Endometrial Ablation Discussion

Interview with Dr. Buchele on Endometrial Ablation

Barry K. Buchele, MD, FACOG was kind enough to do this Q&A interview with me on endometrial ablation. Let's start out with a brief history of Dr. Buchele:

In addition to his practice of Obstetrics and Gynecology, Dr. Buchele has concentrated on Obstetrical Ultra-Sound, Operative Laparoscopy and Hysteroscopy. He also is the first physician in this region of North Carolina to begin performing Rollerball Endometrial Ablations.

Dr. Buchele is a Fellow of the American College of Obstetricians and Gynecologists (FACOG). He is also a member of the American Association of Gynecologic Laparoscopists and the American Society of Colposcopy and Cervical Pathology.

You can read more about Dr. Buchele by clicking the following link:
SPWH - Dr. Buchele

Question:
It appears that many women that end up having endometrial ablations/hysterectomies, have had tubal ligations. In your opinion, does having a tubal ligation have any relation to heavy bleeders, and is there any conclusive studies that support this either way?

Dr. Buchele:
When I was in residency, there were discussions among investigators about a "post tubal ligation syndrome." I was fairly convinced at that time that it existed. The truth is that all women will experience changes in their cycles with time. Many women have been on oral contraceptives for years prior to tubal or have been pregnant. Obviously, the bleeding patterns have been hidden so that after the oc’s or pregnancy the real patterns are now discovered.

Question:
Is the age of a woman directly related to the success of the ablation? It seems it works better for women closer to menopause.

Dr. Buchele:
Obviously the closer a woman is to menopause, the more likely the procedure will be successful. Most women within 5-10 years will have some regrowth of the lining and may start having periods even though they were amenorrheic after the ablation procedure.

Question:
Why does the rollerball or any type of ablation work better on one person than another does? Is it the way the doctor does it or is it our uterine linings themselves?

Dr. Buchele:
Some women have a condition called adenomyosis in the uterus in which the lining grows deeply into the muscle of the uterus. The ablation cannot extend deeply enough into the uterus to destroy the lining, which keeps responding to the normal cyclic hormonal pattern. Another possibility is inadequate destruction of the lining in which case a repeat ablation might be successful.

Question:
What decides what method of ablation is best for one?

Dr. Buchele:
Most of the ablative procedures will have comparable results. It is the skill of the surgeon, which usually determines what is best in their hands.

Question:
Many women who have an ablation performed find it very hard to trust this approach as we wonder just how long the ablation will last. It does not offer that ‘permanent closure’ a hysterectomy would offer. In your experience, how long does a successful ablation last? Can you define a successful ablation?

Dr. Buchele:
I have had ablations that have been permanent fixes lasting 10+ years since they were done. Originally, we hoped that all patients would be rendered amenorrheic, but that is clearly not possible. Success in this situation is now defined as "is the patient happy with her results in the decrease in her flow".

Question:
Shouldn't the success rates be divided up according to health issues and age regarding their success rate and when explaining to a patient what an ablation is and how it will affect them, do it according to their age and health condition? I personally feel that ablations are greatly affected by abnormalities and age.

Dr. Buchele:
Without question this is important. However, the problem is that to take each individual variable into account would make data collection almost impossible. There would be inadequate numbers of, for example, patients who have bleeding problems associated with low platelets who are 35 and have failed with a particular birth control pill. The truth is probably that ablations will work in most women (most studies show a 95-96% success rate) regardless of the history – provided you take into account other pathology in the uterus such as fibroids or a very large uterus with adenomyosis.

Question:
Why do the doctor’s percentages of the success rate vary so much? I've been reading anywhere from 10%-80% for the success range ~why such a big spread?

Dr. Buchele:
What is the definition of success? If the percentage of patients who have a satisfactory decrease in bleeding is only 10%, then there is clearly a problem with the technique. If the definition of success is total cessation of bleeding (amenorrhea), then 10% is still low, and should be closer to 40-50%.

Question:
Can women w/fibroids benefit from an ablation?

Dr. Buchele:
Perhaps. A lot depends on the size and location of the fibroids. If the tumors are in the uterine cavity, then a resection of the fibroids can possibly be done. If the fibroids are on the outer surface of the uterus, then they will not be affected by the ablation, but probably had little to do with the bleeding.

Question:
Some women are getting repeat ablations performed. The first one may not work and/or it may offer some relief, but not enough, or...some women find their individual result will last about a year or two. When an ablation fails, does it not 'just fail'? Is getting repeat ablations a wise choice to make, or, is a hysterectomy more appropriate in situations as such?

Dr. Buchele:
It depends on the wishes of the patient. I have done about 10-15 repeat ablations over the last 10 years. Only one continued to bleed and in her case, she also had fibroids and hysterectomy was indicated. If a patient states she wants a guarantee that she will not bleed, then hysterectomy is the answer. I have been offering my patients laparoscopic supra-cervical hyterectomies over the last year with about half of then going home in 4 hours and most back to work and sexual functioning in 2 weeks.

Question:
How would one find an experienced doctor who has done successful rollerball ablations (or any kind of ablation for that matter)?

Dr. Buchele:
In all cases, the patient has a right to ask the physician about his/her experience and to have a frank open discussion about the different types of procedures done by that physician and why one method or another is selected for her. (The answer "I don’t know or have that experience" is a legitimate answer by the physician.)

Question:
As a physician, what is your own opinion on endometrial ablation as a hysterectomy alternative?

Dr. Buchele:
I am in favor of ablation as and alternative to hysterectomy. I will be offering the new Hydrotherm Ablation procedure in my office beginning next week as a totally outpatient choice for ablation that is safer than rollerball or laser ablation with equal results and success.

Barry K. Buchele, M.D.