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Heavy Menstrual Bleeding

This is probably the most common problem that a general gynecologist sees. It is especially common when women first start getting their periods, and is more common again in women who are entering the last ten or so years prior to menopause. Whether periods are heavy or not is very subjective, and often women who report very heavy periods will have normal hemoglobin and iron levels. Despite this, heavy bleeding can have a negative effect on a woman's quality of life and can sometimes signal other problems that need treatment, and therefore deserves investigation and management.

Often the first steps in investigation are bloodwork and an ultrasound. Bloodwork might detect thyroid dysfunction which can affect bleeding, a blood clotting problem, or hormonal changes that might suggest an ovulatory problem. An ultrasound can help to detect structural problems that may cause heavy bleeding such as fibroids or polyps. In women with risk factors for abnormal cells in the lining of the uterus, a biopsy may need to be done to determine if this is the cause. Other investigations that may be required include a pap smear and swabs for infection.

Treatment options for heavy bleeding vary depending on the cause. If a structural cause is found, such as a fibroid or a polyp, or if a biopsy comes back showing abnormal cells or cancer, the options will be different than if no abnormality is detected during investigations.

Many women report a family history of needing to have a hysterectomy and therefore believe that they will too. They may report that their grandmother, their mother, and/or many aunts all needed to have a hysterectomy. This is a very common history to have, because years ago we did not have many other options to manage heavy bleeding and so many women ended up having hysterectomies. We are very lucky today that we have many other less invasive options that are effective at reducing or eliminating heavy bleeding, and we recommend in most circumstances that less invasive options are pursued first, leaving hysterectomy as a last resort if those do not work. Many options available for control of menstrual bleeding are also used as contraceptives. These are very safe to take to control bleeding, even if you do not require the contraceptive benefits, as long as you do not have contraindications to them.

Options that may be discussed depending on their suitability for you include:

  • Ulipristal Acetate (Fibristal): this is a medication that can be taken to reduce bleeding especially when related to fibroids, and to help shrink fibroids.
  • Uterine Artery Embolization: this is a procedure that can be done by interventional radiology to reduce or eliminate the blood supply to fibroids in order to cause them to shrink. This usually involves an overnight stay in the hospital, but is much less invasive than a hysterectomy with a much quicker recovery time.
  • Tranexamic Acid (Cyclokapron): this is a non-hormonal medication that helps to decrease the flow and shorten the duration of your period. It is taken only on days when you are bleeding.
  • Birth Control Pills/Patches/Rings (various): these contain a combination of estrogen and progesterone which over time helps to thin the lining of the uterus so that bleeding decreases.
  • Progesterone Only Pills (Micronor): these contain only progesterone and are suitable for women who cannot take estrogen, and work in a similar fashion to thin the lining of the uterus.
  • Progesterone Injections (Depo Provera): this is an injection received every 3 months that is effective both for contraception and for managing heavy bleeding. Many women stop having their periods after receiving a few injections.
  • Progesterone Containing IUD (Mirena): this is a device that is inserted into the uterus in the clinic. It delivers progesterone locally to the uterus to help thin the lining directly at the source. It is very effective at reducing bleeding and pain associated with periods. Most women will have a significant reduction in their bleeding, and many women even stop having their periods after a few months.
  • Endometrial Ablation: this is a day surgery where the lining of the uterus is cauterized to reduce bleeding. Recovery time is short and most people have great results. This can only be done for women who are certain they are done having children, and ideally in women who are within about 10 years of menopause.
  • Hysteroscopy: this is also a day surgery where we look inside the uterus with a scope. This may be recommended if it appears that there is a polyp in your uterus. We can visualize it, or any other abnormalities inside the uterus, and remove it. This is often done in conjunction with an endometrial ablation.
  • Hysterectomy: this is a major surgery to remove the uterus +/- the fallopian tubes +/- the cervix +/- the ovaries.