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Heavy periods

Heavy menstrual bleeding (HMB) is defined as excessive menstrual blood loss which interferes with a woman's physical, social, emotional and/or material quality of life. It can occur alone or in combination with other symptoms.

HMB is not associated with significant mortality and may be considered unimportant by some healthcare professionals.  However, the harm caused by heavy periods in terms of strained relationships, tiredness and time off work cannot be over stressed. 

A woman who suffers persistent intermenstrual (between periods) bleeding, is over 45 or has had ineffectual treatment should see a specialist.  The National Institute for Health and Clinical Excellence  suggest that you should read this publication before you see the specialist.

http://www.nice.org.uk/nicemedia/live/11002/30406/30406.pdf

Initially your doctor will ask you about your periods: how many days do they last, how much protection do you need, do you have clots, or flooding? Do you suffer mare pain than before? You may have an internal examination , or your doctor might rely on an ultrasound scan to discover the size and shape of the womb. If all seems normal, a diagnosis of Dysfunctional bleeding would be made and your treatment could be started by your GP.

Pdf of recording chart to download and print

Drug Treatment

One of the best treatments for dysfunctional bleeding is the Mirena IUS.  This is a contraceptive “coil” which is inserted into the womb and releases levo-norgestrel (a progesterone like hormone) in tiny quantities on to the lining of the womb.  Periods are almost always reduced a bit and may be reduced to zero.  The first six months may be complicated by irregular bleeding and, occasionally,  some premenstrual like feelings might occur.  It is a very effective contraceptive while in place and your fertility returns as soon as it is removed.

Tranexamic acid:  This is taken in the form of tablets from the first day of your period for 4 days.  It works by helping the blood in the womb to clot.  It is not a contraceptive.  Occasionally women have suffered indigestion.  If this has not worked in about three months, it is probably not worth continuing.

Non-Steroidal Anti-Inflammatory Analgesics (NSAIDs):  These are tablets taken from the first day of your period (or just before if you can tell) until the heavy bleeding has finished.  They affect prostaglandins which control the size of blood vessels in the womb.  Indigestion and diarrhoes are a bit more common than with tranexamic acid.  Again, three months should be all you need to know if it works for you.

Combined Oral Contraceptive Pills:   These tablets are taken for 21 out of each 28 days.  They suppress the menstrual cycle and produce a “withdrawal bleed” instead.  Side effects depend on the formulation of the pill and should be discussed with your doctor.

Injected or implanted Progestogen:    Depo-Provera or Implanon are marketed as progestogen only contraceptives but will reduce menstrual blood flow. Irregular bleeding may be a problem but they may also reduce the period to zero.

Gonadotrophin Releasing Hormone Analogue (GnRH):   These injections will stop periods.  Theymay be used in special circumstances by a specialist.  For example, they might be used to shrink fibroids before surgery. 

Surgical Treatments

Endometrial Ablation or Resection There are many different techniques whereby energy is applied to the lining of the womb to destroy the cells of the endometrium.  It may be heat, electricity, radio frequency waves, cold or laser light.  Each specialist will have become proficient in the use of one or two and you should discuss the details with your surgeon.  Normally, a diagnostic hysteroscopy will have been performed to assess the regularity of the cavity of the womb. Resection with an operating hysteroscope could be appropriate if the cavity of the womb is distorted with a fibroid or a septum.

Myomectomy:   Cutting out fibroids is not really appropriate for the treatment of heavy menstrual bleeding.  It is rarely effective.

Hysterectomy:   If all else fails, this is still the only treatment which guarantees to stop periods for ever. 

Links to these operations inProcedures

Delaying a period

I have often been asked if a woman can delay a period which is expected to clash with an important event. This might be her wedding, honeymoon, a sporting event or exams. This is quite easy if one prepares beforehand.

When an egg is released by an ovary, the follicle starts to produce progesterone, It is now called a corpus luteum (white body). Unless it is instructed to continue, by a hormone (beta human chorionic gonadotrophin, β hCG) produced by an embryo, a corpus luteum only lasts for two weeks and then shrivels up. A normal period starts in response to falling levels of progesterone in the blood stream. Having a menstrual bleed is of no benefit to your body. It is simply to produce a new lining to the womb for each new embryo.

If one is taking a combined (estrogen and progestogen) oral contraceptive pill, a withdrawal bleed starts when you stop taking the pill for a week (or when you take the hormone free pills in a 28 day packet).

Thus we have three ways already to postpone bleeding. We could use βhCG to keep the corpus luteum working, but this involves injections. The commonest treatment used by doctors in the UK is to administer a progestogen, commonly norethisterone, which can be taken by mouth. Relatively high doses are required and one might feel rather “pre-menstrual”. If you suffer pre-menstrual acne, this might not be the best for a wedding.

The best way to postpone a period is to use combined oral contraception. If you take one packet after another without a gap (and do not take the inactive pills if you have a 28 day formulation), the withdrawal bleed does not happen. In general, I would recommend three packets consecutively (3x21 days) and then a week off to have a withdrawal bleed. This, I have found, minimises break-through bleeding.

Break-through bleeding is likely if you:

• Miss a pill
• Smoke
• Start a medication that interferes with the contraceptive . e.g. some antibiotics
• Become ill with vomiting or diarrhoea, which may impair absorption of the medication


Are there any risks?
Combined oral contraceptive pills are not suitable for everybody. For example, it is recommended that women over 35 years of age who smoke should not use combined oral contraceptives. All our evidence for risk is in women who use the preparations for years for contraceptive purposes and it is not known how this evidence relates to short term usage to postpone periods.

Premenstrual Syndrome

Pre-Menstrual Syndrome (PMS)
This is also sometimes called “Pre-Menstrual Tension” (PMT).  A syndrome is a set of symptoms and/or signs which go together (Greek syn – together, dromos – things).  We use this term when we can describe a problem but do not know the cause or, indeed if all the symptoms represent one disease.

When does PMS happen?
The symptoms of PMS occur before, during or just after a period.  For the diagnosis to be made, there must be at least one week free of symptoms. It is therefore very rare before periods start (the Menarche) though hormone changes are causing all sorts of symptoms at puberty.  It also will disappear when the menstrual cycle stops due to pregnancy, the menopause or surgery which removes the ovaries. 

What are the Symptoms of PMS?
Every woman is different and may suffer some or all of the following:

• Acne
• Breast tenderness
• Sleep disturbance and tiredness
• Changed appetite with or without food cravings
• Upset stomach, constipation or diarrhoea
• Enlarged waistline (Bloating)
• Aches and pains
• Headache
• Trouble with concentration or memory
• Tension, irritability, mood swings or crying.
• Anxiety or depression


Download here the PMS pdf form

Almost every woman will recognise one or some of these in her own experience.  Bloating and breast tenderness are recognised effects of the hormone progesterone which predominates in the second half of a menstrual cycle after the egg has been released.  Fortunately for most women, the symptoms are little more than a monthly nuisance and can be accepted as normal.  However, for a few the problem is devastating, destroying work, relationships and any enjoyment of life.

What causes PMS?
No one knows for sure.  It is obviously something to do with the menstrual cycle.  The theories break into tw groups:

About Your Hysteroscopy

Why?
In the past we used to do a D & C (dilatation and curettage), but nowadays we can see inside the womb and therefore be much more accurate in diagnosis. A thin telescope called a hysteroscope is passed very gently through the cervix (the neck of the womb) into the womb itself. By attaching the hysteroscope to a TV camera and  looking at the screen or just looking down the telescope, a full clear view of the inside of the womb is seen. At this stage, any disease can be seen and a biopsy (a sample of tissue) taken if necessary.

Hysteroscopy might be suggested to you to find out causes of heavy periods or any other unexplained bleeding, causes of miscarriage or several other less common problems. Using special instruments many operations may be performed inside the womb by hysteroscopy.


What Should You Expect?

When you come into hospital, the doctor will explain the procedure to you and ask you to sign a consent form. At that stage, if there are any questions that you would like to ask about the procedure please do so. You need to inform either the doctor or the nurse present if you have any allergies or have had bad reactions to drugs or other tests in the past. They would also like to know about any previous surgery or operations you have had performed. You will be asked to take off all your clothes below the waist and wear a hospital gown. During the procedure you will be made to feel as comfortable as possible on an examination couch.

If you are having a general anaesthetic, the anaesthetist will see you and send you off to sleep.
If you are having a local anaesthetic, a nurse will be at your side throughout. She will ask you to rest your legs on two knee supports which are placed on either side near the end of the couch. Very gently, an instrument called a speculum, used when taking a cervical smear, is placed within the vagina to enable the doctor to see the neck of the womb. A warm antiseptic solution is used to clean the surface of the cervix.

The hysteroscope is gently placed close to the outer opening of the cervix and at this stage a slight cramping feeling may be felt within the lower part of the tummy, not unlike period pain. The hysteroscope is passed through the cervix into the womb and if desired you can watch the progress on the nearby television screen. Any findings seen can be explained at this time. The whole procedure is likely to take about 15-20 minutes. After the examination you will be allowed to rest in a nearby waiting area.


Complications of surgery

These are, in general, very rare for this minor surgery.
Complications of Anaesthesia: The anaesthetist will be able to discuss this with you. Alternatively, look at the Association of anaesthetists web site (see weblinks)
Pain:  This is usually mild and similar to period pain.  It usually needs no more than simple painkillers.
Bleeding:   Scraping the lining of the womb will usually cause light bleeding. It is not more than a period in most cases.  Coming into hospital may affect the timing or nature of your next period (if you are still having them)
Infection:    Probably the most common type of infection is a "water infection", though even this is rare.  Occasionally there may be an unpleasant, smelly discharge from the womb suggesting infection there.  It is easily treated with antibiotics.
Blood clots (DVT):  These are extremely rare for such brief and minor surgery.  Unless you have specific risk factors, no prevention is necessary other than getting up and about quickly after the operation.


Complications of this operation in particular

Perforation of the uterus:  Sometimes an instrument makes a small hole in the womb.  This happens about 6 times per 1,000 operations.  It will only very rarely cause further complications unless you are pregnant when the womb is more likely to bleed.  You may have to be observed overnight to be on the safe side.  Occasionally another operation is needed (risk less that 1 per 1,000).
Failed procedure:  This is rare and simply means that it was not possible to see inside the womb.


Going Home

If you are going home after the procedure, it would be advisable that somebody comes to pick you up. It is important to rest quietly at home for the remainder of the day.


When Do I Know The Result?

Immediately after the examination the doctor will explain his findings in full. If you have had a general anaesthetic, you may have no memory of this and will probably find it better to discuss the findings fully at your follow-up consultation when you are fully recovered from the anaesthetic. If a biopsy or polyps have been removed at the time of the procedure, it will be a couple of weeks before the results are available for discussion at your follow-up consultation.

Endometrial Resection/Ablation

Endometrial (or Hystero) resection is a procedure used as a treatment for women with menstrual problems.  It is sometimes called Trans-Cervical Resection of the Endometrium (TCRE). It may be used instead of an hysterectomy. An instrument called an operating hysteroscope, usually under a general anaesthetic, is inserted into the womb via the cervix (neck of the womb) and portions of the lining of the womb can be cut away surgically or by laser, which will usually either eliminate or greatly reduce the periods.

As this therapy destroys much of the lining of the womb, it must not be used if you ever want to have children, in fact, pregnancies after ablation can be dangerous for both mother and baby. If there is a chance pregnancy could occur, if you or your partner have not been sterilised, contraception must be used after treatment and you should discuss the options with your doctor.

Nowadays, there are more modern techniques to be used, such as Thermachoice or Microwave Endometrial Ablation. Thermachoice Uterine Balloon Therapy works by a soft flexible balloon being inserted into your womb via the cervix. The balloon is then inflated with a sterile fluid which gently expands to fit the size and shape of your womb. The fluid is then heated to 87 degrees and maintained for 8 minutes. When the treatment is complete, all the fluid is withdrawn from the balloon which is then removed from your womb.

 http://www.nice.org.uk/pdf/ip/IPG006publicinfoenglish.pdf

Microwave Endometrial Ablation (MEA) uses high frequency microwave energy to cause rapid but shallow heating of the endometrium (the inner lining of the womb). This heating destroys the endometrium. It takes about 3 minutes to complete.

http://www.nice.org.uk/pdf/ip/IPG007publicinfoenglish.pdf

Endometrial resection can be used to resect fibroids, however the newer procedures such as Thermachoice and Microwave Endometrial Ablation are only suitable for women who have a normal womb, without fibroids or other distortion of the cavity of the womb and you would normally have a diagnostic hysteroscopy before embarking on endometrial ablation to confirm that your womb is suitable for the procedure.


What Should I Expect?

You may be asked to take a course of tablets or an injection before the procedure to reduce the thickness of the endometrium. When you come into hospital, your doctor will see you and ask you to sign a consent form. At this stage, you need to tell the nurse or doctor if you have had any previous adverse reactions to drugs or other tests.
They will also want to know when your last period was and whether you have had any previous surgery. You can also discuss any worries or questions you have. You will be asked to take off your clothes and change into a hospital gown and you will also see the anaesthetist.

After the procedure you will be allowed to rest (possibly overnight) to recover. You may experience some lower abdominal cramping and you will be given painkillers if necessary. You should arrange for someone to collect you and take you home and it is important to rest quietly for at least 24 hours.

You may have a discharge lasting for about 2 weeks or in some cases longer but this is nothing to worry about unless accompanied by a high temperature or worsening pelvic pain in which case you should call your doctor.
We find that using endometrial resection/ablation stops periods altogether for about one-third of patients, another third find periods much reduced and about a third find little difference and it is very useful to hear from patients for some months after the procedure, which category they fit into so that we can gather information about the efficiency of the procedure

Are there other treatments which I should consider?
Other treatments for heavy periods (menorrhagia) may include drug therapy or hysterectomy.

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