Heavy Menstrual Bleeding (HMB) has replaced the old term "menorrhagia". It is not usually practical to accurately measure menstrual fluid volume except in clinical studies, although the more frequent use of menstrual cups recently can allow a more accurate assessment of the volume of bleeding.
HMB is a practical term to describe the effect of the heavy periods on the woman. Do your periods cause you to flood? Do you routinely pass large clots? Do you need double protection with pads and tampons, and flood the bed at night? Are you actually housebound by your bleeding? Does it interfere with your work and enjoyment of life? Have you become fatigued, iron deficient or even anaemic? These are the practical questions that matter to women.
HMB affects women throughout their lives from their teens to their fifties, but fortunately most types are readily treated rather simply, in contrast to days gone by when a high proportion of women would be forced to endure a hysterectomy. In recent years the incidence of hysterectomy has reduced (by about 40% in Australia) thanks to advances in conservative treatments.
Heavy regular periods, especially if it is a lifelong pattern from the time the periods commence, may be due to local abnormalities of bleeding control in the lining of the uterus (endometrium) or due to inherited defects of coagulation such as Von Willebrand's disease. Acquired abnormalities of blood clotting, for instance with medications taken for deep venous thrombosis and heart disease, can also affect the ability of the endometrium to shut down menstrual bleeding.
Anovulatory bleeding usually results in irregular cycles and often occurs at either end of reproductive life; the ovaries may be producing oestrogen which causes growth of the uterine lining, but ovulation is impaired and insufficient progesterone is secreted to temper this growth.
Many women will respond to simple treatments such as the oral contraceptive pill, Implanon, Nuvaring, Depo Provera, and the Mirena IUD, with the added benefit of safe and effective contraception. For women who cannot use these methods, non hormonal methods that preserve fertility include Tranexamic Acid and non steroidal anti-inflammatory drugs.
Insertion of the Mirena IUD can often be performed in the clinic. I have performed successful IUD insertions for thousands of women of all ages, including those who have not given birth or have only had caesarean sections, as outpatients. It may be necessary to remain in the clinic for monitoring for 30 minutes or so afterwards, especially if the patient experiences cramping or symptoms of vasovagal stimulation (sweating, faintness) with procedures in the past. These patients should consider having someone to drive for them after the procedure. For most women Mirena insertion is straight forward and involves minimal discomfort but for those who have had difficulties, taking paracetamol and an anti-inflammatory medication such as Naproxen 550 mg 1-2 hours, or Tramadol 50 mg, before the IUD insertion might be helpful. If you experience fainting with blood tests or pain you should let us know this, so that we can plan your visit. Some patients, particularly those who find they have had difficulties with IUD insertions in the past might benefit from using a Penthrox inhaler during the procedure. This inhaler is very safe, provides excellent pain relief, and is available on prescription for less than $60. This can be arranged for you at your visit, if you would prefer it, and we will instruct you on its use before the IUD insertion. You must have someone to drive you home after use of Penthrox.
Women whose HMB does not respond to the methods described above may need further investigation by ultrasound scanning to rule out fibroids, polyps, endometriomas (cysts on the ovary containing endometriosis) and adenomyosis.
Of course any woman with irregular bleeding in between periods, or bleeding after intercourse, needs to have lesions of the cervix and cancer of the uterus excluded. This might require further investigation with a colposcopy.
Some women will need to undergo hysteroscopy to exclude polyps, fibroids and cancer. Often polyps and fibroids substantially inside the cavity of the uterus can be resected with a camera inserted into the cervix, as a day procedure, with no cuts in the body, and minimal down time.
Women who have a normal or only modestly enlarged uterus and who have definitely finished their families, may also be offered the day surgery procedure of Endometrial Ablation; it is not contraceptive so attention must be paid to ensuring some other contraceptive method is used. In addition, endometrial ablation destroys the lining of the uterus, so pregnancy is contraindicated afterwards; it is only suitable for women who have definitely finished their families for good.
Currently I use the Novasure Endometrial Ablation System and I perform this procedure in the Day Surgery Unit of the Wesley Hospital, under a very light anaesthetic, which means you have an Anaesthetic Specialist to care for you during the procedure, and get excellent pain relief, whilst being fit to return home the same day and resume normal activities the day after. I may discuss with you other contraceptive measures including vasectomy, tubal ligation or the Mirena IUD. I have trained in the placement of the Essure device, but do not favour it over other methods. If you decide to have a Mirena placed after endometrial ablation, you need to be aware it can occasionally (but certainly not always) be difficult to remove on the couch subsequently, and could require a light anaesthetic so to do. However, for those women for whom the only other alternative is the more invasive procedure of hysterectomy, the addition of Mirena insertion to Endometrial Ablation may be a very acceptable contraceptive option which has the potential to markedly reduce recurrence of heavy bleeding (thanks to the progesterone in the device) whilst they await the onset of natural menopause. In addition the Mirena IUD has been shown to reduce the incidence of polyps, pre cancers and cancers in the uterus, and in women over the age of 45 can provide contraception for up to 10 years. We will discuss all these options fully at your visit, but I am aware that many women want to avoid major surgery such as hysterectomy with its attendant down time and risks, so I am willing to tailor a solution to their problem that suits them individually.
Finally, there will be some women for whom a hysterectomy may be the only solution, especially in the case of very large fibroids or severe adenomyosis. Fortunately, in most cases now it is possible to perform these procedures with laparoscopic surgery which means less risk and downtime to the woman.
Since all women with HMB have different causes, medical issues, and social and work concerns, it is necessary to take an individualistic approach.My belief, supported by evidence from studies, is that we should try the safest and least invasive options first, which are often cheaper as well. First do no harm.
You should remember that any surgical or invasive procedure carries risks. Before proceeding, you should completely familiarise yourself with all the options and risks, and if you are uncertain, seek a second opinion from an appropriately qualified health practitioner.
References for Mirena IUD at the same time as Endometrial Ablation for women wishing to avoid hysterectomy:
(2) Comparison of combined transcervical resection of the endometrium and levonorgestrel-containing intrauterinesystem treatment versus levonorgestrel-containing intrauterine system treatment alone in women with adenomyosis: a prospective clinical trial.Zheng J1, Xia E, Li TC, Sun X.
(3) Combined Endometrial Ablation and Levonorgestrel Intrauterine System Use in Women With Dysmenorrhea and Heavy Menstrual Bleeding: Novel Approach for Challenging Cases.Papadakis EP1, El-Nashar SA1, Laughlin-Tommaso SK1, Shazly SA1, Hopkins MR1, Breitkopf DM1, Famuyide AO2.
(4) An evaluation of the simultaneous use of the levonorgestrel-releasing intrauterine device (LNG-IUS, Mirena®) combined with endometrial ablation in the management of menorrhagia.Vaughan D1, Byrne P. J Obstet Gynaecol. 2012 May;32(4):372-4. doi: 10.3109/01443615.2012.666581.
" Although hysterectomy is a definitive treatment for heavy menstrual bleeding, it can cause serious complications and most women may be well advised to try a less radical treatment as first-line therapy. Both LNG-IUS (Mirena) and conservative surgery (Endometrial Ablation) appear to be safe, acceptable and effective."
(Cochrane Database of Systematic Reviews, January 2016)
Dr Melissa Buttini m.b.b.s franzcog