Is it possible to control heavy periods without hysterectomy?
Heavy periods or heavy menses are a common problem that patients discuss with their obgyn. Menorrhagia is the medical term for very heavy menstrual periods. Frequently, patients believe that their heavy menstrual cycles are normal – but needing to change a soaked tampon every 1-2 hours is not normal.
Sometimes, patients will describe needing to wear 2 super tampons together, or a super tampon and overnight pad together. This volume of bleeding is NOT normal. It can also be dangerous as it can lead to anemia and iron deficiency. It can also cause dizziness and low blood pressure. Heavy menses and heavy menstrual bleeding require evaluation for both the safety of the woman as well as for her quality of life.
Causes of Heavy Periods
Some of the causes of heavy menstrual bleeding and heavy periods include bleeding disorders (hemophilia, von Willebrands disease), hormonal disorders (polycystic ovarian syndrome, hypothyroidism), uterine abnormalities (polyps, fibroids), adenomyosis (endometriosis of the uterus), or precancer/cancer of the uterus. It is important to evaluate for these as the treatment should be geared toward the underlying cause. Evaluations might include hormonal labs, ultrasound, or endometrial biopsy. Some of these disorders are better treated with medication, while others are better treated with surgery.
Treatment Options for Heavy Periods and Heavy Menstrual Bleeding
There are many treatment options for heavy periods and menorrhagia.
Oral medication / Nuvaring / Xulane patch
People often think that the only oral medication to treat heavy periods and heavy menstrual bleeding is birth control pills. This is not the case. Birth control pills which mostly contain both estrogen and progesterone do work well to reduce bleeding for patients with bleeding disorders, hormonal disorders, and often adenomyosis. These same hormones can also be administered through a monthly vaginal ring (nuvaring) or weekly skin patch (xulane) which increases convenience.
Today, individuals sometimes prefer to avoid daily hormonal medications – and thankfully there are options for those women too. When cycles are far apart (every 2+ months), bioidentical progesterone can be used for 1 week to cause the uterus to empty. By emptying the uterus more frequently, the total amount of bleeding with each cycle is reduced. Another option is lysteda (transexamic acid) which has been used in Europe for many years. It is non-hormonal and works on the blood system to reduce bleeding by up to 50%. It is only taken on the heavy days of flow – 2 tablets three times per day. More recently, a medication that reduces hormone production was introduced, called Orlissa. This can reduce both pain and bleeding by decreasing the stimulation of the ovary, and thus decreasing estrogen in the body. Depending on other health issues, some of these medications may not be appropriate for individuals, so it is essential to discuss all options with your physician.
There are three different progesterone Intra-Uterine Devices that can also help with heavy periods and heavy menstrual bleeding related to bleeding disorders, hormonal disorders and adenomyosis. In order of increasing progesterone content, they are the Skyla, Kyleena, and Mirena/Liletta. Each of these cause the lining of the uterus to thin which reduces blood flow. The higher the amount of progesterone in the IUD, the thinner the lining becomes and the greater the reduction in bleeding.
IUDs can be used in both women who have had children as well as those who have not. They can remain in place for 3-5 years depending on which IUD is chosen. The Nexplanon is a small rod about the size of a match stick that inserts into the inner upper arm. It also delivers continuous progesterone, having a similar impact on the uterine lining. Many will experience irregular bleeding in the first few months after insertion but this usually resolves and ultimately accomplishes good control of bleeding.
Minor surgical procedures
Because heavy menstrual bleeding and heavy periods can frequently be caused by fibroids or polyps, the removal of those benign growths can resolve the heavy bleeding. This can often be done using a hysteroscope – inserting a 6-10 mm telescope-like device through the cervical canal and into the uterus. These procedures can often be done in the office or an outpatient surgery center. Patients can frequently return to work within 1-2 days and often only need ibuprofen for post-operative pain relief.
An endometrial ablation (burning of the lining of the uterus) can be done at the same time as the above procedure, or independently for those without polyps or fibroids. By destroying the lining of the uterus, there are fewer cells to respond to the female hormones (estrogen and progesterone) which reduces or eliminates bleeding altogether. Nearly 70% of these women will have no further bleeding. This has a similar recovery to hysteroscopy alone.
Fibroids can also be treated with various destructive techniques such a uterine artery embolization, high-intensity focused ultrasound, and Acessa (laparoscopic radiofrequency fibroid destruction). These procedures reduce the size of fibroids which can reduce the irritation of the uterine lining to decrease bleeding. As with medications, some surgical procedures are not appropriate for individuals and need to be reviewed with a physician.
Major surgical procedures
The major surgical procedures to treat heavy periods include myomectomy (removal of fibroids) and hysterectomy (removal of uterus). Myomectomy can be accomplished either laparoscopically or through an open abdominal incision, like a c-section. These procedures tend to be reserved for women who plan to have more children and thus need to keep their uterus. More surgical blood loss tends to occur with myomectomy than with hysterectomy, and new fibroids can often form in the uterus, therefore hysterectomy is preferred when childbearing is complete.
Hysterectomy can also be accomplished vaginally, laparoscopically, robotically, and through an open abdominal incision. Today, most hysterectomies are done laparoscopically unless the uterus is too large to safely remove using that technique. Robotic surgery has been heavily advertised but has never been shown to improve patient outcomes when compared to traditional laparoscopic surgery for hysterectomy. The cervix, fallopian tubes, and ovaries can be removed but that is not required to achieve bleeding control and should be discussed with a physician. Choosing major abdominal surgery is a significant decision and some woman prefer to not lose their uterus, which is a choice that should be respected by the medical community.
Thankfully, medical advances allow women many options for treating their heavy periods and heavy bleeding. Each of these options should be reviewed to assess which is appropriate for the individual. The job of physicians is to educate women on their choices. Women should then be trusted to make their own decision as to which treatment to try first in attempting to resolve their symptoms.
If you are looking for an OB/GYN in Austin, Texas for treatment of heavy periods and menorrhagia, please don’t hesitate to contact us at ObGyn North! Also, check out our testimonials to see what people are saying about our gynecological services.