Cons Of Endometrial Ablation and Fibroids: What to Know

September 13, 2025

Cons Of Endometrial Ablation and Fibroids: What to Know

Endometrial ablation is a minimally invasive procedure that destroys the uterine lining to reduce heavy menstrual bleeding. For many, it can be life-changing. But if you have uterine fibroids, especially those that distort the uterine cavity, ablation comes with important limitations and risks that are easy to miss in quick consultations. Here’s what to understand before you decide.

Endometrial Ablation 101

Endometrial ablation uses heat, cold, radiofrequency, or fluid to remove or destroy the endometrium. It is intended for people who are finished with childbearing and have heavy menstrual bleeding not well controlled with medication. It does not remove the uterus or treat the underlying causes of bleeding such as fibroids or adenomyosis.

Authoritative sources, including the American College of Obstetricians and Gynecologists (ACOG) and NIH’s MedlinePlus, emphasize that ablation is not a sterilization procedure; reliable contraception is needed afterward because pregnancy can still occur and carries significant risks after ablation.

Why Fibroids Complicate Ablation

Fibroids (benign uterine tumors) can protrude into the uterine cavity (submucosal), grow within the uterine wall (intramural), or project outward (subserosal). When fibroids distort or enlarge the cavity, the ablation device may not contact tissue evenly, leading to incomplete treatment and higher chances of persistent bleeding. Device manufacturers and the U.S. Food and Drug Administration (FDA) list significant intracavitary distortion from fibroids as a contraindication or caution for many ablation systems.

Key Drawbacks and Risks if You Have Fibroids

1) Lower chance of lasting relief and higher retreatment rates

Compared with patients without fibroids, those with cavity-distorting fibroids are more likely to have persistent or recurrent heavy bleeding after ablation. Many ultimately need another procedure—such as repeat hysteroscopy, myomectomy, uterine fibroid embolization (UFE), or hysterectomy—over subsequent years. Systematic reviews and comparative effectiveness reports note that retreatment is not uncommon, and risk appears higher in younger patients and those with fibroids.

2) It does not treat bulk symptoms from fibroids

Ablation targets the endometrium—the lining—but fibroids themselves remain. Symptoms like pelvic pressure, urinary frequency, constipation, abdominal enlargement, or pain caused by fibroid size or location will not be addressed by ablation. If those are your main complaints, a fibroid-directed therapy is usually more appropriate.

3) Pregnancy can still occur—and it’s high risk

Ablation is not birth control. If pregnancy happens afterward, risks are substantially increased, including miscarriage, abnormal placentation (such as placenta accreta), preterm birth, and uterine rupture. ACOG advises that patients who undergo ablation must use reliable contraception or consider sterilization if childbearing is complete.

4) Evaluation of future bleeding can be harder

After ablation, scarring and a thinned or obliterated uterine cavity can make endometrial sampling, imaging, or hysteroscopy more technically challenging. If irregular bleeding occurs later, it may be harder to rule out endometrial hyperplasia or cancer, sometimes necessitating more invasive evaluation.

5) Risk of cyclic pelvic pain or hematometra

Some individuals develop trapped blood in the uterus (hematometra) or cyclic pelvic pain after ablation. A specific pain syndrome is more likely if you previously had a tubal ligation (often called post-ablation tubal sterilization syndrome). These complications may require additional procedures and, in some cases, hysterectomy.

6) Procedure-related risks and device-specific complications

Although uncommon, risks include uterine perforation, infection, bleeding, cervical or uterine burns, fluid absorption problems (with certain hysteroscopic systems), and thermal injury to nearby organs. The FDA monitors ablation devices and advises adherence to device-specific contraindications and safety precautions, especially in the presence of fibroids that distort the cavity.

7) Not appropriate for several common scenarios

Known or suspected endometrial cancer or precancer (atypical hyperplasia)
Active pelvic infection
Desire for future pregnancy
Significant uterine cavity distortion from fibroids or congenital anomalies
Postmenopausal bleeding

Before ablation, most clinicians will confirm the uterine cavity’s size and shape with ultrasound or office hysteroscopy and may sample the endometrium to exclude cancer or precancer.

Special Considerations With Fibroids

Submucosal fibroids

Small submucosal fibroids (those protruding into the cavity) can be a major cause of heavy bleeding. In many cases, a targeted hysteroscopic myomectomy (removing the fibroid from inside the cavity) offers better bleeding control than ablation alone. Some surgeons combine hysteroscopic myomectomy with ablation, but this should be individualized.

Intramural fibroids

Fibroids within the uterine wall may still contribute to bleeding and pain, and they can reduce ablation success if they distort the cavity or are large. Fibroid-directed options (UFE, radiofrequency ablation of fibroids, myomectomy) may offer more durable symptom control.

Alternatives to Consider

The “best” option depends on your goals (bleeding control, fertility, avoiding surgery), fibroid size and location, and overall health. Evidence-based alternatives include:

Levonorgestrel-releasing intrauterine system (LNG-IUS): Often first-line for heavy bleeding; can substantially reduce flow and cramps. May be less effective if the cavity is markedly distorted by fibroids.
Medications: Tranexamic acid during menses; hormonal options (combined pills, progestins); and, selectively, GnRH analogs or antagonists for short-term fibroid shrinkage.
Hysteroscopic myomectomy: Removes submucosal fibroids and preserves the uterus; often effective for bleeding control.
Uterine fibroid embolization (UFE): Minimally invasive radiology procedure that shrinks fibroids and improves bleeding and bulk symptoms.
Radiofrequency ablation of fibroids or MRI-guided focused ultrasound: Uterus-sparing options that target fibroids directly in selected patients.
Hysterectomy: Definitive cure for bleeding and fibroids; higher upfront risk and recovery time, but lowest chance of recurrence.

How to Decide: Questions to Ask Your Clinician

Do my fibroids distort the uterine cavity? If so, how does that change ablation success or risks?
What is the likelihood I’ll need another procedure after ablation in my situation?
Could hysteroscopic myomectomy or UFE better address my symptoms?
How will we safely evaluate any bleeding after ablation?
What contraception will I use after the procedure?

Bottom Line

Endometrial ablation can help reduce heavy bleeding, but it is not a fibroid treatment and has important limitations—especially if fibroids distort the uterine cavity. It may leave bulk symptoms untouched, increase the likelihood of retreatment, complicate future evaluation of bleeding, and carries rare but serious risks. A careful assessment of fibroid size and location and a frank discussion of long-term goals will help you choose among ablation, fibroid-focused therapies, or hysterectomy.

This article is for educational purposes and does not replace personalized medical advice. Discuss your specific situation and priorities with a gynecologist who manages both heavy bleeding and fibroids.