HEAVY MENSTRUAL Bleeding is bleeding which interferes with a woman’s physical, emotional and general quality of life.
It can be due commonly to: 1. Fibroids, which are growths in the uterus.
2. Adenomyosis, where the lining of the womb grows into the womb and causes severe pain at every cycle.
3. Dysfunctional uterine bleeding, where one gets heavy bleeding due to circulating hormones.
When a patient presents to the gynaecologist, a history is taken first, then a gynaecological examination is performed, followed by an ultrasound scan to determine the cause of the bleeding. A blood test, called a full blood count to check for anaemia, is done initially and subsequently management is tailored to the needs of the woman.
If lining of the womb pathology is suspected like bleeding between menses for more than 6 months, 45 years or older, a history of PCOS/obesity or if polyps(fleshly growths) or fibroids are seen on ultrasound scan these patients should be referred and counselled for outpatient hysteroscopy where a small camera is placed in the uterus and a biopsy/removal of polyp or fibroid is done.
This diagnostic and treatment technique can be performed in a doctor’s office with no anaesthesia or local anaesthesia, avoiding the routine use of sedation or general anaesthesia.
It should be noted that less than 5% of gynaecologists routinely perform outpatient diagnostic hysteroscopy and even fewer offer operative outpatient hysteroscopy, so adequate counselling is of importance as it might not be routinely offered.
Medical management consists of Mirena coil as first choice if the uterine cavity is regular in shape, and fibroids if present are less than 3cm.
If this is not acceptable to the patient, then other medical treatments should be offered like northisterone and trans-examic acid or the oral contraceptive pill.
If medical management is not suitable or the patient has failed medical management, then before hysterectomy is offered, other minimally invasive techniques should be offered if fertility is not required. These include Endometrial Ablation and Endometrial Resection Endometrial Ablation is a procedure where the lining of the womb is destroyed, this procedure takes two minutes and can completely stop periods. There is a quicker recovery as the procedure doesn’t involve any scars as everything is done via the vagina and can be done with simple analgesia and local anaesthetic, sedation or under general anaesthetic.
Endometrial Resection (camera in the womb) is a procedure where fibroids or polyps are removed via the vagina with a camera under direct vision, and has the same advantages as endometrial ablation.
Other conservative management includes Uterine Artery Embolization (UAE) where the blood supply to the fibroids are blocked off causing them to shrink.
If fertility is required then myomectomy should be offered,, but UAE can be offered after detailed counselling.
Hysterectomy can be offered if neither of the above is acceptable to the patient or if surgically indicated.
In conclusion women with heavy menses should be seen and examined and have an ultrasound done if endometrial pathology is suspected,, then these patients should be referred for outpatient hysteroscopy and biopsy. The patient should be counselled about all available options available to them.
Dr John Barker Bsc MBBS MRCOG Dip (Risk Management). Obstetrician/ Gynaecologist at Arnos Vale Medical Center His special interests include Endometriosis, Gynaecological Oncology, Alternatives to hysterectomy, Out-patient Hysteroscopy, Fibroids.