uterus from myhealth alberta
reproductive system from myhealth.alberta.ca

It’s now been five months since I had an endometrial ablation. I thought I would write a few thoughts about it for anyone who might be considering having this operation, since it’s surprisingly hard to find useful personal accounts of this procedure online. While this is a different sort of content for this blog, since reproductive health is a feminist issue and because I frequently argue the personal is political, it seems pretty on brand!

As many of you know, I’ve had almost lifelong issues with my periods – I started menstruating fourth months shy of my twelfth birthday (so that’s 24 years ago this month! Next year I should have a quarter-century party perhaps?!) and by the time I was twelve I was taking a regular prescription painkiller during my period. (Sidenote: these painkillers are probably what gave me a hiatus hernia, which ended up causing me agonising pain as an undergrad; long-term use of NSAIDs can do massive damage to your digestive system. However I carried on taking this painkiller – though I tried to reduce my usage as much as possible – but none of the other options I tried had the same effect. Hurrah!) When I was sixteen I went on the pill for the first time – not for contraceptive reasons (it would be a long time before that was relevant!) but to control my periods. That helped a little, but I suffered quite a few side effects that never went away, so I ditched them after six months or so. At university I tried another pill; again after six months I dropped them because of side effects more aggravating than painful periods – and suffered a massive breakthrough bleed that I had to take a coagulant to stop, which freaked me out enough I didn’t try a hormonal contraceptive for several years. (Another sidenote: when I went crying to the GP about this bleeding – it really freaked 20-year-old me out! – I was told not to be hysterical. I was also told my periods would improve when I had a baby. Definitely on the cards then…!) I took a bunch of different supplements and changed my diet to see it it had an impact – no dice. In the meantime I had lots of different tests. At one point I was diagnosed with PCOS, and then that diagnosis was rescinded. I certainly suffered from luteal cysts that often caused extreme pain during ovulation, too. I had several uterine polyps removed under general anaesthetic. Then I had a Mirena put in, which stopped the polyps returning but made me put on about 20lbs in a few weeks, and ended up needing to be surgically removed because it got stuck in my cervix.

I’m not detailing all this personal medical history to make anyone uncomfortable or to overshare, but just to give readers (particularly those who don’t menstruate) an idea of just how many options the average person with problem periods may try. Anyway, not long after I had the Mirena out, Kieran and I decided we were open to the idea of conceiving. We assumed it might take a long time because of my problems so when I got knocked up pretty quickly it was quite a lovely surprise!

Three months after our daughter was born, my periods came back. On Halloween. Yes, really! The universe has a horrible sense of humour. This was despite the fact I was breastfeeding around the clock and had many friends whose periods hadn’t returned for a year or more after birth. I’m not ashamed to admit I cried. How was I going to cope with a baby and my periods? Maybe they would be better now, I thought hopefully.

Reader, they were not. I bled and bled and bled, often in agony. I gave it lots of time to get better, because hormones after pregnancy are whack. But when my baby was ten months old I went on a combined contraceptive pill as by this point I wasn’t worried about my milk supply dropping. I had researched the pill very carefully and it paid off – virtually no side effects, much lighter and less painful periods. I might take two or three prescription pills the whole period. That was great!

Then I had a pulmonary embolism probably caused by taking the pill. Whoops!

As you can see, I had come to the end of the line on medical options by this point. As we’d decided to have only one child, it was an easy decision (though not an unemotional one) to go for an endometrial ablation. This is only an option if you do not want to conceive again, as it’s unlikely you could carry a pregnancy to term and it would probably be dangerous to do so. Luckily, my GP was very happy to refer me and my surgeon was very happy to do it. This isn’t always the case for women who want fertility-ceasing treatments, where there is a lot of policing of our reproductive bodies and institutional anxiety about whether we will regret becoming functionally infertile.

There are several methods of endometrial ablation. I had radiofrequency, which I believe is the most commonly used. At my hospital, ablation is done under general anaesthetic. From everything I’ve read, unless you are at high risk under general, don’t go for a local! That numbs your cervix but you can feel what is going on inside you and by all accounts that’s not a good time. The actual operation takes only a few minutes and you should, even after a general, be able to go home the next day.

When I came around I thought – okay, this is going to be hard for a couple of weeks, as my pain levels were very high. I was given several boosters of morphine over the first few hours I was on the recovery ward and then in my room. So I was very pleased that my surgeon wrote me a script for codeine, as the NHS guidelines suggest taking paracetamol afterward, which I knew would do absolutely nothing! But in fact my recovery was much less painful than anticipated. I had virtually no bleeding, which I think is a sign my surgeon had done a very tidy job cleaning up inside, and I only needed the heavy duty painkillers for a day or two. I was signed off work for two weeks, which I took because I was exhausted, but I wouldn’t be surprised if a lot of people only need a week. However, do not plan to have less than this. My hospital recommended a week minimum, and I’d ignore the online advice of only 2-5 days off unless you absolutely can’t afford to.

But here’s what you really want to know: how are my periods now? Well, I’m still quite cautious talking about the status quo, as sometimes the effects of ablation reverse over time. Still, five months on, I am very glad I had it done. My periods did not stop altogether, unfortunately, but they are so light that I hardly notice them. During my last period I did not take a single painkiller. Not even basic ibuprofen! I’ve gone from having to lie on a towel at night because of leakage to having a pad in the morning that is barely stained.

A word of caution: the only side effect I’ve noticed, but it has impacted on me, is that I’ve developed acne on my cheeks. Cheek acne is a good indicator of hormonal change (although of course environmental factors can’t be ruled out). Changing hormone levels is not something any online guide to ablation ever mentions, and my surgeon certainly never mentioned it. I have only found one clinical study which talks about it. But this peer-reviewed study makes it clear that ablation seems to have almost as much of an impact on FSH levels as simple hysterectomy (when womb and cervix are removed but ovaries etc are left intact). That is, both procedures cause FSH level to rise, which indicates impaired ovarian function. Now, this study seems to neglect a number of other factors – endometrial ablation is most commonly performed in women who are at an age where they may be entering perimenopause, for instance – but nonetheless, the data seems to be to be convincing:

Compared to the preoperative level, 6 weeks, 6 months and 1 year after surgery, a significant rise in serum FSH was found in the hysterectomy group, as well as in the ablation group … An unexpected the finding was the equal rise of FSH level after the operation in both hysterectomized and ablated patients. A paracrine effect of the endometrium on the ovarium function, as seen in rabbits is often suggested, but never scientifically substantiated in humans. On the other hand, one can speculate, that also after endometrial ablation in some way the uterine and thereby the ovarian bloodflow is reduced, resulting in an `acute effect’, described by Stone. To proof a relationship of uterine surgery and a rise of the FSH levels, participation of a control group without uterine surgery should be appropriate.

So far as my searches have thrown up there doesn’t seem to have been much work done on this issue after this 1998(!) study, which as you can see in the quotation above raises a good many unanswered questions about the relationship between uterine and ovarian functions. (If any of my science buds know differently, please chime in.) I am not surprised by this, because in my experience if your reproductive system isn’t actively killing you then it’s hard to get the medical industry interested – particularly if you can’t be easily fobbed off with one pill or another. Of course there are exceptions to this, as my current GP for instance shows! But in my experience, if you aren’t able to do both your own research and self-advocacy, suggesting treatments to your medical providers and pushing for specialist care, you aren’t likely to get any help. This is very frustrating, since I know many people who don’t have the advantages I do – experience doing research, ability to access articles behind paywalls (see above) – and who end up suffering because no one will talk to them frankly about what the literature actually says and help them work out the best options for them as an individual, instead of offering a one-size-fits-all cure. Rising FSH levels are only seen as a cause of concern for women who want to conceive, but they can cause all sorts of perimenopausal/menopausal symptoms and so should be handled with more care than they seem to be in this case.

Anyway. I have really spotty cheeks right now and they make me feel pretty self-conscious. But I’m on a new skin care regimen (probably a good idea as I age, anyway!) and there’s always make up. For me, the price is worth having less pain, less mess, and much less exhaustion every month. I hope I continue to barely notice my periods until it’s time for them to stop altogether!