Endometrial Ablation

Endometrial ablation is a uterus-conserving procedure that destroys or removes the endometrium — the lining of the uterus — to reduce or stop heavy menstrual bleeding. It is performed through the cervix without an abdominal incision, and modern second-generation devices use energy such as heat, radiofrequency, or freezing to treat the whole cavity. It is an alternative to medical therapy and to hysterectomy for people with heavy menstrual bleeding who do not wish to preserve fertility.

Definition

Endometrial ablation is a procedure that destroys or removes the endometrial lining of the uterus, performed transcervically to reduce heavy menstrual bleeding while conserving the uterus.

Scope

This topic covers what endometrial ablation is, the distinction between first-generation (hysteroscopic resection/ablation) and second-generation (global) techniques, its place relative to medical therapy and hysterectomy, and the requirement that fertility no longer be desired. It is a reference entry and does not give individualized treatment advice.

Core questions

• How does endometrial ablation reduce heavy menstrual bleeding while conserving the uterus?
• How do first-generation and second-generation ablation techniques differ?
• How does ablation compare with hysterectomy for heavy menstrual bleeding?

Key concepts

• Heavy menstrual bleeding (menorrhagia)
• First-generation (hysteroscopic) techniques
• Second-generation (global/non-resectoscopic) techniques
• Uterus-conserving treatment
• Contraindication when future fertility is desired
• Re-intervention and later hysterectomy

Mechanisms

Endometrial ablation destroys the full thickness of the endometrium and superficial myometrium so that menstrual bleeding is markedly reduced or stopped, while leaving the uterus in place. First-generation techniques use a hysteroscope to resect or ablate the lining under direct vision; second-generation (global) techniques apply energy — thermal balloon, radiofrequency, microwave, or cryotherapy — to treat the whole cavity more quickly and often without continuous hysteroscopic visualization. Pooled trial evidence shows the two generations achieve broadly similar bleeding outcomes, with second-generation devices generally faster and more suitable for use under local anaesthesia (Bofill Rodriguez et al., 2019). Because the procedure damages the endometrium, pregnancy afterward is unsafe and discouraged, so ablation is reserved for those not seeking future fertility.

Clinical relevance

Endometrial ablation offers a less invasive, uterus-conserving alternative to hysterectomy for heavy menstrual bleeding, but bleeding can recur and some patients later proceed to hysterectomy, so it is one option among several. This entry describes the procedure and the comparative evidence and is not a basis for individual treatment decisions.

Epidemiology

Heavy menstrual bleeding is a common reason for gynecologic consultation and surgery. Population follow-up shows that a proportion of women treated with ablation subsequently undergo hysterectomy, reflecting incomplete or recurrent bleeding control over time (Cooper et al., 2011).

History

Endometrial ablation began with hysteroscopic resection and laser and rollerball techniques (first generation), then expanded with second-generation global devices designed to treat the whole cavity rapidly and with less operator dependence. Successive systematic reviews have compared these techniques against one another and against hysterectomy as the field matured (Bofill Rodriguez et al., 2019; Bofill Rodriguez et al., 2021).

Debates

Should heavy menstrual bleeding be treated by ablation or hysterectomy?

Hysterectomy definitively stops bleeding but is more invasive, whereas ablation is less invasive and uterus-conserving but carries a risk of persistent or recurrent bleeding and later hysterectomy; the trade-off between durability and invasiveness drives the choice.

Do second-generation devices outperform first-generation techniques?

Second-generation global ablation is generally faster and more amenable to local anaesthesia, but pooled evidence shows broadly comparable bleeding and satisfaction outcomes with first-generation hysteroscopic techniques, so superiority is mainly procedural rather than in efficacy.

Seminal works

• bofill-rodriguez-2019
• bofill-rodriguez-2021

Frequently asked questions

Can someone become pregnant after endometrial ablation?

Endometrial ablation is intended for people who do not wish to become pregnant. It damages the uterine lining, so any pregnancy afterward would be high-risk and is discouraged; reliable contraception is still needed because the procedure is not a form of sterilization.

How does endometrial ablation differ from hysterectomy?

Endometrial ablation removes or destroys only the lining of the uterus and keeps the uterus in place, while hysterectomy removes the entire uterus. Ablation is less invasive but bleeding can return over time, and some people later go on to have a hysterectomy.