A Doctor's Guide To

Dr. Rachel Yankama – VoiceAmerica: A Doctor’s Guide to Bleeding Abnormalities

Now if you happen to be one of those individuals that just has a very heavy period and you decide to go to your doctor about it,  what kinds of options do you have to treat the heavy bleeding?   Part of what might be offered to you will depend upon your age, your smoking status, your prior medical history and medications that you may already be taking.   So let us dive in and discuss what you can do provided that you do NOT smoke or have any underlying bleeding/clotting abnormalities that would contribute to the problem, and for purposes of this discussion  I will assume that you have not yet gone through the menopause.  (The options for treatment are somewhat different if you have already gone through the  “change”).

To begin with,  the options include:

1. some form of hormonal manipulation with synthetic hormones  including oral contraceptives,  (patch)  Ortho Evra,  (ring) Nuvaring,  oral Provera,  DepoPr0vera shot,  or the Mirena IUD;
2. some form of hormonal manipulation using natural hormones such as progesterone , given orally (Prometrium),  vaginally (Crinone),  or topically (there are many companies that make topical progesterone),  I personally have had good success with topical Prolief made by Arbonne International;
3. some form of hormonal manipulation that affects the pituitary gland and suppresses cycles such as Lupron,  Danazol, Zoladex:
4. radio-graphic uterine artery embolization  which reduces blood flow to the uterus and decreases flow;
5. some form of endometrial ablation–such as with Thermachoice,  Novasure, and  Her Option to name a few;
6. and finally,  hysterectomy–which involves removing the uterus.

Now to go into each of these in a little more detail.  The first one involving synthetic hormone manipulation  does work about 95 % of the time to regulate the periods and to reduce bleeding each cycle.  Most individuals also notice a reduction in the amount of pain experienced with  the periods.   However, there are potential side effects and complications possible.   The most common side effects of the contraceptive category are  headaches,  water retention,  moodiness and irritability, weight gain,  nausea, and break-through-bleeding.  The problematic complications are clots in the leg,  heart attack, and stroke–all of which are usually very rare.   However, if you are over  35 and smoke the chances of these complications are significantly higher, and I would NOT recommend the oral contraceptive category, or the patch or the ring.  If you decide with your doctor that you would like to go this route,  I would suggest a trial of at least a 3-6 months  to see if there is an improvement.  Oral Provera,  DepoProvera,   and the Mirena are single agent synthetic progestins  (meaning that the progesterone molecule has been tampered with and adjusted to have several side chains on it),  This changes the actual effect of the hormone at the cell level and is very potent  with side effects:   predominantly headache,  hair loss, acne, weight gain,  moodiness and depression.   In my practice I have seen about 10% to 20% of people on Provera have side effects,   about 40% of people getting the DepoProvera shot have side effects,  and about 2% of people with the Mirena IUD have side effects.  Provera is usually taken orally for 10 to 14 days out of each month,  DepoProvera is given every 3 months and 75% of people will stop getting periods altogether on the shot,  and the Mirena is associated with a lot of irregular bleeding within the first 3 to 6 months after insertion,  but after that the periods get significantly lighter.

The second category of natural hormone manipulation is that this really addresses the real reason why people run into problems with their periods.  Many times it is because there is some element of estrogen  dominance,  and so by adding natural progesterone,  this actually helps the person with balancing out their hormones.   Plus the body has all the receptors to deal with progesterone,   it does not have the receptors to deal with all the synthetic drugs  ( which in fact contribute to the hormone imbalance).   Now of the natural progesterones available,   studies show that topical administration is really the best way to get it into your system.  So topical creams that deliver about 20 to 25 mg per day of use  (on days 12 to 26 of the cycle)   give the person a physiologic dose of the progesterone.  Ther is good absorption of the progesterone in the vaginal forms as well, although this is not as popular because it does tend to be a little messier for the person using it,    as it is usually inserted at night and it can run out of the vagina  the following day.    Oral forms are not absorbed as well from the gastrointestinal tract   and so in order to get some benefit from it,  doses have to be considerably higher than the topical forms  (between 5 to 20 times higher).   This contributes to a higher side effect profile on the oral form–mainly drowsiness and so it does have to be taken before going to bed.  The advantage to the oral and the vaginal route is that most insurance companies cover this as it is a prescription,  and the disadvantage to the topical forms is that most insurance companies do not cover it because people can by it over-the-counter, at health food stores,  or on-line  (like from my web site:   www.womenshealth.myarbonne.com).

The third category of treatment is the gonadotropin releasing hormone agonists  (Lupron, and Zoladex)l:  meaning they suppress the function of the pituitary gland in producing the hormones that signal the ovary to do its job,  so women stop having their periods.  Treatment is usually given for 6 months and causes known side effects of hot flashes, night sweats,  moodiness, irritability,  vaginal dryness and has been associated with contributing to osteoporosis.   In other words, it places people prematurely into a temporary state of menopause.   (I say temporary, because most individuals  will start having their periods again after they get done with this treatment.)   Danazol works a little differently and is a derivative of a male hormone, so additional side effects with this  treatment include hair growth (like on the face and chin), weight gain,  lowering of the voice,  shrinkage of the breasts,  and acne.    This  is not a very popular treatment for the reasons of the side effects–not many women want to get male-type side effects.

Fourthly  radiographic uterine artery embolization has helped women who are candidates for this.  Usually a women has an enlarged uterus with fibroids as the reasons for the excessive bleeding and this is a form of  treatment that addresses the fibroids.   What is done is that an IV (or intravenous line)   is started in the groin area,   then with flouroscopy  the blood flow to the uterine fibroids is identified.  Then a substance that blocks  the blood flow to the fibroid is injected into the artery thus causing the fibroid to shrink.  Eventually  the uterus   shrinks and amount of bleeding decreases.    This is temporary solution, and potentially the blood flow to these fibroids can increase over time and cause them to grow again.   However for some people this is a good temporizing option.

Fifthly,  endometrial ablation is another option, but does depend on the size of the uterus.  It is not as successful a form of treatment for a uterus that is larger than 12 weeks size.   (A non-pregnant uterus is compared in size to a pregnant uterus).  All of the endometrial ablation techniques have similar success rates and can be associated with quite a bit of cramping in the first 24 hours after the procedure.   There is also a watery discharge for a few weeks afterward as well.   About 85% of women will notice a significant reduction in the amount of bleeding that occurs each month.   Of the women that respond, about 1/3 of the women have no period,  about 1/3 have a very light flow, and about 1/3 have a more “normal” period.  About 15- 20% of women may still have heavy bleeding.   There are some potential complications with each one,  and that includes infection, bleeding and uterine perforation.  Thermachoice endometrial ablation involves putting a catheter that has a balloon on the end of it into the uterus.   The balloon is then filled with fluid to reach a pressure of 160 to 180 mm of Hg  (millimeters of mercury, a standard pressure measurement).   Once the appropriate pressure is obtained,  the fluid is then heated up to 87 degrees Centigrade for a total of 8 minutes   (after reaching the goal of 87 degrees.)   Then the catheter and the balloon are removed when the procedure is over.   The Novasure procedure involves putting a triangular wand shaped structure into the uterus, that (when open)  mimics the interior shape pf the uterus.   A negative pressure is applied and the wand has an electrical current run through it which then destroys the superficial endometrial lining.      The cryoablation procedure involves putting a probe up into one side of the uterus and identifying its location by ultrasound and then freezing the lining of the uterus. Then the other side is done , and if needed, the middle.  The last endometrial ablation procedure  involves circulating hot water into the endometrial cavity without being enclosed in anything.  Potentially, the hot water could traumatize other structures as well.

Finally there is a hysterectomy,  which means removing the uterus  (and usually the cervix, but not always).    In this procedure,  the organ that  is the source of the bleeding is removed so periods will stop completely.   This will mean the the woman is also not able to get pregnant and have a child,  so this procedure is not offered unless the women is done having her children or unless cancer is found in the process of figuring out why someone is having a lot of bleeding.  There are 3 major ways of doing a hysterectomy–abdominal,  vaginal, and laparoscopic (either with or without a robot).   Using the robot, the procedure is called a DaVinci Hysterectomy.  All three have potential complications of infection, bleeding, and injury to some other internal structures such as the bowel or the bladder or the ureter,  also there is a chance for developing either clots in the leg or pneumonia postoperatively.   The main advantage to the  laparoscopic approach is that there is less bleeding,  less infection,  less postoperative pain,  shorter hospital stay and also   sooner return to work.

Menstrual Irregularity  is something that is a problem many women experience particularly either before having children,  between children,  or after completing child bearing.   In other words,  it is a very common problem.   It occurs especially frequently as women get into their 40’s and 50’s,   before the periods finally stop.   Either   the periods are too long,  or too heavy,   or they are  too frequent or too painful.       What I will cover next will be the basic approach to assess the problem so that the appropriate treatment can be offered.

The average period lasts about 4 to 6 days and some people are just lucky to have a  period that only lasts 2-3 days with light flow.   Whereas, others may experience 7-8 days of moderate to heavy flow.    If a person has so much bleeding that they are unable  to leave their home,  then that is a heavy period!   The amount of bleeding for a normal period  also varies from person to person.   On the average,  not more than about 2 ounces  (or about 60 mL)  of blood are lost.   For someone with a heavy cycle,  the amount of blood lost could be significantly more than this.   And once a person has a period that lasts more than 10 days,  this is TOO long;  it is definitely time to talk to your doctor about the periods if this is what is happening.     Conversely,  if your periods are occurring  more frequently than every 21 days  (from the first day of one cycle to the first day of the next cycle),   then this is also more frequent than normal and you should be addressing this with your doctor.   Symptoms that would indicate that you are loosing too much blood each month and could possibly be  anemic (or have low iron),    include feeling fatigued,   dizzy,  lightheaded,  drowsy,  having shortness of breath with minimal activity,  or wanting to chew on ice.

So,  what are the ways to find out if  there is a problem?   Well when you see your doctor, he/she  will want to know the following information:

1. how long has it been going on?
2. are there any other associated symptoms,  such as dry skin, weight loss or gain, hot  flashes, night sweats, pain or cramping besides fatigue, dizziness, or fainting?
3. what was your cycle normally like before the bleeding problems started?
4. are you taking any medications  that may affect your menses?
5. and are  there other pertinent factors related to your prior medical history,  surgical history,  family history  (particularly in relationship to bleeding disorders),  and your current family planning methods, that may have a bearing on the problem?

Of course your doctor will want to examine you–to check for  conditions that can have an effect on your menstrual cycle  such as thyroid conditions,  and enlarged uterus,  pregnancy,  etc.   In addition,  certain blood tests may be ordered.    A pelvic ultrasound may be a helpful test as well.   Now if you end up having all of these tests and there is still not an answer,  then there is a choice between 3 other tests  which may give the answer to the bleeding problems.   The first is an endometrial biopsy,  the second is hysteroscopy, and the third is a D & C  (or dilatation and curettage).      The endometrial biopsy is usually done in the doctor’s office,  the hysteroscopy can be done either in the doctor’s office or as an outpatient procedure,  and the D & C is usually done as an outpatient procedure with some form of anesthesia.   They all have similar risks:   infection,  bleeding, and the potential for uterine perforation (or making a hole in the uterus,  accidentally of course).   The endometrial biopsy involves passing a small narrow, usually plastic, catheter into the uterus through the cervix in order to get a small sample of tissue  that can then be analyzed by the pathologist–this is a medical doctor who specializes in evaluating tissue under the microscope.  This test can cause some cramping (similar to a bad period),  and there may be a little bleeding afterward,  but it is normally done without any form of anesthesia, and takes less than 5 minutes to do.    Any cramping that occurs with the process ends shortly after completing the procedure.   For those individuals who have a low pain tolerance or who have been bleeding so heavily or for a long period of time that it is necessary to stop the bleeding,  then a D & C would be offered.    This can be done with a general anesthetic,  with a spinal anesthetic,  or with local anesthesia  (and perhaps a little sedation).   In this procedure, the cervical opening is stretched a little in order to be able to insert equipment that can scrape off the lining on the inside of the uterus.   Some doctors will combine the hysteroscopy with either the endometrial biopsy or with the  D & C,  in order to actually look inside the uterus to find polyps or irregular areas.   Once the procedure is done,  your doctor will want to discuss the results with you at a later visit as it normally takes several days to get the pathology report back  which hopefully has the answers for you.

Now what are the main problems that contribute to  menstrual or bleeding abnormalities?   One of the most common is related to the thyroid gland–if it is underactive or overactive,  period problems can occur.    Irregular bleeding can also occur in situations where  a person is not ovulating because of polycystic ovary.   In this situation there is a considerable build up of tissue in the uterus which then bleeds for weeks on occasion,  especially after an episode of no periods for  a few months.  The pathology report can show chronic proliferative changes or even hyperplasia  (too much tissue and gland formation),  or endometrial polyps.    These are thought to be due to too much estrogen and not enough  progesterone,  (an estrogen dominant condition).   Another source of irregular bleeding is endometritis,  or a low grade infection in the uterus that causes bleeding to occur between periods.  This bleeding may not be heavy,  or it could simulate the bleeding that one has with the usual cycle.   The endometritis could be acute  (meaning developing over a short period of time)   or chronic  (meaning developing over a long period of time).   Needless to say,  there are also fibroids  (or smooth muscle tumors in the uterus),  and last but not least,  endometrial cancer.  This is not an exhaustive list,  but basically covering the most common problems.

I will cover the treatment options of these various problems in “Bleeding Abnormalities,  Part II”.