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Menstruation: Heavy Bleeding (Menorrhagia)

Description

An in-depth report on the causes and treatment of heavy periods.

Alternative Names

Bleeding: menstrual; Menstrual Disorders

Surgery

Women with heavy menstrual bleeding, dysmenorrhea, or both now have surgical and medical options available to them. Surgical procedures include endometrial ablation, resection, or hysterectomy. Women with fibroids have additional options. Most procedures eliminate the possibility for childbearing, however. Hysterectomy removes the entire uterus while ablation and resection destroy most or all of uterine lining.

Studies in 1999 and 2001 reported that more women who chose endometrial resection were satisfied with their decision after two to five years than women who chose medication. It should be noted, however, that these studies most likely did not include comparisons to newer hormonal treatments, notably the levonorgestrel-releasing intrauterine system, or LNG-IUS (Mirena), which is proving be a good alternative to surgery. In a 2003 study comparing ablation with the LNG-IUS, the two were equally effective. Women should be sure to ask their physicians about all medical options before undergoing surgical procedures.

Choosing Between Endometrial Resection or Ablation

In either standard endometrial resection or ablation, the entire lining of the uterus (the endometrium) is removed or destroyed. The standard endometrial ablation and resection techniques are equally effective in reducing bleeding. In general, either one reduces bleeding by about half. At least 90% of women find either procedure acceptable and about three-quarters are totally or generally satisfied with the treatment. Only about 15% of women require a hysterectomy later on. Since no procedure has any particular advantage, a woman's best option may be to select the procedure based on their surgeon's skill and experience with it.

Newer second-generation endometrial ablation approaches that compare favorably to the standard techniques and are less invasive are being used or investigated. Some of these techniques are so-called "blind" approaches, in which the surgeon inserts devices that destroy the uterine tissue but the physician cannot observe the procedure either on directly or on a monitor. Many are showing promise. A major 2002 analysis of studies on many of these methods indicated that they were as effective and faster than resection. Nevertheless, technical problems exist with some of these techniques, and comparison studies are needed to identify the optimal approaches.

Hormonal Pretreatment. The hormonal agents GnRH analogs or danazol used before the procedures help to prepare the uterus by thinning the lining. Evidence now strongly supports their use for improving operating conditions and at least short-term outcome. GnRH analogs may be slightly more effective than danazol.

Postoperative Effects of Endometrial Ablation or Resection Procedures. Postoperative effects of either procedure include the following:

  • Anesthesia may cause nausea and even vomiting for a few hours following the operation.
  • Cramping and pain occurs but can usually be relieved using over-the-counter painkillers.
  • Patients may experience frequent urination for the first day after the procedure and blood-tinged, watery vaginal discharge for more than a month.

Complications of Endometrial Ablation or Resection Procedures. Complications from either procedure may include perforation of the uterus, injury to the intestine, hemorrhage, or infection.

In standard resection and ablation, the uterine cavity is expanded by filling it with fluid. In rare instances, excess glycine from the fluid instilled in the uterus builds up in the bloodstream and causes an abnormal drop in sodium levels. This can be a serious event resulting in mental confusion, convulsions, and very rarely, death. General anesthesia may pose a lower risk for this complication than local. Some of the newer ablation procedures do not require fluid instillation.

In one 2002 study, 10% of patients who were given standard ablation using the roller ball technique experienced blockage or blood build-up in the fallopian tubes that require a follow-up procedure or a hysterectomy later on.

Endometrial Resection

Resection procedures benefit those women who have very heavy menstrual bleeding but do not have any other underlying uterine problems, such as polyps, hyperplasia of the endometrium, or cancer. Resection also seems to have a higher success rate in reducing bleeding and relieving pain in older women than younger women.

Resection procedures typically involve the following:

  • The patients are given a local or general anesthesia.
  • The surgeon dilates (widens) the cervix and fills the uterine cavity with fluid to improve visualization.
  • The surgeon then removes the uterine lining.

Standard Endometrial Ablation with Hysteroscopy

Endometrial ablation involves the destruction of the uterine lining using a number of approaches that include heat, electricity, laser energy, and other methods. The standard ablation approach uses hysteroscopy to allow the physician to view the uterus.

A typical procedure uses the following approach:

  • The physician uses hysteroscopy to view the uterine cavity. This is a fiber optic light source inside a long flexible or rigid tube, which is inserted into the uterus in order to view the cavity. The image of the uterine cavity is transmitted by camera lenses to a video screen.
  • The uterine cavity is filled with fluid for better visualization. A special substance such as glycine, sorbitol, or mannitol may be added to the fluid so that it does not conduct electricity. This process prevents accidental burns.
  • With ablation, uterine tissue is usually vaporized using a thin powerful laser beam or high electric voltage. One ablation technique, known as electrocautery with roller ball diathermy, uses a device that looks like a tiny steamroller. This device applies heat and destroys endometrial tissue as it rolls across the uterine lining.
  • The procedure typically takes 15 to 45 minutes. Although a general anesthetic is usually required, the patient can go home the same day.

It takes about three months to determine whether the procedure has been effective. There should be a follow-up appointment about two weeks after the procedure. One study revealed 80% of the women were satisfied with ablation; however, this was lower than the 89% satisfaction rate reported by women who had had hysterectomy. About 30% of women who have this procedure still require additional surgeries, including hysterectomies, within five years. The risk is higher in younger women. It should be noted that the risk for complications increases with repeat ablations.

Second-Generation Endometrial Ablation Procedures

Balloon Endometrial Ablation. Balloon ablation (e.g., ThermaChoice in US, Cavaterm in Europe) is proving to be very effective:

  • A balloon at the tip of a catheter tube is filled with fluid and inflated until it conforms to the walls of the uterus.
  • A probe in the balloon heats the fluid to destroy the endometrial lining.
  • After eight minutes the fluid is drained out and the balloon is removed.

Studies show that bleeding is controlled in 70% to 90% of patients for at least five years. It is fast, simple to perform, and comparison studies are suggesting that it is as effective as resection and standard ablation.

Treatment is less likely to succeed in younger women, those with a tipped uterus, when the uterine lining is 4 mm or thicker, and when menstrual bleeding is prolonged. Pregnancy is possible if some of the lining is maintained, but generally women should not depend on it to preserve fertility.

Electric Wand Ablation. One approach now approved involves inserting a slender wand up through the cervix (the NovaSure System). A triangular mesh-like device is the passed through the wand and expands to fit the uterus. Electrical energy is passed through it for about 90 seconds and the mesh and wand are then withdrawn. As with many other second-generation ablation techniques, it is quick, effective, and does not require pretreatment to expand the uterus. In one 2003 study, it achieved significantly lower bleeding rates than balloon ablation.

Freezing (Cryoablation). With cryoablation (Her Option Uterine Cryoablation Therapy System), the uterine tissue is frozen which destroys the lining. The procedure takes about 10 minutes to destroy the lining, and it requires no fluid to expand the uterus and little anesthetic. Ultrasound is used to guide the procedure so that the surgeon can view the depth of the ablation. In one 2003 study, cryoablation was slightly less successful than a standard ablation procedure. However, bleeding still declined by 92% with the freezing technique, and quality of life significantly improved.

Hot Saline. Another recently approved technique (Hydro-Therm-Ablator (HTA) system) uses hot saline (salt water) to destroy the lining. It takes about 10 minutes to do this. This is not a "blind" procedure but uses hysteroscopy so that the surgeon can view the uterus.

Laser Ablation. Endometrial laser intrauterine thermotherapy (ELITT) is an ablation technique that does not require either fluid or devices for expanding the uterus or direct contact with the endometrium. This appears to be a very effective approach.

Microwave Endometrial Ablation. Microwave endometrial ablation applies very low-power microwaves to the uterus, which limits tissue destruction only to the lining without causing any unnecessary harm to other tissues. It takes about three minutes. A 2002 study reported success rates equal to standard ablation and resection procedures.

Radiofrequency. An interesting investigative technique (Novacept RF Ablation Generator) employs an inflated device that uses radiofrequency to deliver power and evenly destroy uterine tissue. A suction device then removes moisture.

Specific Procedures for Women with Uterine Fibroids

Until recently, hysterectomy was the only surgical option for uterine fibroids. Other procedures, however, are now available:

  • Myomectomy. Myomectomy involves surgical removal only of one or more fibroids. It may be accomplished by performing a laparotomy (a procedure that uses a wide abdominal incision) or with less invasive surgical techniques such as laparoscopy and hysteroscopy. In such cases, unlike hysterectomy, fertility may be preserved.
  • Other Procedures. Endometrial ablation may be useful in women with small fibroids and heavy bleeding. More experimental procedures include myolysis and uterine artery embolism, which use unique techniques to shut off the blood supply to the fibroids.

Women should discuss each option with their physician. Deciding on the surgical procedure depends on the location, size, and number of fibroids and the experience of the physician. The risk for complications diminish with the surgeons additional experience, so patients are urged to evaluate the surgeon's track record. [For detailed information, see Well-Connected Report #73 Uterine Fibroids.]

Hysterectomy

Hysterectomy is the surgical removal of the uterus. About 600,000 hysterectomies are performed each year in the US, which is the highest rate among any nations with published data on this procedure. By age 60, about a third of American women have had this procedure. The highest hysterectomy rates are in women between ages 40 and 44. Women in the South and Midwest are more likely to have the operation than those in the Northeast and West.

Hysterectomy - series Click the icon to see an illustrated series detailing a hysterectomy.

Heavy bleeding, often from fibroids, is the reason for about two-thirds of all hysterectomies. However, in about half of these hysterectomies, no abnormalities are detected to explain the bleeding. In one European study, women with menorrhagia were more likely to choose hysterectomy over conservative treatment if they also had pelvic pain and were inconvenienced by the heavy bleeding. The number of procedures has continued to increase, but the rise has slowed substantially in recent years.

In its support, hysterectomy, unlike medical treatments and less invasive procedures, cures menorrhagia completely, and most women are satisfied with the procedure. Less invasive hysterectomy procedures are also improving recovery rates and increasing satisfaction afterward.

Still, in one study in 70% of cases when physicians recommended hysterectomies, they did not give their patients alternative choices or adequate diagnostic evaluations. It should be noted that some evidence suggests that the levonorgestrel-releasing intrauterine system, or LNG-IUS (Mirena, FibroPlant) might help avoid hysterectomy in 80% of cases. Any woman, even one who has reached menopause, who is uncertain about a recommendation for a hysterectomy for fibroids or heavy bleeding should certainly seek a second opinion.

[For more details on hysterectomy, seeWell-Connected Report #73, Fibroids: Uterine or Report #74, Endometriosis.]

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