I thought I'd switch tracts and go over to gynecology for a bit. One of the most common reasons people come to see the gynecologist besides pregnancy is abnormal bleeding. There are lots of causes of irregular or heavy menstrual cycles, but it's easy to narrow it down to two main categories.
I like to try and break bleeding problems into irregular cycles (metrorhagia) and heavy cycles (menorrhagia). Irregular cycles are menstrual cycles that do not come once a month. In most women, cycles come every 26-34 days. Any less than 26 or more than 34, and you aren't ovulating. It's not uncommon for this to happen every once in a while, mostly with stresses or weight change, but if it happens a lot it's worth while to call your doctor. Most of the time people don't ovulate it's a hormonal problem. Too much testosterone (called PCOS or polycystic ovarian syndrome), thyroid issues, high prolactin issues, or low estrogen levels can all make menstruation irregular.
Heavy cycles are more likely from an anatomic issue. Uterine fibroids, polyps, and adenomyosis (where the inside of your womb grown into the muscle tissue) are common causes of menorrhagia. These distort the uterine cavity, making it hard for it to clamp down and stop the bleeding. Women with fibroids with have monthly cycles that will be heavy and long, sometimes with an excessive amount of cramping or clots.
Fibroids are very common. They are benign balls of muscle inside the uterus. Fibroids can be on the outside, middle or inside of the uterus, and where they are located determines how much problem they cause. They are mostly found in women aged 30-40, but can occur at any age. About 30% of women have them by the time they go into menopause, for African Americans it's about 50%. There is a strong genetic link, and a lot women with fibroids remember their mothers having them as well.
Fibroids can be diagnosed by pelvic exam, but the most common way of visualizing them is by ultrasound. Ultrasound will be able to tell the number and size of fibroids inside the uterus. MRI is another way to see, although it is much more expensive. This is used when doctors need to get more exact information about fibroids.
Fibroids are not cancerous, and do not turn into cancer with time. If they're not
causing problems, there's nothing to do about them. If they are giving you really heavy bleeding, pressure, or other issues, there's a bunch of options. Here's a list, from least invasive to most:
1. Nothing - as above, you don't have to do anything. If your cycles are heavy, but you're not anemic, they will either stay the same size or slowly grow until you go through menopause, then shrink.
2. Hormones - birth control pills will generally help with the bleeding. They will not change to size of the fibroids (for good or bad), but if they control the bleeding, in most people it's safe to take them until menopause.
3. Mirena IUD - another good minimally invasive option. Once again, it does nothing to the fibroids themselves, but will decrease the monthly bleeding. It only involves an office visit, and lasts for 5 years.
4. Uterine Artery Embolization/Uterine Fibroid Embolization - this is done by a radiologist in the hospital. A catheter is threaded through the artery in the leg over to your uterus. Small plastic beads are then injected. Since fibroids get a lot of blood supply, the beads will preferentially go to the fibroids and decrease or stop the blood flow to the fibroids. The fibroids will shrink and most people's cycles will get lighter. A UAE will not make your fibroids go away totally. Most radiology places quote about a 20% reduction in fibroid size. The advantage of this is that it is minimally invasive, most of the time does not involve a hospital stay, and has a good chance of helping with the heavy bleeding and pelvic pressure that fibroids cause. The disadvantages are that since the fibroids are not removed, they tend to come back over time. Over the years a significant portion of people's bleeding will come back. It also will not work if you have adenomyosis, and an MRI will be done before the procedure to rule this out. They do not recommend pregnancy after a UAE, although there are a lot of studies showing that it is safe.
5. Endometrial ablation - Once again, an in-office procedure. It does not remove the fibroids themselves, but the goal of ablations is to remove the endometrium, thuse making your cycles very light or nonexistent. Most of what our office does is the Novasure brand, which uses electrical current to burn off the endometrium. This then gets replaced with scar tissue, and I quote that 25-50% of people will have no more cycles. 25-50% will have much lighter cycles, and 5% of the time it does not work. The advantages of an ablation are that it is low risk, can be done in the office, and has a very good chance of helping with the bleeding. The disadvantages are that it is not something you can have done if planning future pregnancies. You must have some form of reliable/permanent contraception in place. The size of fibroids will also determine if you can have it done, the larger the fibroids, the higher the failure rate.
6. Myomectomy - this is a surgery that removes the fibroids themselves. It can be done with a larger incision, called a laparotomy, or with a camera, called laparoscopically or robotically. An incision is made onto the uterus and the fibroid is cut out. After all the fibroids are removed, the uterus is sewn back together. A myomectomy is good for somone planning future pregnancies. It is a surgery and involves a hospital stay and recovery period. People with multiple fibroids can have very small ones that can't be seen at first, and so sometimes after a myomectomy fibroids return years later. After most myomectomies, women need c-sections for deliveries because of the scar tissue on their uterus.
7. Hysterectomy - Removal of the uterus is the one sure way of making fibroids gone forever. It's advantage is that it is 100% curative- no more bleeding ever again. It is a major surgery, however, and has all the risks that go along with it. Remember, a hysterectomy DOES NOT INCLUDE removing the ovaries, so there should be no hormonal changes afterwards. A hysterectomy will not make you go through menopause, gain weight, or grow facial hair. Sometimes the ovaries are removed with a hysterectomy, but that is a separate part of the procedure.
There are 4 main ways a hysterectomy can be performed. An abdominal approach involves a c-section type scar and removal of the uterus through the abdomen. A vaginal approach removes everything vaginally, and no abdominal incisions are made. Robotic or laparoscopic hysterectomies involve making 3 or 4 small incisions on the abdomen and using a camera and small instruments to remove the uterus. Patients undergoing vaginal and robotic hysterectomy generally stay in the hospital overnight and go home the next day. Abdominal hysterectomy patients stay 2 or 3 days, and the recovery takes a bit longer. I'll have to blog later about hysterectomy in general.
Hysterectomy is one of the most common surgeries performed in the US. Most of these are for heavy bleeding, and fibroids are the most common cause of this. As you can see, though, hysterectomy is only one of many possible treatments. There is a wide range of ways of treating bleeding problems, and no one way will work for everyone. Talk to your doctor about the best way for you. Heavy menstrual bleeding is a common problem. Don't be afraid to bring it up to your doctor. That's what we're there for!