With 20+ years of clinical experience, Dr. Karla Loken, DO, OBGYN, FACOOG, GYN Surgical Head of Clinical Development, dives into the “hot topic” of endometrial ablation and provides insights and guidance for providers as they counsel their patients on GEA.
GEA or IUD: How can physicians determine which treatment approach is best for a patient?
When it comes to treating abnormal uterine bleeding (AUB), global endometrial ablation (GEA) and intrauterine devices (IUD) can both be effective options to consider. When initiating treatment counseling, it’s important to assess all symptoms the patient is experiencing. For example, a patient may be experiencing heavy menstrual bleeding and painful menses. As you piece together individual factors, symptoms, and goals, it’s important to identify the cause for the patient’s bleeding to ensure the proposed treatment option will address the underlying cause. It is also important to assess the patient’s phase in life as different treatments are appropriate if a woman desires future fertility, and others are more appropriate for those closer to menopause. If a woman is done with childbearing, ablation is a great first choice for many women, as it does not require hormones and has a very low re-intervention rate. While an IUD is also a good option, it also has some drawbacks. It may cause intermenstrual bleeding and needs to be replaced every 5 years.1 It is important to take the time to discuss risk factors and potential side effects of each procedure, while also listening to the patient as they share their treatment goals, which can all impact the treatment selected. It really comes down to the physician and patient’s choice of what is the optimal treatment at that point in their life. Those needs may change over time, so patients should be routinely counseled accordingly. If a patient has failed treatment options such as an IUD to treat their heavy menstrual bleeding, they may consider NovaSure® endometrial ablation as their next option.
How should physicians counsel their patients about the benefits and risks associated with GEA?
The biggest benefit to endometrial ablation is decreased bleeding and patient satisfaction. For example, NovaSure endometrial ablation can ease the hassle of heavy menstrual bleeding resulting in less pads and tampons.2 This gives patients freedom to do the activities they’re interested in and wear the outfits they want because they are no longer afraid of bleeding through their clothes. However, it’s important to set the patient expectation that they may still experience spotting. At the same time, the patient could also see significant improvement in quality of life and reduced discomfort physically and mentally.3 This reduced burden often leads to women having the ability to become more active. I have seen patients do wonderfully after the NovaSure procedure because they are out exercising again and no longer held back by their period. Patient counseling about endometrial ablation should always include a discussion about risks. Physicians should counsel patients on the rare but serious risks of the procedure including uterine perforation or thermal injury. As you counsel your patients about endometrial ablation, it is also important to determine what their contraception prevention protocol is going to be as pregnancies following ablation can be dangerous.3
How has GEA evolved over the years and where do you see it going in the future?
Over my 20 years in Clinical Medicine, I have seen a great evolution of women having a choice. The NovaSure endometrial ablation device represented the first wave of women having the opportunity to choose a different treatment option other than hysterectomy. This evolution was two-fold, as providers gained the ability to confidently offer other treatment options to their patients. When I started as a practicing physician, GEA was done with a rollerball and the NovaSure procedure was just coming on the market. In my practice, I was able to watch these procedures and the level of anesthesia needed to perform them evolve. As I transitioned towards the in-office setting, I simultaneously saw the design of the product evolve. I noticed a migration towards the in-office setting which led to an evolution in the design of the product. For example, narrowing the diameter of the NovaSure device shaft allowed for less cervical dilation resulting in an increased patient comfort during the in-office procedure. Specific patient selection has also greatly improved over the years. We are now able to make clinically accurate treatment recommendations for patients because we have a much greater understanding of who makes the best candidate for these procedures. I am now fortunate enough to take part in the evolution of products from the other side. I get to watch the progression of a highly skilled physician relay feedback that could help improve the efficiency of the product, and then visualize, from an engineering perspective, how Hologic implements these adjustments to the product to continuously strive for the most innovative technology and best outcomes for patients.
What are the common misconceptions about endometrial ablation?
A big misconception about endometrial ablation is that patients will never have any bleeding, pain or cramping again post-operation. Every patient has a unique response in the 24-48 hours following the procedure, and I have found that it is imperative for physicians to counsel their patients about the potential short-term symptoms as well as long-term post-operative expectations. For example, patients are surprised by their experience of discharge for several weeks post-operation, as the body heals. This is why it is important to address patient expectation and conduct comprehensive pre- and post-operative counseling. We need to be very clear that after GEA, the patient will be done with childbearing, and will need to have a plan in place for contraceptive needs. Endometrial ablation can be highly beneficial to the patient and allow them an increased quality of life, however, patient satisfaction greatly hinges on expectation setting, and it is the responsibility of the physician to provide that.
1Mayo Clinic – Hormonal IUD (Mirena) – https://www.mayoclinic.org/tests-procedures/mirena/about/pac-20391354
2NovaSure Endometrial Ablation IFU – https://www.hologic.com/sites/default/files/2019-07/AW-09898-000_012_02%20%281%29_RFC10%20controller%20IFU_Rev%2012.
3Hologic, Inc. Data on File; AUB Patient Journey Research, conducted January 2017. Survey of 1,003 women who self-identified as currently
or recently experiencing heavy bleeding with need to change feminine hygiene product every hour or more.