Synopsis
Compare endometrial ablation with hysterectomy after appropriate medical and structural treatment, confirm reproductive and endometrial suitability, and support informed consent about effectiveness, recovery, complications and future surveillance.
- Consider specialist procedural care when HMB is severe, medical treatment is declined or unsuccessful, or a structural lesion needs direct treatment; do not jump from one short tablet trial to definitive surgery.
- Endometrial ablation destroys the uterine lining to reduce bleeding while leaving the uterus in place; it is suitable only when future pregnancy is not desired and the cavity is appropriate.
- Ablation is not contraception. Use reliable contraception afterwards because pregnancy remains possible and carries increased ectopic, miscarriage, preterm and abnormal placentation risk.
- Before ablation, exclude pregnancy, assess the cavity and fibroids, address infection, investigate endometrial risk and obtain histology where indicated; device limits determine acceptable cavity dimensions and myometrial integrity.
- Ablation may cause amenorrhoea or reduced bleeding but does not guarantee either, and some patients need repeat treatment or later hysterectomy.
- Hysterectomy removes the uterus and is definitive for uterine bleeding; route may be vaginal, laparoscopic or abdominal according to uterine size, disease, previous surgery, expertise and other planned procedures.
- Discuss total versus subtotal hysterectomy, cervix implications, tubes and ovaries as separate decisions, expected recovery and effects on fertility and menopause.
- NICE advises a full discussion before hysterectomy covering sexual feelings, fertility, bladder function, complications, alternatives, psychological impact and expectations.
- Conserving normal ovaries avoids immediate surgical menopause, although menopause may occur earlier after hysterectomy; removing them may be appropriate for separate disease or cancer-risk indications.
- After either procedure, escalating pain, heavy bleeding, fever, offensive discharge, urinary problems, leg swelling, chest pain or breathlessness needs urgent review.
Key red flags
Future pregnancy desire, current pregnancy or uncertainty about completing fertility makes endometrial ablation inappropriate because subsequent pregnancy can be dangerous.
Endometrial hyperplasia, suspected cancer, unexplained postmenopausal bleeding or unassessed high-risk bleeding requires histological diagnosis rather than ablation.
Large cavity distortion, active pelvic infection, very thin myometrium or previous surgery affecting wall integrity can make a particular ablation device unsafe or ineffective.
Persistent cyclical pain, haematometra or new bleeding after ablation needs assessment; scarring may make later endometrial sampling more difficult.
Removal of ovaries creates immediate surgical menopause in a premenopausal patient and needs separate explicit consent, not automatic inclusion in hysterectomy.
Unrecognised ureteric, bladder or bowel injury after hysterectomy may present late with pain, fever, ileus, urinary leakage or renal dysfunction.
Increasing pain, fever, ileus, urinary leakage, haematuria or renal dysfunction after hysterectomy may indicate bowel, bladder or ureter injury.
Unilateral leg swelling, pleuritic pain, unexplained tachycardia, hypoxia or breathlessness during recovery requires urgent VTE assessment.
Investigation priorities
Confirm that pregnancy is absent and future pregnancy is not desired before ablation or hysterectomy.
Management branches
HMB remains unacceptable after adequate medical and lesion-specific management or the patient declines those options.
- Reconfirm diagnosis, pain mechanism, endometrial assessment, cavity anatomy, prior treatment and the patient’s fertility and bleeding priorities.
- Compare ablation’s shorter recovery and retreatment risk with hysterectomy’s definitive bleeding control and greater operative recovery and complication burden.
- Offer further medical, hysteroscopic, fibroid or no-procedure alternatives and document the patient’s material values before booking surgery.