Excessive heavy bleeding is a very common problem, affecting one out of five women. In the years before menopause, it is even more common, occurring in as many as one of two women in their 40’s and early 50’s. In the United States, over two physician visits each year are due to problems with excessive menstrual bleeding. The average age of menopause is 52, so many women live unnecessarily with excessive bleeding for many years.
Description of Excessive Menstrual Bleeding
Any one or a combination of symptoms identified below may indicate that a woman is experiencing excessive menstrual bleeding. The symptoms include:
- Tiredness ;or paleness (anemia)
- Increased pain from menstruation.
- A need to use double methods of feminine hygiene products to avoid having bleeding accidents.
- Having to change during the night or use protective barriers on the bed.
- Damaged clothing, bedding or carpeting from blood stains.
- Avoidance of light-colored clothing during periods.
- Increased duration of menstrual bleeding (more than 7 days).
- Formation of blood clots.
- Limitations affecting work, social, sexual, or vacation activities.
- Excessive number of soaked pads or tampons on a heavy day(over 3 per day).
- Causes of Excessive Menstrual Bleeding
Excessive menstrual bleeding may be caused by:
- Hormonal changes.
- Benign (non-cancerous) growths like uterine polyps or fibroid tumors.
- Adenomyosis (a benign type of endometriosis in the muscle wall of the uterus).
- Abnormal thickened uterine lining associated with microscopic gland changes that may indicate increased risk of developing future uterine cancer.
Diagnosing Excessive Menstrual Bleeding
Initially, evaluation of excessive menstrual bleeding typically includes a thorough pelvic examination and a review of a recent Pap smear. In women over age 40, it is important to assess the microscopic condition of the uterine lining by obtaining an endometrial biopsy looking for precancerous changes. We often do a special type of pelvic ultrasound called a saline infusion sonogram (SIS). A SIS involves adding water during the ultrasound scan through a tiny tube inserted in the cervix. This allows very detailed views of the inside structure and size of the uterine cavity. The ovaries are evaluated as well with the ultrasound images. In a few cases, an MRI may be helpful when adenomyosis is suspected. Anemia can be detected with a blood count test.
Treatments for Excessive Menstrual Bleeding
In the past, dilation and curettage (D&C) was commonly performed for women with heavy periods but it usually offered only temporary relief of symptoms. The periods usually returned to their prior state within a few months after the procedure. Today it is used mainly as a diagnostic test rather than as a mode of treatment.
Current options to reduce or eliminate heavy periods vary depending on a woman’s age, her desire for future childbearing, and the results of her evaluation. Other factors such as family history, prior cesarean sections, or additional medical conditions such as high blood pressure and blood clotting disorders play a part in identifying the appropriate treatment for an individual patient.
In a woman who wishes to possibly become pregnant in the future, treatment options include (a) oral contraceptive pills, (b) progestin-releasing intra-uterine device (IUD), and (c) hysteroscopy.
Oral Contraceptive Pills
Oral contraceptive pills may control the hormonal balance and reduce the amount of uterine lining produced each month, decreasing the duration and volume of menstrual flow. We can not use these in women over the age of 35 who smoke due to increased risk. They may increase the size of fibroids.
The progestin-releasing IUD (Mirena) reduces the amount of lining in the uterus after several months of use in most women. Some women even stop having periods until the IUD is removed. The IUD also provides very effective, yet reversible, contraception. However, the IUD must be replaced every 5 years.
An operative hysteroscopy is an outpatient surgical procedure to remove polyps or small fibroids inside the uterine cavity with a scope inserted through the cervix.
If a woman has completed childbearing or does not desire to ever have a baby, additional treatment options are available. The treatment options include (a) uterine artery embolization, (b) endometrial ablation, and (c) hysterectomy.
Uterine Artery Embolization
Uterine artery embolization is an outpatient hospital procedure done by a radiologist using strong IV sedation, which involves inserting a tiny catheter during angiography into the uterine arteries and then permanently closing those vessels with tiny plugs. This method helps reduce bleeding from fibroid tumors in 80% of patients treated. Some patients experience very significant pain immediately after the procedure. It is not known whether future pregnancies may be adversely affected or prevented.
Endometrial ablation is an outpatient procedure designed to permanently destroy the tissue lining the uterus and responsible for menstrual bleeding. This can often be done in an office setting with a local anesthetic and minimal discomfort, allowing a rapid return to normal activities, usually in 1 or 2 days. Studies show that over 90% of patients experience a significant reduction in menstrual flow using this method. Some even stop having periods completely after a few months. Since this procedure doesn’t affect the ovaries, hormone levels remain unchanged afterwards, even if the periods stop. This procedure does not induce an early onset of menopause or provide permanent contraception. For that reason, a woman needs to continue to utilize contraception or consider sterilization with this method. Sometimes this procedure is done after an in office sterilization procedure to occlude the fallopian tubes (Essure).
Our practice currently uses several different devices for endometrial ablation. These include Novasure, Her Option, and Hydrothermal Ablation. Detailed information about each method is available from our office and on our website.
A hysterectomy is a hospital surgical procedure to completely remove the uterus, thus permanently stopping all future menstrual bleeding. If a woman’s ovaries are not removed, her natural hormone levels will remain unchanged until menopause occurs. There are several different types of hysterectomy procedures and the gynecologic surgeon considers multiple factors to determine which method best suits the patient. Recovery time and length of hospital stay vary depending on the surgical method and individual patient characteristics. There are newer techniques to reduce the recovery and discomfort of this procedure that may be appropriate for some patients. Some women also need bladder repairs for urinary incontinence done at the same time as the hysterectomy.
All these treatment options mean that it is no longer necessary for a woman to tolerate chronic excessive menstrual bleeding. We are fortunate that there are effective and safe treatments available to help control excessive menstrual bleeding. These treatments may dramatically improve a woman’s quality of life.