Outpatient endometrial ablations
Imagine suffering for six years from incredibly heavy menstrual flow only to discover you can solve the problem in 90 seconds – in an outpatient clinic, with local anesthetic and no incisions and be back on your feet the same day. For 39-year-old Brenda Kleisinger ofReginathat’s exactly what happened. “It was amazing. I spent so many years bleeding, thinking it was normal and just something I had to put up with and then it was fixed in 90 seconds,” says Kleisinger.
This past September, Kleisinger underwent a global endometrial ablation at the Women’s Health Centre at the Regina General Hospital where she works part-time as a nurse.
A global endometrial ablation, or office-based ablation, is one of two kinds of ablations. The other is called a resectoscopic endometrial ablation, which is generally performed in an operating room under spinal or general anaesthetic. With a resectoscopic ablation, fluid is used to distend the uterine cavity and under direct vision by the gynaecologist, the cavity is resected or coagulated.
“Although resectoscopic ablations are just as effective as office-based ablations, the risks of resectoscopic ablations are higher,” says Dr. Sony Singh, Executive Director of the Society of Minimally Invasive Gynaecology and Director of Minimally Invasive Gynaecology at the Shirley E. Greenberg Women’s Health Centre in Ottawa, which also offers office-based ablations. “The fluid used to distend the cavity may lead to fluid overload and/or electrolyte imbalance which can be life threatening. There is also greater skill required for the resectoscopic approach and perforation of the uterus or bleeding may occur. The office-based procedures are more user-friendly and require less time without the need to distend the cavity with fluid.”
That explains why the Society of Minimally Invasive Gynaecology recommends global ablations as the preferred option due to their safety profile, ease of use and minimal anaesthetic requirements.
During Kleisinger’s ablation, her doctor injected a local anaesthetic into her uterus (cervix), and offered her a mild sedative for relaxation, although she was awake during the entire procedure. Her doctor then opened her cervix slightly, inserting a slender wand and extending a triangular mesh device into her uterus. The mesh gently expanded, fitting to the size and shape of her uterus. Precisely measured radio frequency energy was delivered through the mesh for about 90 seconds. The mesh device was then pulled back into the wand, and both were removed from the uterus. The entire procedure usually takes less than 5 minutes. After half an hour or so in recovery, many women are up and around and can go home or even go back to work.
Ironically, even as a nurse working in a health care setting, Kleisinger was unaware of office-based ablations until she started assisting with the procedure. “I was seeing all these women come in for it and thought to myself ‘Hey, this is for me’. After seeing how successful the ablations were, I asked my doctor for a referral.”
Kleisinger went home that night, and despite some cramping, she was back to her normal routine within a few hours. She has not had a period since then, saying her bleeding is “99.9 per cent better.”
Although some Canadian outpatient clinics do offer minimally invasive procedures such as office-based ablations, they are not yet the standard of care for the treatment of abnormal uterine bleeding in Canada.
Despite the availability of minimally invasive procedures such as global ablations, most gynaecological procedures for benign conditions are still performed in the operating room, including hysterectomy, the second most common surgery for Canadian women, after caesarian sections. In 2008-2009, some 47,000 women had the procedure, mostly for benign conditions such as uterine fibroids. Despite advances in minimally invasive procedures such as vaginal or key-hole laparoscopic hysterectomies, the majority of hysterectomies are still being performed through an open abdominal incision.
Dr. Hassan Shenassa, one of Dr. Singh’s colleagues at the Shirley E. Greenberg Women’s Health Centre in Ottawa, says office-based ablations are a safe and effective alternative to hysterectomy.
“This is definitely an alternative to a hysterectomy,” says Dr. Shenassa. “We can treat women here in the office who would otherwise be headed to the operating room. This type of ablation is a safe and simple procedure. We can do it as a one-time therapy for women who have heavy periods, finished their childbearing and who don’t have any abnormalities in their uterus.”
Not all Canadian hospitals, however, are equipped with minimally invasive outpatient clinics such as the ones in Ottawa, Regina and other cities. In order to create one of these clinics, hospitals would have to justify taking money away from one surgical stream in order to fund another, in this case minimally invasive gynaecological surgery. With global funding allocations, there is only so much money to go around.
One could say the question for hospital administrators then becomes “How important are ‘quality of life’ procedures for women compared to ‘lifesaving’ surgery for things like cancer, or heart and lung disease?” The answer lies somewhere between philosophy of care and fiscal realities.
“Although this isn’t cancer, this is about quality of life for women,” says Dr. Shenassa.
“Hysterectomy costs more than an ablation because of the hospital stay, the team that’s involved during the surgery and the greater re-admissions due to complications. The problem is with global budgets. If we replace hysterectomy cases with office ablations, unless I close the operating room, I’m not actually saving the hospital any money. The operating room is filled with other cases because the need is there. So in actual fact we are adding extra costs and never really saving the hospital any money. I appreciate that it’s a concern, but we just have to look at health care differently in Canada.”
Aside from the start-up costs for such a clinic, each disposable device costs hospitals about $1,000, which must be financed out of overall budgets. While patients are covered by health care, hospitals receive no extra funding for the devices.
“That is really tough when you look at budgets these days,” says Dr. Shenassa.
One solution, says Dr. Shenassa and many other Canadian gynaecologists, is for provincial governments to fund freestanding, minimally invasive gynaecology clinics for the treatment of benign conditions using treatments like office-based ablations. Under that model, more women could be treated less invasively more often, waiting lists for operating-room procedures could be reduced, hospitals would have fewer competing priorities and gynaecologists would have the incentive, financial or otherwise, to upgrade their skills in order to perform newer, minimally invasive procedures.
“At the end of the day, the issue is about access,” says Dr. Singh. “Access to all the minimally invasive options that are available to women nowadays, whether it’s an ablation, a hysteroscopic myomectomy, a hormone-releasing IUD, or a laparoscopic or vaginal hysterectomy to name a few. I believe in giving women the choice of having less invasive surgery wherever possible. It’s kind of ironic that I’m a surgeon and we actually celebrate in my clinic when we don’t do surgeries. We give each other a high five when we don’t book surgeries because we feel like we’ve done our job”.
Although minimally invasive gynaecology is perceived by many as a quality of life issue, surgically removing a woman’s ovaries, for example, during a hysterectomy (often elected by many women to prevent ovarian cancer) may nearly double her risk of developing lung cancer, according to a 2009 study at McGill University in Montreal.
Only about 15 per cent of smokers eventually develop lung cancer, however, lung cancer is the overall leading cancer killer of women in Canada. Other studies have shown that ovaries continue to emit hormones even after menopause that can protect vital organs such as the lungs and heart.