Endometrial ablations to control excessively heavy menstrual periods, which afflict about 20 percent of women, are becoming more accessible for women, as doctors here have begun doing the procedure in their offices more frequently.

The procedure, which until the last couple of years was performed mostly in outpatient surgery centers and hospitals, is becoming more common, as women seek alternatives to long-term hormone therapy and hysterectomy to control heavy periods.

Dr. Scott Schade, of Spokane-based Rockwood Clinic PS, was one of the first doctors here to begin doing a form of ablation in-office that uses sound waves to destroy the lining of the uterus, called the endometrium, leaving women with little or no menstrual bleeding. The procedure also often reduces the amount of cramping and premenstrual syndrome that women with difficult menstrual cycles experience.

Schade says offering the procedure in the office setting has made it accessible and affordable for more women. Schade says about 90 percent of his ablation patients report being satisfied with the outcome, and about 60 percent don't have any more periods at all, while most others see their periods and premenstrual symptoms reduced dramatically.

"When we can offer it in office they understand how safe and easy it is," Schade says.

Though the NovaSure ablation equipment that's used in the procedure, produced by Hologic Inc., of Bedford, Mass., first was approved by the Food and Drug Administration in 2001, and about 1 million of the procedures now have been done, Schade says more than half of all those radio-frequency ablations have been done over the past year. Until the last couple of years, they were done almost exclusively as outpatient surgical procedures at hospitals or surgery centers.

Conventionally, the two primary ways doctors have treated excessive bleeding or severe premenstrual problems have been with hormone therapy, in the form of birth control pills, or by hysterectomy, the surgical removal of the uterus. Endometrial ablation, which also is done by other methods, now is becoming a more accessible alternative here, says Dr. Cristian Andronic, who also performs ablations using the NovaSure system at his Women First PS clinic here.

One of the major advantages of ablation is that it leaves a woman's natural hormone balance intact, and eliminates the need for long-term hormone therapy, Schade says. It's a much less invasive alternative to a hysterectomy, he says, which generally requires between six and eight weeks of recovery time.

The primary medical problem treated with the ablation procedure is menorraghia, defined as unusually heavy menstrual flow, which is a problem for between 10 percent and 20 percent of women, and becomes more of a problem for women as they age, says the National Women's Health Resource Center.

Schade says women tend to have more problems with their periods as they age because their ovaries produce fewer eggs. He says radio frequency ablation is an appropriate therapy for women who have trouble with their periods and don't plan to have more children, even if they don't strictly fit a medical definition of menorraghia.

"It's basically to improve the amount of bleeding," Schade says.

Andronic says it's difficult to gauge just how much bleeding constitutes menorraghia precisely, so patient perception is a key factor in determining whether menstrual periods are problematic.

"It's very subjective. There's very little correlation between amount of blood loss and the woman's perception of her period," he says.

Once a physical workup is completed to determine the absence of cancer or other problems, such as uterine fibroids that could cause excessive bleeding, the procedure becomes a good option for up to 70 percent of patients who have troublesome periods, he says. Hormonal imbalance is by far the most common underlying problem, he says.

He says not everyone, however, is a good candidate for the procedure. For example, a woman who thinks she may want to become pregnant again at some point should not have the procedure. Though it is not a birth control method and there is a small chance a woman could become pregnant after the procedure, the pregnancy most likely would be abnormal, and women are advised to use some form of birth control following endometrial ablation, Andronic says.

Schade asserts that once a woman has completed childbearing, there's no particular reason she needs to continue having periods.

The way the lining of the uterus works, the cells just below the surface produce a layer of blood and tissue throughout a woman's cycle, during the time that her body produces estrogen. Then, when an egg is released from the ovary, that triggers the body to begin producing progesterone, which causes the veins below the surface to constrict and stops the buildup of the lining, making it more compact. At the end of the cycle, if no fertilized egg has become attached to the uterine wall, that compacted layer is sloughed off.

As a woman ages, even when she may be some years away from menopause, she might not produce an egg each month, so the progesterone production is not triggered, resulting in a thicker lining with bigger, more open blood vessels and a heavier period.

"The basic problem is not enough progesterone," for most women experiencing uncomfortably heavy periods, Schade says.

In addition to the blood and tissue, the endometrial cells also produce prostaglandin, a chemical messenger that works within the cell to contract blood vessels, which is responsible in part for cramping and premenstrual symptoms, Schade says.

How radio-frequency ablation works

To prepare for the procedure at Schade's office, a patient is given intravenous sedation by an anesthesiologist. At some other physicians' offices here, such as Andronic's, oral pain medications and a local paracervical block are administered in lieu of the IV sedation, says Erika Evenson, a representative here for Hologic.

Andronic's patients take a series of oral medications beginning the day before the procedure, such as one to soften the cervix, and at the office receive an intermuscular pain reliever, he says. The paracervical block is administered about 10 minutes prior to the procedure, he says.

The physician inserts the radio-frequency transmitter into the uterus, where it is spread out like a fan. The transmitter has two antennae that are covered with a gold-plated mesh screen. The device performs a test to ensure that the uterine wall has not been perforated, then gently sucks the uterine wall onto it. It then emits energy that vaporizes the water molecules in the cells, destroying them and leaving behind scar tissue that insulates the uterine wall and creates an increasing resistance, called impedance, to the sound waves. Once the resistance reaches a certain level, the device shuts off automatically.

The procedure takes about 90 seconds. Once the IV sedation is stopped, the patient awakes within minutes and is moved to a recovery area for a short time. Afterwards, because of the sedation, the patient needs someone to drive her home, and is advised to take it easy the rest of the day.

Andronic says that the sensation a patient experiences during the procedure is akin to something most of his patients already have experienced.

"The way I usually present it, and women relate to that, is it's like one bad contraction," and lasts just about as long, Andronic says.

Schade says it's common post-procedure for women to have some significant cramping, for which they are given pain medication. By the next day, the cramping is usually less than that of a typical menstrual period, and most women can resume their normal activities with no problem at that time. For about a week, the woman will have some discharge of the tissue that was ablated, also much like a period.

Schade says doing the procedure in the office saves patients time. Patients at Schade's office can check in at the front desk and be completely finished a little more than an hour later, while having the procedure at a hospital's day surgery center usually takes several hours, he says.

Having it done at a doctor's office also frequently saves patients money, Schade and Andronic say. As an in-office procedure, it's typically covered as an office co-pay procedure by many insurance plans, rather than as an outpatient surgical procedure, which is frequently billed at a percentage by many insurance plans, each says.

Andronic says that without insurance, the procedure costs about $3,500 when done in the doctor's office.

People are less afraid to have an office procedure, but Schade says he prefers having an anesthesiologist there to deliver intravenous sedation to the patient, so he can concentrate on the procedure and know that the patient's needs for comfort are being taken care of.

There are a few other providers in Spokane, including Spokane OB/GYN PS and Northwest OB/GYN PS, that now also are doing the procedure in-office, giving patients oral pain medications and a paracervical block rather than intravenous sedation, Hologic's Evenson says.

Other methods of ablation also are available, including a cryotherapy version in which the cells are frozen, or an electrocauterizing procedure. By comparison, other methods, such as cryotherapy, take longer, up to 20 minutes for the procedure, Schade says. Because it measures the depth of the treatment via radio frequency and turns off automatically, the radio-frequency method gives a precise and consistent result, Schade says.