Excessive Menstrual Bleeding

How do I know if my periods are abnormally heavy?

If you miss work or feel forced to stay home, or if you bleed through tampons / pads and soak through clothing, or if you plan your daily activities around your proximity to a restroom, then you are suffering from menorrhagia. Strictly speaking, menorrhagia (heavy menstrual bleeding) is bleeding that lasts more than 7 days or is associated with clotting or needing to change pads or tampons every hour.

Women suffering from menorrhagia can experience fatigue, anemia, embarrassing accidents, and restricted activity. If you find that you fit into this category, you’re not alone. Some estimates are that 1 in 5 women experience menorrhagia. Amazingly, it can come on insidiously over years, like watching a pot of water boil. Women will put up with amazing bleeding episodes without seeking medical evaluation. Yet the evaluation and treatment of menorrhagia is very simple. Excessive menstrual bleeding is NOT a part of the aging process.

How do you evaluate conditions that may cause menorrhagia?

Instead of simply prescribing pills to treat heavy periods, I prefer looking for specific causes. Such causes include medical conditions like hypothyroidism, polycystic ovarian syndrome, or bleeding disorders. Other causes may include problems with ovulation and abnormal responses to birth control pills or hormone therapies.

In women in their 30’s and 40’s, structural abnormalities of the uterus must also be considered, as these causes are common. These abnormalities include fibroid tumors of the uterus, endometrial polyps, and adenomyosis (a condition similar to endometriosis but confined strictly to the uterus)

How can you diagnose these problems?

For most of the medical conditions listed above, we obtain blood tests when the history of bleeding suggests. When we suspect that menorrhagia is caused by structural problems, we perform ultrasound in the office. If we see fibroids or polyps, we may further characterize them with a procedure called saline hysterography. 

What about treatment?

If we identify medical disorders, we treat with medications that should reverse the abnormal bleeding pattern and restore normal menses.

If we identify structures easily removable by minor surgical procedures (fibroids or polyps dangling in the endometrial cavity), we will recommend removal by a procedure called hysteroscopic polypectomy / myomectomy.

If we see no structural causes and identify no medical conditions that may cause menorrhagia, options for treatment are limited but highly successful. These options include:

• Regulation of periods with birth control pills, or
• Placement of a hormone containing IUD to reduce flow, or
• Perform endometrial ablation either in office or in a surgery center

How do I choose which option is right for me?

Some women do not mind taking birth control pills or other hormone combinations to treat excessive menstrual bleeding. Length of treatment may be from months to years, depending upon the cause of bleeding. On the other hand, some women do not want to add any hormones to their bodies or do not like having to remember to take a pill every day.

The advantage to the pill is that it can be stopped at any time, usually in cases where pregnancy is desired or to see if menstrual cycles return to their previous pattern.

Mirena IUDs are indicated for treatment of heavy periods. The device contains a progesterone compound that is slowly released into the uterus and thins the lining of the uterus. The end result is a marked reduction in menstrual blood loss. They can easily be placed in the office and can be left in the uterus for up to 5 years. Risks of the IUD are minimal. Common side effects include irregular bleeding that can persist for the first few months until the lining of the uterus is well thinned. Some patients do experience bleeding in between cycles, but it is usually light. Like other forms of hormonal remedies for menorrhagia, the Mirena IUD also provides contraception.

Lastly, the Endometrial Ablation should be considered for women finished with childbearing and who are uncomfortable with the idea of hormonal methods of treatment. Success rates are phenomenal and patient satisfaction is greater than 95 percent. With the ablation technique, 90 seconds can stop or lessen excessive menstrual bleeding for a lifetime. The process of “ablation” involves the destruction of the lining of the uterus that grows back and sheds month after month. Once the lining is destroyed, it cannot form the cells that ultimately are shed. The result: Amenorrhea (complete absence of menstrual bleeding) or Hypo-menorrhea (very, very light menstrual bleeding).

What is the procedure for endometrial ablation?

I perform the procedure in my office if possible or in the operating room if need be. I utilize two different techniques in my office. One called Novasure uses radiofrequency energy to burn the lining of the uterus with electrical heat. The other called Thermachoice uses hot water circulating in a balloon catheter placed into the uterine cavity to destroy the lining of the uterus using thermal energy. There are subtle differences in the indications for the two, but the end result is the same overall effect on the uterine lining: destroying the tissue lining responsible for the production of cells destined to be shed once a month.

Prior to the procedure, I perform biopsy to make sure that abnormal bleeding is not caused by a previously undiagnosed endometrial cancer. Additionally, patients will receive instructions regarding medications to take prior to the ablation procedure. We give our patients a series of medications designed to relieve cramping associated with this 90 second procedure. 

On the day of the procedure we give our patients oral pain medications, an injection of Toradol (like a super-charged Motrin),then we inject local anesthesia into the cervix to numb the uterus. We begin the procedure only after we are sure the medications have taken effect.

The actual procedure involves placement of the treatment probe through the cervix into the uterine cavity. After assuring correct placement, the treatment cycle is started. Well tolerated cramping is experienced by most women. After the cycle is complete, the probe is removed and our patients are allowed to rest for a few minutes prior to their departure. They must be accompanied by someone who can bring them to the office and take them home.

We recommend resting for 12 to 24 hours before resuming regular activity. A follow-up appointment should be made for 2 weeks.

Although the results of the procedure are excellent for purposes of ending excessive uterine bleeding, it is important to understand that pregnancy has occurred in women subsequent to this procedure. For this reason contraception should still be utilized!

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