesia to have a global endometrial ablation – permanent treatment of heavy menstrual bleeding. Now, the great majority of our patients are opting for a convenient in office procedure.

What is endometrial ablation?
Endometrial ablation destroys a thin layer of the lining of the uterus. Menstrual bleeding will either stop entirely or is greatly reduced to acceptable levels. If ablation does not control heavy bleeding, further treatment or surgery may be needed.

Why is endometrial ablation done?
Endometrial ablation is used to treat many causes of heavy bleeding. In most cases, women with heavy bleeding are treated first with medication. If heavy bleeding cannot be controlled with medication, endometrial ablation may be used.

Who should not have endometrial ablation?
Endometrial ablation should not be done in women past menopause. It is not recommended for women with certain medical conditions, including the following:

  • Disorders of the uterus or endometrium
  • Endometrial hyperplasia
  • Cancer of the uterus
  • Recent pregnancy
  • Current or recent infection of the uterus

Can I still get pregnant after having endometrial ablation?
Pregnancy is not likely after ablation, but it can happen. If it does, the risks of miscarriage and other problems are greatly increased. If a woman still wants to become pregnant, she should not have this procedure. Women who have endometrial ablation should use birth control until after menopause. Sterilization may be a good option to prevent pregnancy after ablation.

A woman who has had ablation still has all her reproductive organs. Routine cervical cancer screening and pelvic exams are still needed.

What techniques are used to perform endometrial ablation?
The following methods are those most commonly used to perform endometrial ablation:
Radiofrequency—A probe is inserted into the uterus through the cervix. The tip of the probe expands into a mesh-like device that sends radiofrequency energy into the lining. The energy and heat destroy the endometrial tissue, while suction is applied to remove it.

What should I expect after the procedure?
Some minor side effects are common after endometrial ablation:

  • Cramping, like menstrual cramps, for 1–2 days
  • Thin, watery discharge mixed with blood, which can last a few weeks. The discharge may be heavy for 2–3 days after the procedure.
  • Frequent urination for 24 hours
  • Nausea

What are the risks associated with endometrial ablation?
Endometrial ablation has certain risks. There is a small risk of infection and bleeding. The device used may pass through the uterine wall or bowel. With some methods, there is a risk of burns to the vagina, vulva, and bowel. Rarely, the fluid used to expand your uterus during electrosurgery may be absorbed into your bloodstream. This condition can be serious. To prevent this problem, the amount of fluid used is carefully checked throughout the procedure.

Minerva Endometrial Ablation


Minerva is the first new endometrial ablation device on the market in the last 15 years and was designed address some of the drawbacks of previous endometrial ablation systems. Specifically, Minerva reduces patient discomfort during and after the procedure, provides additional safety features, and improves the percentage of patients who experience a complete cessation of their menstrual bleeding. The Minerva system uses three methods to burn the lining of the endometrial cavity and in so doing can use less energy to achieve a more complete treatment of the surface of the entire cavity. After initial measurements of the uterine cavity, a silicone lined membrane is introduced into the endometrial cavity. This membrane is filled with argon gas which is heated until it becomes plasma. The heat from the plasma heats the silicone membrane that is in contact with the surface of the womb cavity. This heat desiccates the endometrium. Heat from the silicone membrane also heats the small amount of fluid that is typically present in the womb cavity to allow superficial burning of any part of the endometrium that is not in direct contact with the silicone membrane. Finally, a portion radio frequency energy used to heat the argon gas also heats the endometrium but with less energy than other radio frequency ablations like Novasure. The use of less energy results in less pain and cramping during the procedure, which means that it can be performed with a patient fully awake in the office under a local anesthetic block of the cervix. Most patients experience only mild to moderate cramping or pressure. The procedure itself takes four minutes to complete. In a study to assess the effectiveness of the Minerva endometrial ablation device, 92% of women who underwent the Minerva endometrial ablation a significant reduction in their bleeding and 66% had no bleeding at all after the procedure. Overall, 98% of those women were satisfied with their procedure. Rates of post-procedure bleeding, cramping, discharge, bloating, and nausea were all low.

Women who are the best candidates for an endometrial ablation procedure are those who have not gone through menopause yet, have bothersome heavy menstrual bleeding, do not desire to have more children, have a method of permanent contraception, and have completed an evaluation to determine the cause of their bleeding and to assess the size and shape of the womb cavity. Patients who have postmenopausal bleeding, have precancerous changes to the womb cavity lining, or have uterine fibroids that protrude into the endometrial cavity are not good candidates.

Glossary
Cervix: The lower, narrow end of the uterus at the top of the vagina.
Endometrial Hyperplasia: A condition in which the lining of the uterus grows too thick. A specific type of endometrial hyperplasia may lead to cancer.
General Anesthesia: The use of drugs that produce a sleep-like state to prevent pain during surgery.
Menopause: The time in a woman’s life when menstruation stops; defined as the absence of menstrual periods for
12 months.
Pelvic Exam: A physical examination of a woman’s reproductive organs.
Sterilization: A permanent method of birth control.
Uterus: A muscular organ located in the female pelvis that contains and nourishes the developing fetus during pregnancy.
Vulva: The external female genital area.
Work a patient needs is the afternoon of the procedure. Recovery time and time off work after a hysterectomy is typically 2-4 weeks and sometimes even 6 weeks. For an ablation, no incisions are made in your abdomen, whereas a hysterectomy, even when performed laparoscopically or minimally invasively, incisions are required.

Endometrial Ablation FAQS

What can I expect after my ablation?
Following the procedure, you might have some moderate to intense uterine cramps that can last 4-6 hours. We ask that you take your pain pills upon arriving home after your procedure to reduce discomfort and allow you to sleep comfortably. Most people find they sleep through a majority of the cramping and awake feeling little discomfort. For some fortunate women, they do not experience any cramping at all.

You may return to work the day following your procedure, but we ask that you avoid sexual intercourse for 2 weeks to avoid infection of the uterus. You may have a watery or bloody discharge for up to 6 weeks following your procedure until the uterine lining heals. If you are not happy with your bleeding pattern after 3-6 months, you may opt to try hormonal therapy, consider a repeat ablation, or consider a hysterectomy to control your abnormal bleeding.

Is ablation a form of birth control?
No. Endometrial ablations are not considered to be contraception. While ablations may stop your periods, ablations do not prevent pregnancy. A pregnancy that occurs after ablation can be high risk both to the baby and to the mother, as the lining of the uterus has now been altered and the pregnancy may not properly implant. This may lead to growth defects, bleeding, and possibly require emergency hysterectomy during pregnancy.

What’s the difference between ablation and hysterectomy?
While both procedures may have the desired effect of no more bleeding or cramps, the ablation can be performed in-office, in a matter of minutes, without general anesthesia. In contrast, a hysterectomy must be performed in the Operating Room (OR) under general anesthesia and may take one hour or more. The downtime after an ablation is minimal; typically the only time off work a patient needs is the afternoon of the procedure. Recovery time and time off work after a hysterectomy is typically 2-4 weeks and sometimes even 6 weeks. For an ablation, no incisions are made in your abdomen, whereas a hysterectomy, even when performed laparoscopically or minimally invasively, incisions are required.

Colposcopy

Colposcopy is a diagnostic procedure in which a colposcope (a dissecting microscope with various magnification lenses) is used to provide an illuminated, magnified view of the cervix, vagina, vulva, or anus]. The primary goal of colposcopy is to identify precancerous and cancerous lesions so that they may be treated early.

Colposcopy is used as further evaluation of abnormal cervical cancer screening tests (Pap smear or HPV test). Colposcopic evaluation is based on the finding that malignant and premalignant epithelium have specific visual characteristics in terms of contour, color, and vascular pattern that are recognizable using colposcopy. If an abnormality is seen, a cervical biopsy is performed. This normally feels like a pinching sensation. Therefore we recommend that you take Motrin 800 mg approximately 1 hour prior to your colposcopic examination. Following the biopsy, Dr. Madejski places medicine on the cervix to stop any bleeding. This may result in a “coffee-ground” discharge for up to 3 days. We recommend that you abstain from sexual intercourse for 4 days following a colposcopy.

Endometrial Biopsy

Endometrial biopsy is a common office procedure to evaluate the cells that line the uterine cavity. It is performed for a variety of reasons:

1. Abnormal bleeding
2. An abnormal appearing uterine lining on ultrasound exam
3. Abnormal cells on pap smear that appear to be uterine, not cervical cells

The procedure typically causes menstrual like cramping and takes 5 to 15 seconds. We recommend that you take Motrin 800 mg about 1 hour prior to the procedure. The cervix is cleaned with betadyne, and a thin pipelle (3 mm wide tube) is inserted through the cervix to the top of the endometrial cavity. Gentle suction is applied to the tube and cells are suctioned in as the tube is spun and withdrawn from the uterine cavity.

It is normal to have cramping and light uterine bleeding for 2 days following an endometrial biopsy. Intercourse should be avoided for 48 hours after the procedure.

Contraception

At the Artemis Center we offer a full complement of the latest contraceptive technologies. In addition to birth control pills and Depo Provera shots which have been available for decades, we emphasize Long Acting Reversible Contraception, LARC for higher efficacy in preventing
unintended pregnancies.

Intrauterine Devices

Invented by Buffalo, New York gynecologist Jack Lippes, MD, the IUD is the favored method of reversible contraception not only by the American College of Obstetrics and Gynecology, but also by the providers at Artemis. IUDs are highly effective (greater than 99%), affordable, and can also reduce menstrual flow and cramping.

Insertion of an IUD is a simple office procedure that normally takes about 10 minutes. We recommend that you eat and take Motrin 800 mg about 1 hour before the procedure. A speculum is used to visualize the cervix, just like during an annual exam. Local anesthetic is used to dull the cervical nerves. The cervix is gently dilated which will feel like menstrual cramps. The uterine cavity is measured and the device is introduced up to the upper part of the uterine cavity. The strings are trimmed to about 4 cm. Following the procedure, you will have light bleeding and cramping for a few days and should avoid intercourse for 1 week.

It is important to come in for an IUD check up about 4 weeks after the device is inserted to assure that it is in proper position and have the strings trimmed if necessary.

Progesterone IUD

The most popular IUDs are the progesterone containing devices which include Mirena, Liletta, Kyleena, and Skyla. These work by releasing the hormone progesterone into the uterine cavity to thin the uterine lining and tighten the cervical mucous to form a sperm barrier and prevent conception. The devices work for between 3 and 5 years. The progesterone often lessens uterine bleeding and some women experience no bleeding whatsoever with a progesterone IUD.

Very little progesterone escapes into the bloodstream. The most common unwanted side effect is irregular spotting or bleeding. Your provider can help you decide which device makes the most sense for you.

Copper IUD

The Paragard IUD releases copper into the uterine cavity which kills sperm. It has the advantage of being completely hormone free and lasts up to 10 years.

Nexplanon

The Etonogestrel

The Nexplanon device is the other major category of Long Acting Reversible Contraception (LARC). The implant is easily inserted just below the skin in a woman’s arm in the office after a local anesthetic is administered. It releases a form of progesterone slowly into the bloodstream and lasts for 3 years. It is similar to Depo provera injections, but does not require coming in for an injection every 3 months and does not cause bone loss over time. The most common side effect is irregular uterine bleeding or spotting.

Minimally Invasive Surgeries

Hysteroscopy, polyp removal

A hysteroscope is a telescope that is inserted into the uterus via the vagina and cervix to visualize
the endometrial cavity, as well as the tubal ostia, endocervical canal, cervix, and vagina.
Hysteroscopy is performed for evaluation or treatment of the endometrial cavity, tubal ostia, or
endocervical canal in women with:

●Abnormal premenopausal or postmenopausal uterine bleeding
●Endometrial thickening or polyps
●Submucosal, and some intramural, fibroids
●Intrauterine adhesions
●Uterine anomalies (heart shaped uterine cavity, uterine septum, double uterus)
●Retained intrauterine contraceptives or other foreign bodies
●Desire for sterilization

Using hysteroscopy for the initial evaluation offers the potential benefit of combining evaluation
with treatment. Also, hysteroscopy avoids the risk of missing focal pathology, as may occur with
blind endometrial sampling.

This is what an endometrial polyp appears like using a hysteroscope. The polyp can be safely
resected through the hysteroscope.

FAQs

What are the risks?
Whenever a surgeon inserts a scope into the uterus, there is an approximately 1% risk of perforation of the uterus (creating a hole in the uterine wall). If this is suspected, you will be monitored closely for any postoperative problems. Normally the hole is small and will heal
without intervention. Occasionally, a perforation of the uterus requires a laparoscope surgery to rule out internal bleeding or very occasionally a hysterectomy.

How long does the procedure take?
Normally a hysteroscopy, D&C will take approximately 30 minutes. It may take longer when there are extremely large polyps or a cervix that is difficult to dilate. Is anesthesia required?

Dr. Madejski can perform your hysteroscopy in the office or at a hospital or surgical center. In the office, we administer medication to relax you and an injection of Toradol to prevent cramping. In addition, local anesthetic is used in the cervix.

If the procedure is performed at a hospital or surgical center, it is generally done with a stronger IV sedation or “twilight” anesthesia. Patients typically remember nothing of the surgery in this case. Office procedures are more cost effective and do not require bloodwork and fasting. You will require a driver in either case.

Laparoscopy

Laparoscopy is a type of abdominal surgery that utilizes small incisions and a fibraoptic scope to view the internal organs on a television screen in order to perform surgery. It offers faster recovery and less risk or scar tissue after surgery than open surgery (laparotomy). In gynecology, laparoscopy is used to evaluate and treat pelvic pain, perform a sterilization or removal of a tube or ovary or adhesions or to perform a hysterectomy. It does require general anesthesia.

Robot Assisted Laparoscopy

Dr. Madejski has been utilizing the daVinci Robot to perform hysterectomies and the more complicated laparoscopies (due to adhesions or a large mass) since 2012. It is now rare that an open surgery is required.

The robot assisted technology offers two huge innovations: wristed instruments and a high definition view of the organs (like never before!). Rather than an assistant holding the laparoscope and the surgeon using “straight stick” instruments to rotate and grasp, the daVinci technology allows the surgeon to drive the camera while simultaneously operating with hand simulators from a consul rather than stand at the operating table.

OR Set up. The assistant stands at the patient bedside. The surgeon operates from the consul.

The daVinci Robot has a camera arm and three operating arms.

The instruments have more degrees of freedom than a human wrist.

These advances result in less blood loss, less postoperative pain, a quicker recovery. We are also now able to use a minimally invasive approach for most surgeries. Most patients will go home on the day of surgery. Almost all require a less than 24 hour stay in the hospital.

 

Hysterectomy

Hysterectomy is the surgical removal of the uterus and cervix. It can be performed with or without removal of the ovaries which is referred to as bilateral salpingoophorectomies. ((BSO). Minimally invasive technologies have made hospital stays and recoveries much quicker. This surgery usually takes about 2 hours to perform. After a hysterectomy, you may never require another pap smear as long as you have never had a history of abnormal pap smears.

Hysterectomy is a major surgery with inherent risks. Major Risks of Surgery Operative injury to surrounding organs such as the bladder, ureters, intestines, and blood vessels Bleeding that may on occasion require transfusion or moving to open surgery Infection Risks associated with general anesthesia