Procedure gains as non-surgical alternative to hysterectomy


A growing number of American women are undergoing a non-surgical procedure to destroy the lining of the uterus as an alternative to hysterectomy.

The method, called endometrial ablation, also eliminates the menstrual period and makes the womb inhospitable to newly fertilized eggs, and some women are using it as a form of permanent birth control, according to doctors who perform the procedure.

It was developed as a non-surgical alternative to hysterectomies in women who suffer from excessive uterine bleeding.

Endometrial ablation "is catching on," said Dr. Jordan M. Phillips, chairman of the board of the American Association of Gynecological Laparoscopists in Santa Fe Springs, Calif.

"Patients are hearing about it from other patients," he said. "Many doctors are doing it for women who no longer want to have periods. It's very logical."

Dr. Alan H. DeCherney, professor of obstetrics and gynecology at Yale University, warned that endometrial ablation was untested as a method of birth control. "It's probably pretty good" for preventing pregnancy, he said, but the long-term safety of the method has not been proved.

For example, Dr. DeCherney worried that small "islands" of endometrial tissue might be left in the uterus. If these became cancerous, he said, the woman might not experience bleeding, which is the most reliable warning sign of uterine cancer.

In addition, as many as 10 pregnancies may have occurred, according to doctors who are tracking the procedure.

Each year more than a million women visit their doctors complaining of heavy, irregular menstrual periods, according to the American College of Obstetrics and Gynecology.

The most common cause of excessive uterine bleeding is the failure to ovulate, Dr. DeCherney said. Then the woman's body does not produce progesterone, and her endometrium -- a layer of uterine tissue -- keeps on thickening, he said, until it bleeds spontaneously and heavily. The condition often responds to hormones that restore a natural balance between estrogen and progesterone.

But hormone therapy fails to help 15 percent to 20 percent of the women, Dr. DeCherney said. Some of them have physical abnormalities inside the uterus such as benign tumors called fibroids and polyps.

Heavy bleeding that does not respond to drug therapy is routinely treated with hysterectomies, Dr. DeCherney said.

In 1989, about 541,000 hysterectomies were performed, the majority of them for heavy uterine bleeding, according to the College of Obstetrics and Gynecology. As many as half of these operations may have been treatable using non-surgical procedures, some doctors say.

Three or four years ago, Dr. DeCherney said, gynecologists realized they could use an endoscope, a tubelike instrument with lenses and a light source attached, to see the insides of the uterus, determine the problem and correct it without major surgery.

The non-surgical alternative, called a hysteroscope, is inserted through the cervix in a procedure that does not require anesthesia and can be performed in a doctor's office.

The uterus, which is normally collapsed in on itself, is inflated with a liquid or with carbon dioxide gas.

If the prognosis is cancer, the uterus and possibly the ovaries areremoved. If it is fibroids, drugs are given for several months to shrink the growths.

Later the doctor re-enters the uterus with a hysteroscope and cutting tool and removes the fibroids. Polyps are similarly removed.

If there are no growths and the woman no longer wants to bear children, the endometrium is cauterized with an electrical wire or laser beam.

Such treatments require general anesthesia or a spinal block and must be administered in a hospital, said Dr. Benjamin Gocial, a gynecologist at the Philadelphia Fertility Clinic. But patients can go home the same day; there are no incisions and no scars.

Women may go back to work the next day, Dr. Gocial said. They may feel sore for one or two weeks, he added, but they are not in great pain.

Recently, women who do not have bleeding problems have begun asking their doctors to perform endometrial ablations to stop their periods, Dr. Phillips said. Many are in their early 40s and do not want more children, he said.

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