Endometrial ablation is an alternative option to hysterectomy for the therapeutic management of excessive menstrual bleeding (menorrhagia). It involves the removal or destruction of the tissue that lines the inside of the uterus, known as the endometrium.
This procedure is often selected when medication has failed or when a woman does not wish to undergo other forms of treatment.
Many doctors recommend a hysterectomy as a treatment for women with heavy or prolonged bleeding. Endometrial ablation (or endometrial curettage) is indicated when the size of the uterus is normal or only slightly enlarged. It is not indicated when the uterus is significantly enlarged, contains multiple fibroids, or when there is suspicion of cancer.
Ablation can be performed with an operative hysteroscope (a small telescope) that has a special channel through which a device called a resectoscope or a laser fiber instrument is passed; the surgeon uses these to mechanically remove or ablate (that is, destroy with laser energy) the endometrium. Today, other devices are also available that are inserted into the uterine cavity to destroy the endometrium, such as thermal balloon or radiofrequency ablation, the NovaSure device and hydrothermal ablation. The method used depends on the surgeon's preference, skill and experience. After the procedure, most women have a significant reduction in bleeding, and some stop having periods completely. Rates vary depending on the technique and each woman's characteristics, and some may need a repeat procedure or another treatment in the future.
Some of these methods can be performed in an outpatient setting (no hospital admission required), while others require general anesthesia.
Which women endometrial ablation is suitable for
Ablation is intended for women before menopause who suffer from heavy menstrual bleeding, have completed their family and have not found relief with medication or a hormonal IUD. A prerequisite is that any malignancy or precancerous change of the endometrium has been ruled out.
It is not suitable for women who want a child in the future. After the procedure, the endometrium cannot safely support a pregnancy, so reliable contraception is needed until menopause.
Curettage and ablation: they are not the same
The two terms are often confused. Diagnostic curettage removes a sample of the endometrium that is sent for histological examination, and today it is almost always done under direct vision, with hysteroscopy. Ablation has a therapeutic goal: it permanently destroys the endometrium so that bleeding is reduced or stops.
Tests before the procedure
- Transvaginal ultrasound, to assess the size of the uterus and any fibroids or polyps.
- Endometrial biopsy to rule out hyperplasia or cancer.
- Pap test that is up to date, and a pregnancy test.
- General blood tests, with emphasis on hematocrit and iron.
Recovery: what to expect
Most women go home the same day. Period-like cramps last one to two days and ease with simple painkillers. Watery or slightly bloody discharge is expected for two to three weeks. Return to work is usually within a few days, while tampons and sex are avoided until your doctor tells you otherwise.
Contact your doctor immediately if you develop a fever, severe pain that does not go away, foul-smelling discharge or bleeding heavier than a period.
Results and possible risks
In most women, periods become noticeably lighter, and in many they stop completely. A smaller percentage, mainly younger women, will later need a second procedure or a hysterectomy. Complications are rare: infection, perforation of the uterus, thermal injury to nearby organs or fluid overload during the hysteroscopic technique.
When menstrual bleeding is considered excessive
Many women live for years with heavy periods, believing that “that is just how it is”. Current guidelines define heavy menstrual bleeding in practical terms: blood loss that affects your physical, social or emotional life. You do not need to measure milliliters. You need to notice the signs:
- You change your pad or tampon every one to two hours, for several hours in a row.
- You need double protection or get up at night to change.
- You pass clots larger than a coin.
- Your period lasts more than seven days.
- You feel tired, dizzy or short of breath on exertion, and tests show iron deficiency anemia.
- You avoid going out, work or travel on the days of your period.
If you recognize yourself in two or more of these, it is worth investigating. The cause may be hormonal, anatomical, such as uterine polyps or fibroids, or, more rarely, a clotting disorder. A correct diagnosis always comes before treatment.
Endometrial ablation techniques: first and second generation
The methods fall into two groups, each with a different logic.
First generation: hysteroscopic techniques
The surgeon sees the inside of the uterus directly and removes or cauterizes the endometrium with an electrical loop, a rollerball or laser. Their big advantage is that small polyps or small submucosal fibroids can be removed in the same session. However, they require more surgical experience, usually general anesthesia and careful monitoring of the distension fluids.
Second generation: “blind” devices
These are devices inserted into the cavity that destroy the endometrium with controlled energy: thermal balloon, bipolar radiofrequency, heated saline, microwaves or freezing. The procedure is short, standardized and often done under sedation or local anesthesia. A prerequisite is that the uterine cavity has a normal shape and size.
- Duration: second-generation devices take a few minutes. Hysteroscopic techniques take longer.
- Anesthesia: lighter with the second generation.
- Removal of lesions at the same time: possible only with the hysteroscopic approach.
- Anatomical limitations: greater with the devices, which need a regular cavity.
Large comparative studies show similar patient satisfaction between the two groups. The choice is individualized based on the anatomy of your uterus.
Diagnostic curettage: when it is needed and how it is done today
Curettage is not a treatment for heavy menstrual bleeding. It is a way to obtain tissue to find out what is happening in the endometrium. The main indications are:
- Any bleeding after menopause.
- A thick or uneven endometrium on transvaginal ultrasound.
- Irregular bleeding after age 45, or in younger women with risk factors such as obesity, polycystic ovaries or long-term use of estrogen without a progestogen.
- Failure of medication, before a decision on surgery.
In many cases, the first step is a simple endometrial biopsy in the office with a thin tube, without anesthesia. If a more complete assessment is needed, curettage is done together with hysteroscopy so that the doctor can target the area that looks abnormal and not miss focal lesions. The “blind” curettage of the past is now rarely used.
Endometrial ablation or hysterectomy: what you gain with each option
Both options treat heavy menstrual bleeding. But they differ fundamentally in how demanding they are and how certain the result is.
- Recovery: after ablation, a few days. After hysterectomy, several weeks.
- Permanence: hysterectomy stops periods permanently. Ablation reduces them significantly, but some women will need another procedure in the future.
- Risks: complications of ablation are fewer and milder.
- Age: the younger the woman, the more likely bleeding is to return after ablation. This matters in the decision.
- Coexisting conditions: with large or multiple fibroids or with adenomyosis, hysterectomy usually gives a more certain result.
Many women prefer to start with the less invasive option and keep hysterectomy as a backup. This is a perfectly reasonable strategy, as long as it is based on proper information.
Preparation and the day of the ablation
The procedure is usually scheduled in the first few days after your period, when the endometrium is thin. For some techniques, the doctor may recommend medication for a few weeks beforehand to thin the endometrium and improve the result. Sometimes a medication that softens the cervix is also given for easier dilation.
On the day of the procedure you arrive fasting, if sedation or general anesthesia will be used. The treatment itself is short. A few hours later, once you have recovered and urinated normally, you go home with someone accompanying you. Bring pads with you, not tampons.
Long term after ablation: what changes in follow-up
- Contraception: continues until menopause. Some women choose permanent contraception at the same time.
- Cervical screening: the Pap test and HPV testing continue as usual, because the procedure only affects the inside of the uterus.
- Hormone therapy in menopause: if you need it later, it will include a progestogen, because islands of endometrium may remain that need protection. See more about menopause and its symptoms.
- Bleeding after menopause: is never ignored. Assessment can be more difficult because of scarring in the cavity, so always tell your doctor that you have had an ablation.
- Cyclic pelvic pain: rarely, months or years later, pain may develop from blood trapped behind scar tissue, especially in women who previously had tubal ligation. It can be treated, but it needs evaluation.
Steps before ablation: medication options
International guidelines usually recommend trying medication first, unless there is a reason for immediate surgery. The options fall into two groups:
- Non-hormonal: tranexamic acid, taken only on the days of bleeding to reduce blood loss, and nonsteroidal anti-inflammatory drugs, which also help with pain.
- Hormonal: the levonorgestrel intrauterine system, contraceptive pills and progestogen medications. Besides reducing bleeding, they also provide contraception.
The effectiveness of each treatment is usually judged after three cycles. If the result does not satisfy you, if the side effects are bothersome or if you simply do not want long-term medication, ablation comes into the discussion.
Correcting anemia before the procedure
Women with chronic heavy menstrual bleeding often have low iron, even when hemoglobin is borderline normal. Fatigue, hair loss, brittle nails and difficulty concentrating are often blamed on stress, while the real cause is iron deficiency. Before any procedure, it is worth checking a complete blood count and ferritin. Iron is replaced orally or, when the deficiency is large or time is short, intravenously. A woman with restored iron stores recovers more easily and feels the difference in her daily life very quickly.
Common misconceptions about endometrial ablation
- “Ablation causes early menopause.” No. The ovaries are not touched and continue to produce hormones normally. Premenstrual syndrome symptoms, if present, usually remain.
- “Afterward, I do not need contraception.” Wrong. Pregnancy is rare but dangerous, so contraception continues.
- “It is the same as the curettage I had years ago.” No. Curettage takes a sample and the endometrium regenerates. Ablation aims to destroy it permanently.
- “It suits every heavy period.” No. If the cause is a large fibroid, extensive adenomyosis or a precancerous change, ablation is not the right solution.
A decision that is not only about the body
Ablation permanently closes the chapter on pregnancy. For some women this is a relief. For others, even when they are not planning another child, the finality brings doubts. Take your time. Talk it over with your partner and ask as many questions as you need, even at a second appointment. If there is even a small chance you may want a pregnancy in the future, the hormonal IUD or medication are safer choices, because they are reversible. The right decision is the one you make well informed and without time pressure.
For a personalized assessment of your case, book an appointment with Dr. Panagiotis Polyzos at his office in Athens or Volos.
Frequently Asked Questions
Can I get pregnant after endometrial ablation?
Pregnancy is unlikely but not impossible, and when it happens it carries serious risks for the mother and the fetus. That is why the procedure is done only in women who do not want another child, and it is combined with contraception.
Will my period stop completely?
Not necessarily. The goal is a significant reduction in bleeding. In many women periods become very light, and in some they stop permanently.
Does the procedure hurt?
It is done under local anesthesia, sedation or general anesthesia, depending on the technique, so you do not feel pain during it. Afterward, mild cramps for one or two days are common.
How long does endometrial ablation take?
The treatment itself lasts from a few minutes to about half an hour, depending on the method. In total, plan on a few hours at the clinic.
What is the alternative if I do not want a procedure?
Medication, such as tranexamic acid or hormonal medications, and the levonorgestrel intrauterine system, which significantly reduces bleeding in most women.
How long does it take to see the result of ablation?
Healing of the inside of the uterus takes time. The first periods may still seem irregular, while the final result is usually assessed three to six months after the procedure.
Can I have ablation if I have fibroids?
It depends on their size and location. Small fibroids that do not distort the cavity are usually not an obstacle, while a small submucosal fibroid can be removed hysteroscopically in the same session. Large or multiple fibroids significantly reduce the chance of success.
Is diagnostic curettage done under sedation?
Usually yes, with brief sedation or general anesthesia, and you go home the same day. A simple endometrial biopsy in the office, by contrast, is done without anesthesia and causes a brief cramp.
Can I have ablation if I have already had a cesarean section?
Usually yes, but the doctor will check the thickness of the uterine wall at the scar site with ultrasound, because some second-generation devices need enough myometrial thickness to be used safely.
