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BackTable / OBGYN / Podcast / Transcript #80
Podcast Transcript: Endometrial Ablation: Past, Present & Future
with Dr. Ted Anderson
Endometrial ablation has become a cornerstone procedure in the treatment of abnormal uterine bleeding, but is it the right solution for every patient that meets the indication? In this episode of the BackTable OBGYN Podcast, Dr. Ted Anderson from Vanderbilt University joins host Dr. Mark Hoffman to discuss the evolution of endometrial ablation and its contemporary utilization, including patient selection, technical considerations, and alternative treatments for abnormal uterine bleeding. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) A Patient-Centered Approach to Endometrial Ablation
(2) The Evolution of Endometrial Ablation: Historical Origins to Current Practices
(3) Advances in Endometrial Ablation Techniques
(4) Clinical Considerations in Selecting Patients for Endometrial Ablation
(5) Alternatives to Endometrial Ablation: Hormonal IUDs & Cryoablation
(6) Addressing Misconceptions and Rebuilding Patient Trust in Treatment
(7) The Future of Endometrial Ablation: New Technology, Fertility Preservation & Adenomyosis Management
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[Dr. Mark Hoffman]
Welcome back to another episode of BackTable OBGYN. This is your host, Mark Hoffman, and I've got a very special guest today. I know I say we always have great guests, but this is one that I'm personally very excited about. I've got a good friend, colleague, mentor, all the things, Dr. Ted Anderson, with us today. Ted, welcome to the show.
[Dr. Ted Anderson]
It's so good to be here, Mark. Appreciate the opportunity.
[Dr. Mark Hoffman]
No, it's a thrill for me. For our listeners, I'm not sure there's going to be many or any who don't know who Ted is, but for maybe the one person who doesn't have internet connection, Ted is at Vanderbilt University. He's Vice Chair of Faculty Development. He's Betty and Lonnie S. Burnett Professor of OBGYN at Vanderbilt College of Medicine. He's President of AAGL and a past president of ACOG. You've been around the block. You've done some pretty cool things, and we're excited to have you on today.
[Dr. Ted Anderson]
It's great to be here, talking about one of my favorite subjects.
[Dr. Mark Hoffman]
Yes, endometrial ablation. A lot of times, we'll have questions set up, but I felt like this is one where this is your story, so I'm excited to see where it goes. Before we dive in, I think it's important-- I always love to hear our guests tell our listeners about how they got to be where they are. I think I always used to look at people like you and our other medical leaders and heroes in many ways, and think they just came out that way. I like to hear how you got to be where you are, doing what you're doing.
[Dr. Ted Anderson]
The Reader's Digest version is I call myself the accidental physician. I never intended to go to medical school when I was in college, and just kept finding myself in positions where I was surrounded by people who expected a lot out of me and gave me good advice, and I had the guts to listen to that advice and take it. Another opportunity would come along, and I would just keep following those opportunities as they arise. The moral to the story is don't underestimate your abilities. Believe in the people who believe in you, and be willing to take a chance. Good things will happen. Doors will open.
[Dr. Mark Hoffman]
Say yes early in your career to a lot of things. I think I've talked a lot about that and how lucky I was from you and others who just put me in a position to succeed, and it took me saying yes and being willing to do that.
[Dr. Ted Anderson]
That's good advice.
[Dr. Mark Hoffman]
Yes. Your med school was in Vanderbilt. You're from Nashville originally?
[Dr. Ted Anderson]
Originally, I'm from San Diego, California. Then my father worked for the government. He was in what I would call economic reconstruction. He had an MBA and also a degree in engineering. It was his job to go into areas that had been destroyed by natural disasters and help rebuild them economically. We always lived along the coast in areas where there were hurricanes and earthquakes, and things like that.
[Dr. Mark Hoffman]
Golly, what an interesting job that is. You probably saw some amazing things.
[Dr. Ted Anderson]
Yes, that's true, and got put in some interesting positions. Initially, my desire was to go into marine biology because I always lived by the coast, and I actually started in marine biology and then realized fairly quickly that was not going to be a very productive field. It's a very closed group of people, and it's hard to do anything fantastic in marine biology. I got interested in cell biology, and while I was in marine biology, I was working with mariculture, artificial reefs and oyster reproduction, and stuff like that.
I really got into the cell biology of how all that worked, and that led me into looking at the cell biology of reproduction. That's how I ended up at Vanderbilt as a PhD in anatomy and cell biology, looking at cell-cell interactions as it relates to implantation.
[Dr. Mark Hoffman]
You got your PhD before you got your MD, right?
[Dr. Ted Anderson]
Yes, I still had not planned to go to medical school at that point, so I was interested in embryo-uterine interactions and defined molecules that appeared on the uterine surface in response to progesterone at the time of implantation, and established that implantation was a receptor-mediated phenomenon. I was then doing my postdoctoral fellowship at Baylor in molecular biology, and I had a good friend who was a guy named Gary Hodgin who was at NIH. He was a director of pregnancy research, and while I was in Baylor, he had moved down to the Jones Institute in Norfolk and was the director of research there. It was the first IVF center in the US.
About that time, my daughter was born, and my brother lived in the DC area. We were going to go visit him. I called Gary and said, "I'd love to come down and see what you guys are doing." He said, "Sure, come give a grand round," so I did. I was talking about the role of the endometrium in implantation, and Howard Jones at the time said, "That's really interesting. Do you think that that would work in humans?" I said, "Well, it works in rabbits and mice and monkeys and every species we looked at. Biology is pretty conservative, so my answer would be probably yes," to which he said, "You need to change your zip code," and he gave me a job there at the Jones Institute. That's how I ended up there.
My research became very clinically applicable, as you might guess, and we published a paper that had used my markers to look at how quickly you could get a uterus ready for implantation, and that was important with things like donor eggs and stuff like that. When that was published, Georgiana came in and said, "Look, you've gone as far as you can go in this business unless you go back to medical school." "Yes, ma'am." That's how I ended up in medical school.
[Dr. Mark Hoffman]
Unbelievable. That's incredible, honestly. I know we've known each other for a long time, but the things people have done in their lives, it just never ceases to amaze me. That's incredible that you've been able to be doing that kind of work at that location at that time with Dr. Jones, where it all started. That's incredible. What an exciting thing to be a part of.
[Dr. Ted Anderson]
It was an exciting time. It's an issue of being at the right place at the right time and being willing to take advantage of the opportunities.
[Dr. Mark Hoffman]
Being prepared when the opportunity comes along.
[Dr. Ted Anderson]
Oh, yes, that's obviously a part of it.
[Dr. Mark Hoffman]
You didn't do all those years of work and the due diligence and have all the chops when you gave the grand rounds to be-- Opportunities comes along, and when that door opens, you better be ready.
[Dr. Ted Anderson]
Exactly, that's true.
[Dr. Mark Hoffman]
Clearly you were ready. Med school was at Vanderbilt then?
[Dr. Ted Anderson]
Correct.
[Dr. Mark Hoffman]
Howard Jones was at Vanderbilt before? I know he's had…
[Dr. Ted Anderson]
His son was there.
[Dr. Mark Hoffman]
His son was there, right?
[Dr. Ted Anderson]
We had Howard Jones III, who's an oncologist, and he was at Vanderbilt.
[Dr. Mark Hoffman]
It was not related why you ended up in Nashville, or was there---
[Dr. Ted Anderson]
No, that was an independent, just happenstance, really. I didn't go to Vanderbilt because he was there, but he did happen to be there. I did my PhD there, and I thought it would be a nice place to go back. I really enjoyed the university, and it would be a nice place to go back. The dean was willing to give me credit for everything that I had done as a PhD. That was good as well.
[Dr. Mark Hoffman]
That's a big deal.
[Dr. Ted Anderson]
Yes.
[Dr. Mark Hoffman]
I'm guessing histology wouldn't have been a good use of your time at that point.
[Dr. Ted Anderson]
No.
[Dr. Mark Hoffman]
Me as an English major, I was in class with a bunch of PhDs, and I'm looking around going, "I don't even know what you're talking about." They had taught the class, and I felt like I was miles behind. Good. Then residency was at Vanderbilt as well?
[Dr. Ted Anderson]
I started at Brigham in OBGYN. At the time that I got there, that's when Brigham was undergoing a big change, and a lot of the key people that I was interested in studying with at Brigham left and went to Mass General. I'm like, "That's really not what I signed up for here." I decided to retool, and I left and did a year of surgical pathology and then ended up back at Vanderbilt to finish my residency there.
[Dr. Mark Hoffman]
Probably at the time it seemed like such a massive thing, but looking back, was that a pretty valuable year for you?
[Dr. Ted Anderson]
It was. It's just a blip when you look at it chronologically. It's daunting when you're in the middle of it, but it was real valuable. I learned a lot. I think anyone in OBGYN, particularly in GYN surgery, can learn a lot from understanding pathology. It really has helped me a lot. It helps me understand what we're going to be talking about today, as a matter of fact.
(1) A Patient-Centered Approach to Endometrial Ablation
[Dr. Mark Hoffman]
Let's dive in. We're going to be talking about endometrial ablation, and this is something that I have a lot of feelings and opinions about. I think our listeners want to hear what your thoughts and opinions are about it. Tell us a little bit how you got interested in this topic and a little bit of the history.
[Dr. Ted Anderson]
First, I should tell you how I got interested in hysteroscopy. When I was doing my fellowship, I did my fellowship with a guy named Jim Daniel, who was a pioneer in laparoscopic surgery back in the '70s and '80s, and I was with him during the mid to late-'90s. Laparoscopic surgery was still an evolving specialty within OBGYN at that time. He really did not like hysteroscopy. I thought, "Well, this would be a great opportunity for me to do something that I could really create a niche for myself because so many people don't like to do this and I did like it." I decided to devote a lot of my time to really becoming a good hysteroscopist. This was about the time endometrial ablation was beginning to emerge again as an area of interest.
I got very interested in that, and I've been involved in the background trials for probably three or four of the devices that have been out on the market. I got very interested in looking at the effectiveness and, more importantly, the downstream outcomes and how to choose the right person for endometrial ablation. That then led me to a little bit of a study of, how do we even think of that in the first place, and how do we get to where we are. I really have come to believe that endometrial ablation has been here for a very, very long time.
It has evolved over the decades, and it has risen and waned in interest, and that's because of the techniques that are used. It's also because of the talent that's required to do it, and it's also because of the alternatives that we have to endometrial ablation. I've come to the conclusion that, not surprisingly, anytime you're thinking of some procedure that you're going to do for a patient or offer a patient to address the issues that they have, you need to think about what are all the alternatives that are available and what's the very best alternative for this particular person. I think that is very well applicable to endometrial ablation.
[Dr. Mark Hoffman]
No, I appreciate that. I always try to think about the longer you do it, the more you think, "Well, if this doesn't work, then what's next?" I think patients, they're suffering in the moment, and it's not up to them to think about the big-picture stuff. They just want the problem solved, and we understand that. We want to listen and validate their concerns. At the same time, we could do this. There's another thing we could do that if it didn't work out, we've got more options. This one might be our last or second-to-last option. Those are things that I think we as surgeons have a little bit more of an opportunity to paint an algorithm for them that they're maybe not as interested in seeing play out.
[Dr. Ted Anderson]
Sure. I always like to give patients choices. I don't like to say, "This is your option. This is what you should do." I try to make my mission to teach the patient enough that she can make a decision that works for her, without necessarily letting her do something stupid, and then work with them to help realize that option that they want to pursue. I think you have to really understand and to convey to that patient the advantages and the pitfalls in that decision and the downstream consequences. That's what I've really learned a lot about over the last several years.
[Dr. Mark Hoffman]
No, it's great advice. It's taken me years to figure it out, but listening to patients and understanding their situation, their lives, their social situation. This may be what the textbook would say is the next best choice, but it doesn't have all the details of where this person lives or what their ability to be near a hospital. You and I both are in states that have large rural populations, and access is a real problem. This may be their only shot at dealing with this problem. Having worked in some rural areas, I've had to really dig in and listen to our patients and try to get a sense of--
They may have some ideas coming in, and like you said, we want to educate them with all the things that are out there. At the end of the day, we provide choices, they make decisions, and we have to be thoughtful and respectful of those decisions. Not saying we can't say no. I want a hysterectomy just because-- Make up some unreasonable reason. You have the right to say, "I don't feel like that's a comfortable choice," but to your point, give them choices and then respect that choice. That's something that took us a little-- When you're young and you think it all, versus I've had a few more years under my belt to help me get to that point, hopefully.
(2) The Evolution of Endometrial Ablation: Historical Origins to Current Practices
[Dr. Ted Anderson]
As you know, abnormal uterine bleeding is really, really common. That brings this really to the forefront of a great discussion on alternatives to treat that. It is historically something that has always been a problem. When you go way, way back to biblical times, women who had abnormal bleeding were basically ostracized from society. They were forbidden to partake in a lot of religious and societal activities during menstruation or if they were having abnormal bleeding. It had a huge impact on people, and there was a great interest in figuring out how to treat that.
I was surprised when I started looking into the history of this, how many different things had been done. You have to think, why would someone do that? When you consider the alternatives, there really wasn't a lot of other alternatives. When I look back at the first recorded example of treating abnormal bleeding, it's actually from the Bible. It's from the New Testament, and there's a story about a woman who had bleeding for 12 years. It says she had suffered much under many physicians and spent a lot of money trying to treat this and to no avail.
She heard that Christ was going to be at a certain place giving some discussions or teaching, and she thought, "If I could only touch his robe, I would be healed." She did touch his robe, and the thought was, or the passage is, that he felt the energy flowing from him, and he turned, and he said, "Daughter, your faith has made you well. Go in peace and bleed no more." That's really the first recorded that I can find-- The first recorded evidence of treating abnormal bleeding. If you go to the first non-biblical treatment of that--
[Dr. Mark Hoffman]
Some of our colleagues might think they could do that still to this day. That's true.
[Dr. Ted Anderson]
It wouldn't hurt--
[Dr. Mark Hoffman]
Unless his robe was made out of Surgicel or tranexamic acid or something.
[Dr. Ted Anderson]
Exactly.
[Dr. Mark Hoffman]
That's right.
[Dr. Ted Anderson]
If you go to the first non-biblical examples of that, it really started around the second century AD. This was really with the Greek gynecologists. There was an example of the use of a lot of plasters that were made and astringents that were created that were inserted into the uterus in order to stop bleeding. These were largely made of herbs like dates soaked in wine and things like that. Surprisingly, they were pretty effective at stopping bleeding or reducing bleeding. That went along for quite some time until when we really started seeing what we could recognize as really efforts for ablation really started around the mid-1800s.
This was the use of vaporization or something that at that time was called atmocosis. This was actually introducing steam into the uterine cavity with a pipe and a little catheter that was put into the uterus, and steam was introduced into the uterus. We don't have a lot of technical data about how long and under what pressures or anything like that. Eventually, there was a technique devised where there was an entry and an exit for the steam so they could control a little bit better the amount of time and the pressures and things like that. That got to be somewhat refined.
The first actual presentation of this as an option came in the late 1800s in Danzig, what is now Czechoslovakia, I guess. They described a series of about 800 patients, and they had about 700 of those 800 that were either cured or greatly improved. That was over 90% cure rate. Exactly how they define cured is unclear.
[Dr. Mark Hoffman]
That was with steam?
[Dr. Ted Anderson]
That was just with steam. Then later, there was a technique instilling boiling water into the uterus using the same device. These sound barbaric. When you think about what is the alternative to treat abnormal bleeding, it would be hysterectomy. At that time, over 70% mortality from hysterectomy.
[Dr. Mark Hoffman]
This is before antibiotics.
[Dr. Ted Anderson]
Absolutely. The alternatives were just not very good. People were willing to do some of these, what we would consider outlandish things, in order to stop abnormal bleeding that would allow them to participate more fully in society. I think it makes a lot of sense. The first hysterectomy wasn't really performed until about 1853. That was actually the first time a patient survived a hysterectomy. There really weren't great options at the time. Still, as I said before, mortality rates were over 70%. That really didn't change until the turn of the century.
It was around 1900, 1910 or so, when Howard Kelly had really begun to do a lot of work on looking at making hysterectomy or surgery in general safer. He made the comment that when you do this atmocosis or these alternatives that were being used at the time, it created a destructive sloughing surface, and that this sloughing surface was regenerative, and that would cause the problem of not necessarily completely destroying it. As that surface regenerated, it could cause potential problems. He recognized at that time what we now know is to be the greatest problem with endometrial ablation, and that is the regeneration of the endometrium.
[Dr. Mark Hoffman]
Interesting. It's not incomplete destruction. It's actual true regeneration.
[Dr. Ted Anderson]
Yes, it is. This is going back to my PhD. I remember a researcher at the University of Massachusetts. Her name was Helen Patakula, and she was working with monkeys, and she was trying to look at the whole concept of regeneration. She actually would take the uterus and she would scrub the uterus with gauze, trying to get all of the endometrium out, in hysterotomies in baboons, then she would sew the uterus back up, and then she would look. These baboons would completely regenerate the entire endometrium even though she had taken anatomical samples and shown that there was no endometrium whatsoever.
She came up with the proposal that there are these progenitor cells in the myometrial-endometrial interface, and if you don't destroy those progenitor cells, they have the ability to completely regenerate the entire endometrium. You think about it biologically, that's what you would want in a reproductive organ, that preservation. The uterus is an organ that is designed to regenerate, and it's very effective at doing that. The effectiveness of an endometrial ablation is that fine line between killing the regenerative capability without destroying the entire uterus. I don't think we ever really achieve that greatly. I think that's a problem. We have to understand what our limitation is.
[Dr. Mark Hoffman]
That's interesting. I always thought it was incomplete destruction, and then you had little pockets scarred in that had nowhere to go.
[Dr. Ted Anderson]
That does happen. Absolutely. That's the McCausland theory, the post-ablation syndrome, where you don't get endometrium destroyed, particularly up in the cornua, and that area regenerates. That happens a lot faster than what Patakula was showing us and what Howard Kelly was saying, and that's where you get these little pockets of regenerated endometrium up in the cornua with a scarred endometrium, so there's no exit. That postablation syndrome is, of course, one of the big reasons why endometrial ablations fail and people have hysterectomy subsequently, not for abnormal bleeding but for intractable pain.
[Dr. Mark Hoffman]
I think that makes sense. I'm trying to think where--- McCausland is a GYN. Where is he?
[Dr. Ted Anderson]
Yes, it's a father and son team in UC Davis.
[Dr. Mark Hoffman]
I met the senior, I think, at AGL one year, and he gave me his whole theory on all this, and I got it from the horse's mouth. He was a Duke fan. We watched the Duke-UK game together.
[Dr. Ted Anderson]
Oh, there you go.
[Dr. Mark Hoffman]
I think Duke won that game.
(3) Advances in Endometrial Ablation Techniques
[Dr. Ted Anderson]
He's a very charismatic guy. They came up with the concept of the partial endometrial ablation.
[Dr. Mark Hoffman]
I want to hear about that, because he told me all about that.
[Dr. Ted Anderson]
That was where you would just ablate, let's say, either the anterior surface or the posterior surface, but not both. What that would do is it would prevent that scarring that typically occurs with an endometrial ablation and provide an outlet for blood if there's been regeneration. That prevents that sequestration of regenerated endometrium in preventing the post-ablation syndromes.
[Dr. Mark Hoffman]
Hemiablation, he called it.
[Dr. Ted Anderson]
Yes, exactly. He was a big fan of that, and he still would be a proponent of it. Now, I think he was on to something, really. When you get down to it, he, I think, was a little bit of a visionary. That's what we really saw. Then, around the turn of the century, we saw the advent of antibiotics. We saw the advent of better surgical technique. The mortality rate for hysterectomy dropped to about less than 10%, 5% to 7%, or something like that. The concept of going back to hysterectomy instead of doing endometrial ablations was a little bit more favored.
Endometrial ablation fell out of favor for a number of different years until two or three things occurred in the 1920s, when we had the advent of the era of electrosurgery. This is when Harvey Cushing and William Bovey did all their experience and learned about how to use electricity to your advantage in surgery. Then the development of the resectoscope, which wasn't until 1989, actually. This was when Karl Storz had the combination of using the Hopkins rod lens and all the digital imaging. It brought hysteroscopy into play. Then, the advent of minimally invasive surgery in gynecology, which occurred in the 1980s.
When we started having all these things coming together, we saw a resurgence in the interest of intrauterine surgery, and in that case, then the actual destruction of the endometrium by-- it first started with lasers and then application of electrocautery or electrosurgery, and full-grading the endometrium. These were really propagated early on as mechanisms for endometrial ablation, and the success rates were pretty good.
When we finally got the rollerball endometrial ablation, that is when it really became popular because it was really difficult to-- As you might guess, using a laser fiber to go in and just tediously eliminate the endometrium line by line by line, that takes forever to do that. It was very effective. When the rollerball came into play, we're basically just burning away the uterine lining. Just mowing the lawn. It's exactly what I tell patients. It's just like mowing the grass or using a miniature steam roller and just going over everything and eliminating it, but even then, unless you get down to the basalis and destroy the basalis, you're going to get some regeneration.
[Dr. Mark Hoffman]
When were you doing a global rollerball, or were you doing Art McCausland's just back half? This theory is that when you did both halves, you had scarring. If you just did one half, you'd have decreased bleeding, but no scarring.
[Dr. Ted Anderson]
When I learned how to do it, this was before the McCauslands had really come out with their theory, and I'd never met them and so I was doing the traditional ablation as you think of it and getting the entire endometrium ablated and burning as far down as I possibly can. As you might guess, the success rate of the endometrial ablation at that time was really a function of surgical skill because you have a visual endpoint and so you would burn this down to the point until you felt like you had to completely destroy the endometrium and there was no real marker to tell you when you were there or not. You just had to know. That only came from experience.
[Dr. Mark Hoffman]
That was monopolar, so you were using saline. You were using glycine.
[Dr. Ted Anderson]
Correct, we were using glycine at the time. You had a time factor involved here as well. You couldn't dally around. You had to get to the point and get it done. It required a certain amount of skill and confidence level to operate within that cavity and feel comfortable. You might guess, not a lot of people did it or were interested in doing it. That is why we began to see the emergence of global endometrial ablation, which is so popular now. Global endometrial ablation was basically the concept of, "Let's develop some sort of tool that you can put into the urine cavity and ablate the entire endometrium at once. That's where the term global comes from.
What it was designed to do was basically take the skill requirement out of the procedure and provide an opportunity for someone who did not necessarily have the skill or the time to learn the skill to do a rollerball ablation, to be able to offer this option to patients and still get a good result. The first one that came out was the Thermachoice.
[Dr. Mark Hoffman]
That was the water balloon.
[Dr. Ted Anderson]
The old water balloon that came out with Ethicon. That was the first one that came out, and that one was pretty good. It first came out in about 1997 was the first one and of course, the balloon was latex. That was a mistake.
[Dr. Mark Hoffman]
Did it just melt?
[Dr. Ted Anderson]
No. People had latex allergies, and so it causes an immune sensitivity. They changed that to silicon in about 1999 or 2000. That made the balloon a little bit more pliable as well, and so it could really get into the cavity. This is when the McCausland started recognizing that post-deblation syndrome, because this was the technique that was not getting up into the cornua very well and was sparing the cornual epithelium, and that's where the regeneration was occurring. That led to the McCausland's recognition of the postablation syndrome and doing something to try to avoid that.
It did show that it worked really well, so a lot of studies came out doing some comparative studies, and we actually did one at Vanderbilt as well. We did a study where we had about 3,000 patients or so who had an endometrial ablation. Some of those had rollerball endometrial ablation, and some of them had thermal balloon endometrial ablation. Then we had broken down further into experienced people doing the ablation versus inexperienced people. The experienced people were considered those people who had had fellowship training in minimally invasive surgery, including hysteroscopy.
The inexperienced people were interns. What we found is if you were using the balloon endometrial ablation, that we had failure rate of about probably 9% or 10% and that was defined as people who end up having a hysterectomy within two years. It didn't matter whether I did the ablation or the intern did the ablation, the success rate was about the same. When we looked at the rollerball, if I did the endometrial ablation with a rollerball, the success rate or the failure rate was the same, about 10% in two years. If the intern did the rollerball, this failure rate was about 27%.
That really illustrated that number one, the rollerball endometrial ablation effectiveness was a function of experience. It also illustrated that the global endometrial ablations did exactly what they wanted to do, and that is to be able to take away that need for experience or technical skill and still be able to offer a good technique to the patient. What it also did is it shifted our onus from necessarily having the skill to do the ablation to the ability to pick the right patient. The success became more patient-dependent than it did physician-dependent. We had a lot of things that were defined as what made a good patient, or even more importantly, what did not make a good patient, or what predicted failure. This is where we began this roller coaster ride of what I called the evolution and the involution of endometrial ablations. We began seeing more and more endometrial ablation devices coming out using different energies, and the problem or the challenge was that they were using amenorrhea as their endpoint.
When you think about endometrial ablations, less than 50% of people ever who get any kind of endometrial ablation actually achieve amenorrhea. I think that's the wrong endpoint. The better endpoint is achieving eumenorrhea, or normalizing endometrial bleeding, so that it's not controlling your life anymore. If we reset that expectation to not achieving amenorrhea, truly replacing hysterectomy, but by reducing bleeding to the point that is controllable, then it becomes a good alternative. The key is trying to pick the right patient that's going to achieve a good result, but not have the complications of endometrial ablation.
(4) Clinical Considerations in Selecting Patients for Endometrial Ablation
[Dr. Mark Hoffman]
What is a good patient for global endometrial ablation? I think you and I both in our practices see a lot of patients who may not have been well selected for the procedure, and not an insignificant chunk of our case volume, at least more so a few years ago, but I was getting a lot of ablation failures in my practice. It's not necessarily that the ablation didn't do what it was supposed to do, it didn't do what the patient was counseled it would do. It's a big difference.
[Dr. Ted Anderson]
Yes, and I think that's on us, because we did not know enough about ablation to really counsel them appropriately. We were giving them information that we knew, we just did not know what we didn't know at the time, and this has come out over a long period of time.
Now, there's something that my daughter taught me. My daughter is an advertising specialist. There's something called the hype curve, and this is something that in every technology that is introduced. You see sort of a rapid increase in utilization and uptake. Then a slope where it begins to go down again, and this is what we call the slope of heightened expectations. You get something that works, and then you immediately think what else can I use this for? This is great. I'm going to use this on all these patients, and then you begin to start seeing these failures and you realize, maybe there's some situations where that isn't appropriate. That's where the research really begins, and you get then what we call the slope of enlightenment, and that's where people have now pulled back from doing endometrial ablations.
Now we're starting to get the studies that show, what is the right patient? Who should we not do ablations on? Then we get better selection. As we get better selection and we start seeing greater utilization, but appropriate utilization, that goes back up again. Eventually levels off into a plateau which is often what the manufacturers told you to do in the first place.
[Dr. Mark Hoffman]
Yes, nuts. It's interesting.
[Dr. Ted Anderson]
What we found over years through multiple people looking at different scenarios is that there are some really good predictors. The best predictor is age, and so we find that people do substantially better with endometrial ablation if they're over 40. I almost never do endometrial ablations on anyone under 40 anymore. Occasionally I will, but I warn them that they likely are not going to get the expected result.
People who have very prolonged bleeding tend to not do as well with endometrial ablations, as people who have shorter bleeding less than seven days or so. People who have dysmenorrhea or chronic pelvic pain, those people are often going to fail endometrial ablation as well, not necessarily because of bleeding, but because of increased pain. Because they're sensitized, and so, they're going to end up with hysterectomy. People who've had multiple prior C-sections, or have had multiple uterine operations, of course, we think myomectomy is being a contraindications for endometrial ablation, but it's not really. It depends on if you have full thickness scarring in the endometrium or whatever, but still a lot of the global endometrial ablations have been shown to be safe in those patients. Or people who have prior sterilization, because that's the risk of this post sterilization tubal syndrome.
[Dr. Mark Hoffman]
Is that still recommended? I feel like I'd heard, it's been a little while since I've looked at it, but the more recent data that I recalled was that you looked at everything those who had tubals and those didn't, and it was similar, so, I need to recheck my sources, though.
Can you talk a little bit about what we know about that, about post tubal sterilization ablation syndrome?
[Dr. Ted Anderson]
Yes. This goes back to the McCausland's and the techniques where we used endometrial ablation that did not get up into the cornea very well. All of the technologies that came out after the thermal balloon, really sort of approached that, or address that issue, so we saw less and less of the post ablation syndrome after that, because we got the better global ablation of the endometrium.
[Dr. Mark Hoffman]
Makes sense.
[Dr. Ted Anderson]
We saw less of that, but the early on, it was a big problem. Obviously, people who have uterine anomalies are not appropriate candidates for global ablation. People who are at increased risk for endometrial cancer, you should not do endometrial ablations on. People who have a history of hyperplasia, you should not do endometrial ablations on those people as well.
The ideal candidate is someone who's over 40, who has a parity of less than 5, who has a benign endometrium, biopsy proven benign endometrium, and an anatomically normal uterus, has completed their childbearing, has adequate contraception, because endometrial ablation is not considered a contraception, and you don't want to get pregnant after it, because placentation will generally be abnormal. It's not that it doesn't because fetal anomalies, but it causes fetal demise, because you have insufficient placentation.
People who are unresponsive to hormonal therapy, or a contradiction to hormonal therapy, and your desire to avoid a hysterectomy. Sometimes we might say it might be a poor candidate for hysterectomy. The problem is that one's a little bit of a gray zone. Sometimes the person who's a bad candidate for hysterectomy, let's say, the morbidly obese diabetic patient is also not a good candidate for endometrial ablation, because when it fails, your hysterectomy is the only option at that point.
[Dr. Mark Hoffman]
That's what we were talking about earlier. I think about Mirena's protective lining, and it's not the only thing you got left right. I think that's something that--
[Dr. Ted Anderson]
Exactly.
(5) Alternatives to Endometrial Ablation: Hormonal IUDs & Cryoablation
[Dr. Mark Hoffman]
What about I've had a couple instances where we have patients who are truly non-operative, liver failure, ascites, all these things, and they're bleeding because they're on blood thinners, or because their liver liver function is terrible. They're not making the necessary clotting factors and things like that, where they're a likely atrophic because they can be older menopausal, so Mirena is not a good option. I've done a couple what I've sort of-- I don't know if I've heard it or termed it, like a rescue ablation.
[Dr. Ted Anderson]
Absolutely, it's a last-ditch effort to try to avoid a hysterectomy.
[Dr. Mark Hoffman]
There's been a few of those that worked really well, like it was one like multiple DNC's and all these things, and progesterone's been tried and I'm going, "That that's not going to help," but we do it. We have not solved the liver failure, but it's one thing that has allowed us to not come in with a hysterectomy either. Chronic anemia and transfusions, that's been a situation where I have done it in patients who would otherwise check a lot of the do not use boxes in this, but that's been really useful.
[Dr. Ted Anderson]
Yes, you're absolutely right. I've done the same thing, and it's a great tool to have in your armamentarium, because occasionally, they're great patients because they're probably not going to regenerate their endometrium very well. They're sick as stink to begin with, and this is something you can do that's not very invasive, is not very taxing on their system to do a quick ablation, particularly a global ablation, and get them in and out of the operating room quickly. Now that's going to stabilize them enough that they can have whatever therapy they need, and so often, that can become a good friend of the internist or whoever's taking care of that patient to at least stop that portion of their disease process.
It's a good option to have. That goes back to the concept you have to think about this in terms of relative harm, and relative good that you do for a patient. You mentioned the Mirena. I think the Mirena is one of the greatest inventions of all time. It's been one of the reasons we've been able to reduce hysterectomies, and also reduce endometrial ablations, because its effectiveness is probably better than some of the endometrial ablations, and it's reversible. What more could you ask for?
Sometimes patients are a little hesitant to use it, because they're nervous about the hormones. They don't understand how it works. They're nervous about having an object inside the uterus. They think it might be actually a contraceptive ,which is really designed to be a contraceptive, but it's not a report a patient, and so we have to explain that to patients. I think the Mirena IUD and other progestin eluding IUDs are wonderful options for treating abnormal bleeding. It has been one of the pieces of the equation that you need to consider when you're thinking about alternatives with an endometrial ablation.
[Dr. Mark Hoffman]
I echo that. I think that leaving a gestural IUD Mirena is one of the most incredible medical advancements devices ever created to do all the things. It treats a problem of heavy periods. Oh, by the way, it's birth control, oh, by the way, it's the lowest possible hormone dose we have, oh, by the way, it's no pill you have to remember, oh, by the way, your periods go away, just like while we're at it.
I think about the Dalkon Shield, and the impact, just the generational impact. I was in residency around the time they were doing a lot of research on the Mirena, and really sort of pushing it back out into the market, and getting to work with people like Mishka Terplan, who had really dug into the data on the Dalkon Shield. Reading about the guy who, I guess, put it out, did he spend time in prison, or at least got in trouble for falsifying some of the data that it actually wasn't as bad. It wasn't that threads were a problem. They actually went back and reanalyzed the data, and it was actually safe the whole time.
There were other reasons why those women got sick, but what the media and all those things can do to really scare a generation of women away from a pretty great, and the Dalkon Shield's not the Mirena. They're very, very different, but just IUDs, in general. Copper IUDs have been around since Egyptian times?
[Dr. Ted Anderson]
I know. It's amazing, and they're very effective. They have such little impact on your body. Have you ever seen a Dalkon Shield?
[Dr. Mark Hoffman]
Yes. I've never removed, but I've seen a photo of one. I've taken out a Chinese steel ring before. I've never seen a Dalkon Shield come out of a baby.
[Dr. Ted Anderson]
The Chinese have some interesting-looking IUDs
.
[Dr. Mark Hoffman]
There's a great poster. It's got all the ones from all over the world. It's fascinating. It's amazing to see what shapes they've come in.
[Dr. Ted Anderson]
I remember taking a Dalkon Shield out of a patient who was about 60-something years old. She had that Dalkon Shield in for over 50 years. It just never bothered to take it out. Now she was starting to have this serious discharge. We went in and took out the Dalkon Shield. It's a pretty nasty looking thing. It's really regressive.
[Dr. Mark Hoffman]:
It's like a fish or something like that, right? It looks like it was never meant to come out.
[Dr. Ted Anderson]
I know.
[Dr. Mark Hoffman]
Was it supposed to come out?
[Dr. Ted Anderson]
I don't see how you would get it out, normally. It had these shields that sort of angled down, and it would sort of prevent it from coming out. The Chinese rings, I'm pretty sure were not supposed to come out. The one that I took out in the office, she was committed, and we had talked. We had a hysteroscope and I saw the hook on it. I put my foot in the table, like I was doing a forcep, and I kept checking on her like, "You okay?" She was just kind of nodding.
She was very stoic, and I had to keep checking to make sure I wasn't pulling her uterus out with me. That thing was very comfortable where it was, and was not interested in coming out. To think about those versus Marina, it's just like, man, it's pretty easy. Listen, two guys talking about it. I've never had one before. I get there's more to it than that. I'm actually trying to figure out. I'm working with some biomedical engineering students about a better way to place IUDs, because I think we deserve that, at least to look into it. It's a phenomenal device without question. It's an incredible device.
[Dr. Mark Hoffman]
Absolutely. I think patients accept it pretty well also, regardless of age, because it's so versatile. It really brings up a great point about looking at alternatives, and the downstream consequences. Because when you get into the problems with endometrial ablations is all these companies came out with these devices that are giving more and more energy, and more powerful energy, particularly burning energy, which creates scarring. The number one problem that we see is that you begin getting scarring inside the cavity, and destruction of the architecture of the endometrium and the uterine lining, and the uterus itself. So that when they come back in with a problem such as bleeding, and we know that over half of people will have some bleeding afterwards, we really have lost the ability to evaluate that.
We can't, with absolute certainty, tell patients, "You don't have cancer." Now, we know historically that an endometrial ablation will somewhat decrease your likelihood of developing cancer, but it doesn't eliminate it. What we find is about 20% of patients who have a hysterectomy after an endometrial ablation have that hysterectomy strictly because we cannot prove to that patient they don't have cancer. They're having some bleeding. We have a very low threshold for going ahead with the hysterectomy, because we cannot assure them that there's nothing wrong.
That has led to sort of a rethinking of what are we doing with endometrial ablations, and should we actually be using amenorrhea as our endpoint? Should that be the metric that we use to consider success, or is it better to maybe retool our thought process and say, "Let's find something that decreases your bleeding, makes your bleeding more manageable, but does not preclude our ability to evaluate the cavity later." That's what we've seen with a couple of the more recent ablation tools that have come out. For example, a new cryoablation technique that came out a few years ago called Serene.
We've had Barbara on the show to talk about it, which I hadn't tried. Have you used it?
[Dr. Ted Anderson]
I have. I was actually involved in the FDA trial.
[Dr. Mark Hoffman]
That's what I thought.
[Dr. Ted Anderson]
I'll have to say that I was totally blown away. It wasn't anything that I expected it to be. It's essentially painless to do in the office.
[Dr. Mark Hoffman]
Because it numbs, right? As opposed to burning. It's actually like an analgesic as well.
[Dr. Ted Anderson]
Exactly. We had patients who came in and had forgotten to take their pre-meds, their non-steroids or whatever. They said, "Well, let's just go ahead and do it while we're here." I'm like, "Okay." I'm doing this ablation, and we're just sitting here talking about their kids and, life in general, and they're not having any pain whatsoever.
Now, about 30 minutes, when things begin to thaw, they begin to get some serious cramping, but it only lasts for about 30 minutes, and it's over with.
[Dr. Mark Hoffman]
Do they hang out for a while afterwards, or do you just-
[Dr. Ted Anderson]
Yes, we did keep them there just because we wanted to find out exactly that question, but it wasn't something that was unmanageable. They said it's just like really bad cramps. We gave them some Toradol or something, and they did fine. Then what we found is that to our surprise, we only had a pretty low amenorrhea rate, probably 13% to 14%, but we're getting to satisfaction rate. The satisfaction rate was still in the 90 percentile. People were saying, "Look, it's reduced my bleeding to the point where I can live with it."
[Dr. Mark Hoffman]
Avoid a major surgery, and they can go on about their life. You menorrhea. I just want it to be what I would consider normal.
(6) Addressing Misconceptions and Rebuilding Patient Trust in Treatment
[Dr. Ted Anderson]
Yes, and the problem is women don't necessarily know what normal is. It's not something that people talk about more now than before, but we're beginning to get a little bit more-
[Dr. Mark Hoffman]
What are you even talking about? It's hard to know it's a lot for me or a little for me, it's a-- I'm not seeing what anyone else has got. It's a very private problem, which makes it more challenging.
[Dr. Ted Anderson]
Sure. How many times have you had a patient who came in and says, "I just thought this was normal."
[Dr. Mark Hoffman]
Every clinic day, there's one.
[Dr. Ted Anderson]
"I'm having this problem, I'm in pain. Is that normal?" I'm like, "What you're describing doesn't sound much fun, normal or not. It sounds like we can try to help you out, and see what we can do." Yes, it's a very subjective thing. It's not like you said, it's something we don't spend a lot of time. From what I understand, my patients are spending a lot of time chatting with their friends about.
[Dr. Mark Hoffman]
Measuring the amount of blood loss has always been sort of a challenge. There are a lot of very intricate ways that you can do that, but there's onerous, and difficult to do the analytical tools that you can use to measure actual blood loss.
There's a great study that was done in the 1960s where they looked at patients perception of their blood loss, versus their actual blood loss. What they found is that about 20% of people who had actual documented menorrhagia, meaning, a large amount of blood, more than 80 CCS of blood was defined at that time, but 20% of those people thought that was normal. On the other hand, about 50% of people who had minimal blood loss thought they were hemorrhaging to death.
The moral to that story is that a little bit of blood in the toilet looks like hemorrhage if it's your blood. People don't have a way of gauging what normal menstrual bleeding is. I sort of define it as, if a patient feels that their menstrual bleeding is interrupting the things that they need to do or want to do, it needs to be treated. That's a very easy question.
[Dr. Ted Anderson]
If it bothers you, then it's significant to me.
[Dr. Mark Hoffman]
Now, I'm not saying we need to do a hysterectomy, but we need to have some sort of option that we can offer these patients, whether it's hormonal or whether it's a IUD, whether it's an ablation or whatever, that treats everything going on, including their abnormal bleeding, but minimizes the downstream consequences as well.
[Dr. Ted Anderson]
Normal, for me, is zero. Anything more than that, I'm listening. Whatever you tell me is a problem for you, I will just believe you. It's amazing when you tell that to patients, "Whatever you tell me, I'm just going to believe it." They look at me like I'm first person that's ever said that like, "Well, what do I have?"
Patients have become very suspicious of medicine, in general. I think, the media has a lot to do with that, and patient's perception that we're trying to be controlling, or that we're trying to push drugs or whatever, I think is a big problem that we have to overcome.
[Dr. Mark Hoffman]
I think some of us have done that.
[Dr. Ted Anderson]
I think it's also a business. The idea that we get paid more for one treatment, over the other is a little bit of a conflict of interest. If I was a patient going to see a surgeon, and I tell my patients, "You should be not skeptical, but at least have your eyes open when you come see us, because the reality is I can tell you about it, but that's the reality of our business. Be willing to ask questions, ask those tough questions."
It's important for us as physicians to partner with our patients. Like I said, try to educate our patients, and help them make a decision that works for them, and then reassure them that we're on their side. We're going to help them get the treatment that they feel like is right for them, but we have to be able to give them options, and realistic expectations of those.
(7) The Future of Endometrial Ablation: New Technology, Fertility Preservation & Adenomyosis Management
[Dr. Mark Hoffman]
You mentioned, you said there's a couple of devices. Is there anything besides Serene that you're seeing that's out there, that's on the horizon, or what other ablation
[Dr. Ted Anderson]
The two devices that are out there that seem to address this issue of the cavity access are the Serene and the MORA, which is interestingly going back to what was used in the 1800s, it's interdicting steam into the endometrium. We find that also has a pretty high success rate in terms of cavity patency at one in three years. These are patients where if they come back with abnormal bleeding, we know we can at least evaluate the cavity.
[Dr. Mark Hoffman]
Is that done in the ORs, the steam one?
[Dr. Ted Anderson]
It's done in the office as well. I think most of them were done in the office in the FDA trial, but you could do it either way. The Serene, the cryoablation, I would 100% do those in the office.
[Dr. Mark Hoffman]
Are you doing those in your practice now?
[Dr. Ted Anderson]
I am doing it. When I have those patients that are maybe a little bit higher potential for failure, I'll suggest that as a possibility, because if they do have bleeding, I'm going to be able to evaluate the cavity. You could do it again, potentially, in a few years do it again.
We haven't really looked at that. That's technically repeat ablations are not considered to be very favorable. That's really because when we do an ablation, we're altering the biophysics of the endometrium, including the circulatory system, which takes that heat away and dissipates it, and prevents a lot of damage to the uterus.
Once we've done that, we don't really know the effect that a subsequent ablation would have.
[Dr. Mark Hoffman]
It may be a conductor than it was before.
[Dr. Ted Anderson]
It may be, yes.
[Dr. Mark Hoffman]
Oh, interesting.
[Dr. Ted Anderson]
We need to look at that. Another thing that I think an experiment of nature will tell us, and that is looking at people who get pregnant after endometrial ablations. I'm just waiting for people who have had these cryoablations that don't really completely destroy the endometrium, are they going to be able to have successful pregnancies after? Would this be a treatment for people who have, for example, adenomyosis and other problems with bleeding, but don't want to forego their fertility?
[Dr. Mark Hoffman]
Oh, I hadn't thought about adeno with the Serene. If it freezes deep enough, it's one of the most challenging things for me to think about treating. Taking the uterus out is one thing, but treating the glandular disease within the myometrium, it's pretty inaccessible for most of us. Occasionally you get, Keith Isaacson telling you he can dig and find these things, but for most of us-
[Dr. Ted Anderson]
Maybe Keith can.
[Dr. Mark Hoffman]
That's what I'm saying, it's a bit of a challenge for me.
[Dr. Ted Anderson]
As we're mortals.
[Dr. Mark Hoffman]
That's right.
[Dr. Ted Anderson]
For the rest of us, though, it's a pretty challenging disease to discuss, and more importantly to specifically treat while maintaining fertility, and so that'd be very interesting.
[Dr. Mark Hoffman]
There really aren't any treatments that are designed to adequately treat adenomyosis that are fertility-sparing. There's birth control pills, Mirena IUD, hysterectomy, maybe ablation. There's some evidence that endometrial ablation failure is higher with people who have extensive endometrial adenomyosis.
[Dr. Ted Anderson]
I would think so.
[Dr. Mark Hoffman]
How do you define that?
[Dr. Ted Anderson]
Pathologically, later on.
[Dr. Mark Hoffman]
It's too late. It's only been recently that we have criteria for ultrasound to describe the extent of adenomyosis and be able to identify it. Now we're beginning to look at that a little bit more carefully and prospectively, how are these patients doing if we look at their adenomyosis? We did a study here. Howard Curlin and I did this study a few years ago where we looked at patients who had endometrial ablation failure, meaning a hysterectomy.
Then we looked back at their ultrasounds to determine how many of these patients, is there a comment on their ultrasound suggesting that they had adenomyosis? Then we looked at the pathology report to see, did they really have adenomyosis? What we found is about 50-50. It really didn't seem to be weighted one way or the other. Of course, that's not a very well-controlled study, and it was just sort of anecdotal. We miss all those people who had adenomyosis, and did fine with endometrial ablation. We really don't know the answer to that question. It's going to be a difficult study to do.
[Dr. Mark Hoffman]
That was Keith's theory too that, a lot of our patients that have dysmenorrhea, they go in there and laparoscopy and they got a couple of spots and you're going, "This ain't it." There's likely almost certainly an adeno component to it, because it's all central, and hysterectomy cures it. Why would that matter if it was an extra uterine issue like endo?
Clearly, there's a continuum of disease with all of it, and adeno is a much bigger problem than we-- I think we're starting to recognize it now, but much more so than I think when I was trained.
[Dr. Ted Anderson]
Yes, we used to think of adenomyosis as being something after people had two or three children, and it had something to do with the reaction of the endometrium in the placenta and everything. Now we're seeing it in younger people who've never been pregnant. I think our ability to recognize it, and our mental ability to acknowledge it has become much better.
We're seeing a lot more adenomyosis than we used to, and hopefully, we'll be able to get some good treatments for that preserve fertility. I'm just wondering in the back of my mind, where my warp mind sort of goes sometimes is, clearly this is not something you would intentionally do in someone who's trying to get pregnant is ablate the endometrium. But I'm thinking with some of these more gentle methods of endometrial ablation that sort of preserve that uterine lining and uterine architecture, would a successful pregnancy be an option in those people?
[Dr. Mark Hoffman]
I think about uterine fibroid ablation, like with Sonata and the others, like why do we think that's more destructive than a myomectomy to the uterus? I get that endometrial or rather uterine fibroid embolization, you're just dropping bees. You're causing ischemia and necrosis to more areas than just the fibroid itself. But if we're going to be pretty specific about where we ablate a fibroid, and the myometrium in theory around it is still intact and healthy, myomectomies are not atraumatic to the uterine muscle, uterine architecture.
That's one of those, like you said, you don't tell them to do it, but it will happen. I'll be very curious to see what those, and I've seen early data on those post Sonata pregnancies. With a Serene, again, it just takes some time, but very curious to see what that looks like down the road.
[Dr. Ted Anderson]
The same thing with repeat ablations, is it something that would be safe to do with that? Even using something like a Mirena after a Serene ablation?
[Dr. Mark Hoffman]:
Yes, because that's been studied after endometrial ablation. It sounds like there's some data to suggest that the cavity is a little more patent and accessible after IUD placement. I don't know if you're seeing that.
[Dr. Ted Anderson]
Exactly. Yes, that's a thought. People often will put an IUD in, whether it's progestin secreting or not, after something like extensive myomectomy, or intrauterine surgery to help preserve the integrity of the cavity, just having something physically keeping the sides apart. We don't know, for example, and there have been some evidence to show that progesterone treatment after endometrial ablation improves its effectiveness also.
Could a Mirena do that? We don't know what the pharmacological dynamics are of a progesterone absorption after Mirena would be after an ablation. We have no idea whether it would work the same way. There's a lot of open questions there.
[Dr. Mark Hoffman]:
Lots still left to learn, but we learned a lot today. I appreciate you coming on the show. Any more last wise words of endometrial ablation wisdom for our listeners?
[Dr. Ted Anderson]
I guess the bottom line is, it is a great technique for the right person, and there are many right persons, and there are many right motives for doing endometrial ablation. Always think of the alternatives. Always try to think of the downstream consequences of what you do, whether it's ablation or any procedure you're doing for a patient. Think of what are the downstream consequences, and tell people to think of your interventions like playing pool. You need to make a good shot, but you need to leave yourself set up for the next shot as well.
[Dr. Mark Hoffman]
More importantly, if you can't do that other option, don't just keep your patient to yourself, because you're not able to do the other options. That's something that I always say, "I don't do this, I don't have assessor where I work before I had Sonata, and these are the options, whether I can do them or not. Just because you don't have access to them, or you don't have the skillset to do something, it's our responsibility to make sure patients understand what all the options are, not just the options that we offer.
[Dr. Ted Anderson]
Sure, and help them access them if they need to.
[Dr. Mark Hoffman]
Yes, absolutely. Here's the guys doing it, here's the doctors that are out there that have these abilities or access to these devices.
Ted, I feel like I could keep you all night. I know you're a busy guy. I've always looked up to you as a friend and mentor. It's a pleasure having you on, and every chance we get to catch up, I'm always excited to do it.
[Dr. Ted Anderson]
Thanks, Mark. It's been a pleasure being here with you to talk about this, and of course, to see you again. We don't see each other very often, so it was great to have a chance to talk with you.
[Dr. Mark Hoffman]
It's my absolute pleasure. Great to see you. Be well and we'll hopefully see you soon.
[Dr. Ted Anderson]
You bet. Absolutely.
Podcast Contributors
Cite This Podcast
BackTable, LLC (Producer). (2025, March 25). Ep. 80 – Endometrial Ablation: Past, Present & Future [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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