Table of Contents

Q 24. 1 Are heavy periods a common problem?

        Menorrhagia (Greek: Meno - uterus; rhegnunai - to burst forth), the medical term for heavy periods, is a common problem. It has been estimated that one woman in 20 aged 25- 44 years will attend her general practitioner each year requesting treatment. No doubt many more suffer in silence as, during a heavy period, most women understandably feel that they could not see a doctor because they would not wish to be examined. After a heavy period they will defer attending the doctor hoping that future periods will be normal.

        Heavy periods can be debilitating, causing more than the usual inconvenience of menstruation. At times they can lead to social embarrassment. Modern women have the benefits of effective contraception, which has only been available for a generation or two. With a reduction in family size and less breast feeding, a woman can now expect to see a nine-fold increase in the number of menstrual cycles in her lifetime compared to her great-grandmother.

References:

Surgical management of menorrhagia (1994) 24-07-873

Q 24. 2 What is in my menstrual flow?

        The fluid lost during a period is only partly blood. The percentage of blood in the fluid varies from 1.6 to 82% the average being 36%. Some women with heavy flow may be losing very little blood although the loss of other fluid may be troublesome and account for fluid loss symptoms such as fatigue and exhaustion.

References:

Blood and total fluid content of menstrual discharge (1985) 24-02-878

Q 24. 3 What range of menstrual cycle length is considered to be normal?

We time periods from the first full day of menstrual loss as “Day 1”. The menstrual cycle duration is timed from the first day of one period to the first day of the next. We consider menstrual cycles of less than twenty-one days to be too short, and they are too long if the cycle exceeds 35 days. The first day of the last period is called the ‘last menstrual period’ or ‘LMP’.

Q 24. 4 How can menstrual blood loss be measured?

In routine clinical practice, the number of pads or tampons used for each period gives an indication of blood loss, although some women may change these more often than others. Passage of blood clots indicates heavy loss. Some women require “double protection” which is another indicator of heavy loss. There are charts that allow you to indicate the number of tampons and sanitary towels that you are using and how heavily these have been stained. These charts correlate with more scientific estimations of blood loss. The recent development of absorbent sanitary wear tends to preclude accurate assessment with these charts.

        Laboratory methods have been established for exact measurement of menstrual blood loss. All sanitary wear is collected and the blood is extracted and measured. This is unpleasant for patients and staff and it is only used in research. The technique proved invaluable in establishing normal menstrual blood loss and defining abnormality. Laboratory measurement of menstrual blood loss is regarded by the perfectionist as the gold standard in evaluating new treatments. This research has shown that the average period blood loss is  40-60 mls  (8-12 teaspoonfuls). Some women losing up to 400 mls do not realise that they have a problem (500mls is about a pint). Other women may complain of excess loss when they are losing less than 10mls.

References:

Psychosocial and other characteristics of women complaining of menorrhagia, with and without actual increased menstrual blood loss (2001) 24-04-3341

Assessment of menstrual blood loss using a pictorial chart: a validation study. (2000) 24-04-3045

A new method for measuring menstrual blood loss and its use in screening women before endometrial ablation (1996) 24-04-1565

The alkaline hematin method for measuring menstrual blood loss–a modification and its clinical use in menorrhagia (1986) 24-04-880

Relation between measured menstrual blood loss and patient’s subjective assessment of loss, duration of bleeding, number of sanitary towels used, uterine weight and endometrial surface area (1980) 24-04-879

A preliminary study of factors influencing perception of menstrual blood loss volume (1984) 24-04-877

Q 24. 5 How can I tell if my periods are abnormally heavy?

 A noticeable increase in blood flow during menstruation, or bleeding between periods (inter-menstrual bleeding – IMB), is abnormal and should be reported to your doctor. Periods lasting more than 7 days or occurring more frequently than every 21 days are abnormal.

 It is difficult for a woman to quantify her own loss. An increase in the requirements for sanitary wear indicates a change in pattern. Blood clots or flooding are indications of heavy loss. Normally the blood lost from the vessels in the lining of the womb forms small clots and this tends to reduce the flow. The small blood clots within the uterus are broken down by chemicals called fibrinolysins and the normal menstrual loss should be a fluid. When the bleeding is heavy, the blood is extruded too quickly for it to clot within the uterus. In this situation, the blood clots in the vagina and the menstrual flow includes blood clots. Whilst menstruation is inevitably an inconvenience, it should not result in limitation of social activity.

References:

A simple visual assessment technique to discriminate between menorrhagia and normal menstrual blood loss (1995) 24-05-895

Q 24. 6 What could be the cause of my period problems?

• In at least 50% of patients with menstrual disorders, including heavy periods and bleeding between periods, there is no obvious explanation; we call this dysfunctional uterine bleeding. Furthermore, the fact that fibroids, for example are found in a patient with heavy periods, does not prove that the fibroids are the cause of the problem. The periods may be heavy even if the fibroids were not present (Q4.3). The same would be equally true for other abnormalities including endometriosis.

• Fibroids (Q23.14).

• Endometriosis(Q23.18) is a condition where tissue similar to the endometrium (lining of the womb) is found in other sites usually around the pelvic area.

• Adenomyosis (sometimes called internal endometriosis) is a condition where endometrial-type (lining of the womb) tissue can be found in the muscle wall of the uterus. When there is adenomyosis, the uterus is enlarged and may be tender. Ultrasound may suggest adenomyosis but the diagnosis can only be confirmed when the uterus is examined following hysterectomy.

• Pelvic inflammatory disease (Q20.2).

• Conventional intra-uterine contraceptive devices – IUCDs (Q17.1).

• Endometrial polyps (a polyp is like a skin-tag; Figure 24.1).

• Occasionally, the development of the uterus may have been abnormal (congenital uterine abnormality Q6.5).

References:

• Sterility of the uterine cavity. (1995) 24-06-2631

Q 24. 7 I have been sterilised. Could this be the cause of my heavy periods?

At one time it was suggested that female sterilisation increased period loss. This change in the periods is now thought to be related to stopping the pill around the time of sterilisation.

Women on the combined oral contraceptive pills tend to have light periods. When the pill is discontinued after sterilisation, the periods return to the loss that would have been experienced without the benefit of hormonal control. There is no difference in the bleeding pattern of women who have undergone sterilisation compared to women whose partners have had a vasectomy.

References:

The effect of sterilization by bipolar cautery and falope ring on menstrual bleeding patterns (1980)

24-07-901

Q 24. 8 Should I have tests to find the reason for my heavy periods?

        This depends on your age and the severity of the bleeding. A blood count should be considered at any age as heavy bleeding can result in anaemia, which can be corrected with tablets containing iron. Teenagers and young women are likely to be particularly anxious, as they may be concerned that they will prove to have a fertility problem in due course. Furthermore, younger women tend to be more physically active and may particularly resent the limitations imposed by period problems. An ultrasound examination of the pelvic organs will usually provide reassurance. It may be prudent to check that the blood clotting mechanism is normal, particularly if there is a story of “bleeding problems” in the family or if you bruise or bleed very easily.

        From late teens through the twenties and thirties, when obvious problems have been excluded, further investigation may be necessary only if the bleeding is extremely heavy or if it fails to respond to medication.

        A physical problem becomes more likely in the forties and fifties. Visualisation of the uterine cavity by means of a hysteroscope (thin telescope – Figure 24.2) and biopsy of the lining of the womb (cervical dilatation and endometrial curettage, Q24.12) are generally recommended by gynaecologists.

Q 24. 9 How will my heavy period problems be investigated?

        It is usual for your doctor to record the details of your problems and you will probably be examined. The story together with the examination findings may indicate the cause of the problem. A blood count is required to exclude anaemia resulting from the excessive blood loss. Ultrasound of the pelvic organs may be considered. Sometimes a biopsy from the lining of the womb (endometrial biopsy) is taken in the clinic. Frequently, particularly in women aged 40 or more, a “D and C and hysteroscopy” is performed (Q24.12).

        In younger women, particularly if there is a tendency to bruise or bleed easily, tests to check that the blood clotting mechanism is normal may be indicated.

        There is no indication for testing the thyroid routinely as part of the investigation of heavy periods. Thyroid function tests should be considered if there is any other suggestion of possible clinical thyroid disorder. Hypothyroidism (underactive thyroid) is more likely to be associated with heavy periods than hyperthyroidism (overactive thyroid). Picture charts of menstrual loss have been helpful but the newer absorbent sanitary wear has decreased their value.

References:

Use of transvaginal ultrasound in diagnosing the etiology of menometrorrhagia (1994) 24-09-896

The efficacy of the Pipelle endometrial biopsy in detecting endometrial carcinoma (1993) 24-09-891

Q 24. 10 What is meant by “anaemia” due to heavy periods?

Blood consists of fluid (plasma) and cells. The cells are the white blood cells, which protect against infection and the red blood cells, which carry oxygen from the lungs to the tissues of the body. The pigment in the red blood cells that carries the oxygen is called haemoglobin. Iron is an important part of haemoglobin. We absorb iron from certain foods including meat. There are also platelets, which are the tiny “bricks” in blood clots – the body’s mechanism to stop bleeding.

When blood is lost from the body, new blood cells must be produced to replace the loss. If periods are heavy for more than a few months, iron may be lost faster than it can be replaced and this is reflected in reduced haemoglobin concentrations. The average haemoglobin level is 14.6 g/dl (grams per 100ml). Anaemia means that the haemoglobin has dropped below 11.5 g/dl. There are other causes of anaemia including blood loss from the stomach and intestine and inadequate absorption which can be due to inadequate intake (e.g. malnutrition or special diets). Occasionally there may be deficiency of other essential requirements particularly vitamin B12 or folic acid. Some people are born with abnormal haemoglobin (e.g. sickle cell disease or thalassaemia which are more common in people from African or Mediterranean countries respectively).

Q 24. 11 What is intermenstrual bleeding?

 Intermenstrual bleeding (IMB) is bleeding between periods that is not associated with intercourse (post-coital bleeding – PCB). Bleeding about fourteen days before periods may be related to ovulation (Q2.3) or a little bleeding for a day or two before the period begins properly (premenstrual spotting) may be more of a nuisance than a medical anxiety.

 There are a variety of causes for IMB. The bleeding may be coming from the cavity of the womb with causes including those for heavy periods (Q24.6). The bleeding could be arising from the cervix or vagina. Whereas heavy regular periods are almost invariably due to benign conditions, intermenstrual bleeding can occasionally be the first indication of more worrying disease.

 Physical examination by your doctor should detect problems around the cervix or the vagina. Serious disease within the uterus is unusual before the age of forty. If you are less than forty years old, hormone treatment may resolve the problem. If the IMB persists despite medication or if you have reached forty, further investigation including hysteroscopy and endometrial curettage are usually recommended.

A forty-five year old lady had been happy with a LNG- intrauterine system (Q14.26) for three years. She then developed a little irregular bleeding. On examination her uterus was a little bulky but there were no other problems. Ultrasound demonstrated a few small fibroids. Endometrial biopsy showed inflammation and progestogen effects. The bleeding settled completely with a course of antibiotics.

A thirty-eight year old lady presented with intermenstrual bleeding. She had one child but then had difficulty conceiving. She was overweight and there had been evidence of PCO (Q7.1). Hysteroscopy and D & C (Q24.12) were performed. The histology (Q2.1) of the endometrium (lining of the uterus) demonstrated severe atypia (abnormal cells) and after full discussion hysterectomy (hysterectomy) with bilateral salpingo-oophorectomy (removal of both ovaries and Fallopian tubes – Q24.23) was performed. The histology of the uterus showed foci of malignancy. As the malignancy was detected early, radiotherapy was not required and the prognosis is excellent.

Q 24. 12 What is a hysteroscopy and D and C?

 D  & C  involves the dilatation of the cervix  (neck of the womb) and curettage (a curette is a surgical spoon) to "scrape" representative samples of the lining of the womb. These "curettings" are sent to the laboratory and examined under the microscope. These days most gynaecologists combine the D & C with hysteroscopy (Q24.8). Polyps or fibroids distorting the cavity of the womb may be diagnosed or excluded. The “D and C” is generally recommended to ensure that the lining of the womb is not seriously abnormal (for women aged 40 or more) before commencing medical treatment.

 For many years it was believed that the D & C had a therapeutic effect. It is now recognised that the first period after a D & C may be lighter but there is no long-term improvement. It should be emphasised that the D & C, like a blood test or an x-ray, is a diagnostic procedure and not a treatment.

Q 24. 13 What is cervical cautery?

        If there is cervical ectopy (Q21.3) the inner lining of the cervix has come on to the vaginal surface (Figure 21.3) or if there is chronic inflammation (cervicitis Q21.3), your gynaecologist may wish to take the opportunity of cauterising the cervix whilst undertaking a hysteroscopy and D & C for you. Cervicitis and cervical ectopy may be a cause of vaginal discharge, post-coital bleeding or intermenstrual bleeding (Q24.11). Cervical cauterisation destroys the ectopy or cervicitis and allows a healthy covering to develop.

Q 24. 1 Are heavy periods a common problem?
Q 24. 2 What is in my menstrual flow?
Q 24. 3 What range of menstrual cycle length is considered to be normal?
Q 24. 4 How can menstrual blood loss be measured?
Q 24. 5 How can I tell if my periods are abnormally heavy?
Q 24. 6 What could be the cause of my period problems?
Q 24. 7 I have been sterilised. Could this be the cause of my heavy periods?
Q 24. 8 Should I have tests to find the reason for my heavy periods?
Q 24. 9 How will my heavy period problems be investigated?
Q 24. 10 What is meant by “anaemia” due to heavy periods?
Q 24. 11 What is intermenstrual bleeding?
Q 24. 12 What is a hysteroscopy and D and C?
Q 24. 13 What is cervical cautery?
Q 24. 14 What happens after the “D & C”?
Q 24. 15 What treatments are available for my heavy periods?
Q 24. 16 What are the medical treatments available for heavy periods?
Q 24. 17 How do the various medical treatments for heavy periods work?
Q 24. 18 What would be reasonable initial treatment for a teenager or young woman with heavy periods?
Q 24. 19 What is a hysterectomy?
Q 24. 20 What are the indications for hysterectomy?
Q 24. 21 What are the risks of hysterectomy?
Q 24. 22 What is vault granulation?
Q 24. 23 What are the different types of hysterectomy?
Q 24. 24 Is it essential to remove the neck of the womb at hysterectomy?
Q 24. 25 Should my ovaries be removed or conserved during hysterectomy?
Q 24. 26 How long will I be in hospital when I have my hysterectomy?
Q 24. 27 I have had a hysterectomy. Do I still need to have smear tests?
Q 24. 28 What are the other surgical alternatives to hysterectomy?
Q 24. 29 How do endometrial ablation and hysterectomy compare?
Q 24. 30 Are there any psychological effects following hysterectomy?
Q 24. 31 How do we decide the best treatment for my period problems?
Q 24. 32 Could I have some useful Web sites?
Q 24. 33 Are there any support groups?
Women’s Health – Home Page

Q 24. 14 What happens after the “D & C”?

        The first period or two following a D & C may be early or late, light or heavy. If the cervix has been cauterised an antiseptic vaginal cream may be supplied by your gynaecologist to reduce the chance of infection and assist healing. By means of an applicator, the cream should be introduced each night for about ten nights starting the day after surgery. About 7-10 days following cautery there may be a little bleeding when the scab comes away. In the unlikely event that the bleeding seems worryingly heavy you should contact the hospital.

        We recommend that for three weeks after this operation, tampons should not be used and sexual intercourse should be avoided.

References:

Measurement of menstrual blood loss in patients complaining of menorrhagia (1977) 24-14-881

Q 24. 15 What treatments are available for my heavy periods?

        Several factors including age, fertility requirements, duration and severity of the heavy bleeding will influence decisions. Concurrent problems such as pelvic pain and premenstrual syndrome may influence clinical advice but you should be presented with all relevant information to help you plan with your doctor the most appropriate choice. Treatment may depend on the underlying cause for the heavy loss. Medical and surgical treatments (Figure 24.3) as well as a special intra-uterine contraceptive device, the levonorgestrel intrauterine system (Q14.26; Figure 14.1) are available.

        We can consider specific interventions for a particular cause of the heavy loss such as removing fibroids or an intra-uterine contraceptive device. As previously stated, your periods may be heavy despite the presence of fibroids or endometriosis and not necessarily because of them. Fibroids, endometriosis or an intrauterine contraceptive device may be found in association with heavy periods but that does not necessarily mean that they are unequivocally the cause in every patient. It may be appropriate to offer treatments used in dysfunctional uterine bleeding (Q24.17) even in the presence of these conditions. When there is a possible cause for heavy periods, such as fibroids, skilled judgement is required to decide whether specific treatment such as myomectomy (Q23.17) is required or whether to offer a non-specific treatment such as tranexamic acid.

        Every gynaecologist has a personal preference resulting from a combination of education, experience and sub-speciality interests. We should ensure that you are aware of all the options so that you can make an informed choice.

        Heavy and irregular periods may respond to progestogens, particularly at the extremes of the reproductive years. Women with menopausal symptoms commencing cyclical hormone replacement therapy often report improvement in their periods. This probably relates to the fact that they are having anovulatory cycles (eggs are not being released) and the cyclical progestogen in the HRT is replacing the progestogen deficiency.

References:

A comparison of flurbiprofen, tranexamic acid, and a levonorgestrel-releasing intrauterine contraceptive device in the treatment of idiopathic menorrhagia (1991) 24-14-926

Q 24. 16 What are the medical treatments available for heavy periods?

Medications used include:-

• combined oral contraceptive pills.

• progestogens (e.g. Norethisterone{e.g. Primolut N}, Dydrogesterone {Duphaston}, and Medroxyprogesterone {Provera})

• tranexamic acid (Cyclokapron)

• non-steroidal anti-inflammatory agents (e.g. mefenamic acid {Ponstan})

• gonadotrophic releasing hormone agonists.

• hormone replacement therapy (HRT)

• danazol (Danol)

• gestrinone (Dimetrioise)

• ethamsylate (Dicynene)

• antibiotics

• buscopan – (an antispasmodic) may help painful periods.

• the levonorgestrel intrauterine system, although developed as a highly effective and reversible method of contraception, provides excellent reduction in menstrual loss. This benefit is due to local release of the progestogen levonorgestrel within the uterine cavity. (Q14.26).

• depo-Provera (Q14.19)

References:

Can the levonorgestrel intrauterine system replace surgical treatment for the management of menorrhagia? 24-16-3523

Treatment of menorrhagia during menstruation: Randomised controlled trial of ethamsylate, mefenamic acid, and tranexamic acid (1996) 24-16-1600

The effect of tranexamic acid on measured menstrual loss and endometrial fibrinolytic enzymes in dysfunctional uterine bleeding. (1994) 24-16-916

Treatment of menorrhagia with tranexamic acid. A clinical trial of an underestimated
problem in general practice. (1993) 24-16-914

An alternative to hysterectomy? GnRH analogue combined with hormone replacement therapy (1993) 24-16-340

Treatment of ovulatory and anovulatory dysfunctional uterine bleeding with oral progestogens (1990) 24-16-898

Gestrinone in the treatment of menorrhagia (1990) 24-16-1210

The effects of mefenamic acid and norethisterone on measured menstrual blood loss (1990) 24-16-911

Comparison between antifibrinolytic and antiprostaglandin treatment in the reduction of increased menstrual blood loss in women with intrauterine contraceptive devices (1983) 24-16-917

Comparison between mefenamic acid and danazol in the treatment of established menorrhagia (1989) 24-16-912

An objective evaluation of flurbiprofen and tranexamic acid in the treatment of idiopathic menorrhagia (1988) 24-16-910

Treatment of dysfunctional uterine bleeding with danazol (1985) 24-16-904

Long-term treatment of menorrhagia with mefenamic acid (1983) 24-16-908

Efficacy of mefenamic acid in patients with a complaint of menorrhagia (1981) 24-16-913

Studies in menorrhagia: (a) mefenamic acid, (b) endometrial prostaglandin concentrations (1980) 24-16-905

The effect of danazol on menorrhagia, coagulation mechanisms, haematological indices and body weight (1979) 24-16-903

Q 24. 17 How do the various medical treatments for heavy periods work?

A: Combined oral contraceptive Pill.

         During the first 14 days of a natural menstrual cycle, the lining of the womb (endometrium) is stimulated by oestrogen alone. Under the influence of the oestrogen the endometrium becomes thicker (proliferates – Figure 2.3). Following the release of the egg (ovum – ovulation), about 14 days before the next period is due, the endometrium comes under the influence of progesterone as well as oestrogen. The combined oral contraceptive pills contain combinations of oestrogen and progestogen (Q16.1). Each pill contains both hormones. They are usually taken cyclically for 21 days with a 7-day gap. One of the effects of the progestogen is to keep the lining of the uterus thin so that in the event that an egg is fertilised, the lining of womb cannot allow implantation, thus preventing pregnancy. As the endometrium is relatively thin and underactive, the monthly withdrawal bleeds tend to be lighter.

B: Progestogens

The standard “textbook” recommendation is that progestogens should be taken in the second half of the menstrual cycle e.g. from day 16 to 26. The logic behind administering the progestogen in the second half of the cycle seems to be that in the natural cycle this is the time that the ovaries are releasing progesterone. When young teenage girls or peri-menopausal women are troubled by heavy periods, cyclical progestogens taken in the second half of the menstrual cycle may confer benefit. In these situations, there is often evidence of anovulation (eggs are not being released) so that there may be oestrogen but no cyclical release of progesterone.

The majority of women with heavy periods, however, are ovulating indicating that their progesterone levels are normal. Most of the evidence would suggest that progestogens given in the second half of the cycle do not reduce blood loss. There have been suggestions that progestogens, may reduce period loss when they are given much earlier in the cycle, perhaps from day 5 to day 26. This would be compatible with the twenty-one day course of progestogen given in the combined oral contraceptive pill. It should be noted that the progestogen alone does not provide contraception.

If there is any likelihood of pregnancy occurring, dydrogesterone (Duphaston – Solvay) tends to be my first recommendation: Duphaston is licensed for use in pregnancy for women who recurrently miscarry. There is some reassuring data that medroxyprogesterone (Provera – Pharmacia & Upjohn) has no detrimental effect on a fetus. Norethisterone (Primolut N – Schering; Utovlan – Searle) could cause problems (masculinisation) to a female fetus, although this is not a problem in the early weeks of pregnancy. Nevertheless, before administering norethisterone, one would wish to emphasise the particular need for contraception.

C: Tranexamic Acid (Cyclokapron – Pharmacia & Upjohn).

During each period, the blood lost from the vessels within the womb should clot (coagulate). As with a cut or a graze, the clot tends to stop the bleeding. Fibrin is an essential part of the blood clot. Fibrinolysins (lysis – Greek, a loosening) in the cavity of the womb break down the clot so that the period loss is normally fluid. Tranexamic acid reduces this fibrinolytic activity so that the tiny blood clots sealing the bleeding vessels can continue to function for longer thus reducing the period blood loss. There is no reason to withhold tranexamic acid before investigation such as hysteroscopy and D & C. Two or three tablets three or four times daily as and when required would be the recommended dose. Tranexamic acid should not be taken if you have a history of thrombosis (a blood clot – Q4.21).

D: Mefenamic Acid and other prostaglandin synthetase inhibitors – non-steroidal anti-inflammatory agents (NSAIs).

Prostaglandins are a group of hormones that have a variety of functions. They derive their name from the prostate gland (a gland of the male reproductive tract) although they are produced in other tissues including the endometrium. Endometrial concentration of prostaglandins is increased in association with menorrhagia. Prostaglandin synthetase is an enzyme (a chemical that acts as a catalyst promoter of a chemical reaction) that is crucial to the production of prostaglandins.

Prostaglandin synthetase inhibitors, also called “non-steroidal anti-inflammatory agents”, have a variety of valuable therapeutic uses. These include treatment of pain in general and arthritis in particular. Most of the research in relation to menorrhagia relates to mefenamic acid (Ponstan) although there are others in this group, including naprosyn, ibuprofen, indomethacin and diclofenac that may also prove effective. Mefenamic acid has been shown to reduce menstrual blood loss significantly. It tends to be of particular value when treating a combination of menorrhagia and dysmenorrhoea (painful periods). NSAIs are not recommended if you have a history of peptic ulcers or asthma.

E: Gonadotrophic Releasing Hormone Agonists.

Gonadotrophin Releasing Hormone (GnRH) is released by the hypothalamus and results in release of the gonadotrophins, FSH and LH, which in turn stimulate ovarian follicular development (Figure 2.6). Gonadotrophic releasing hormone agonists are used to block GnRH production in a variety of gynaecological situations. They can be used to stop the menstrual cycle and thus stop periods.

As oestrogen levels fall, menopausal symptoms (Chapter 26) are common. Prolonged suppression of ovarian function will lead to osteoporosis (weakened bones Q26.24) and disease of the arteries. GnRHs can be used for a maximum of six months by themselves. They are extremely valuable in preparation for removal of fibroids (Q23.17) and occasional situations such as stopping periods in patients with severe menorrhagia when blood transfusion is not an option (e.g. Jehovah’s Witnesses). GnRH can be used in combination with HRT (add-back therapy) for longer than six months. GnRH treatment is extremely expensive precluding its prolonged use except in extreme situations.

F: Hormone Replacement Therapy (HRT)

Menorrhagia beyond the age of forty years should be investigated (Q24.9). Frequently women presenting with menopausal symptoms and menorrhagia, report reduced menstrual flow after cyclical HRT has been commenced. The menstrual cycles before the menopause are often anovulatory (eggs are not released). There is, therefore, progesterone deficiency in the second half of the cycles and the progestogens in the cyclical HRT would account for the improvement in the periods.

G: Danazol

Danazol (Danol – Sanofi – Winthrop) seems to be active in a number of areas of the reproductive system. It has some gonadotrophin inhibitory activity. It may also have a direct action on the endometrium. At higher dosage levels, it frequently induces side-effects particularly sickness. At lower dosage, such as 100mg daily, side-effects are less common and yet heavy menstrual flow may be reduced.

H: Gestrinone

This agent seems to have similar modes of action to danazol. It is longer acting and a typical dose would be 2.5mg twice weekly.

I: Ethamsylate.

This drug seems to increase capillary wall strength, increase platelet stickiness and reduce some of the adverse effects of prostaglandins (Q24.17D). There is less convincing evidence of benefit with heavy periods.

J: Antibiotics.

Clearly when there is evidence of pelvic inflammatory disease (Q20.2) antibiotics are likely to be beneficial. It is possible that there may at times be sub-clinical bacteria within the uterus (bacteria endometrialis) that may account for some otherwise unexplained menstrual disturbance.

      A 34 year old lady had been investigated for intermenstrual bleeding and a polyp was removed. She presented again two years later as her periods had become extremely heavy on the first day for nearly a year. Clinical and ultrasound examination showed no obvious abnormality. Tranexamic acid (Q26.16:C) to be taken during heavy loss and a course of erythromycin and metronidazole (antibiotics) were prescribed. She returned for review three months later. The tranexamic acid had not been required as her periods had returned to normal following the course of antibiotics.

         There is evidence that intrauterine infection may be associated with bleeding between periods that may respond to antibiotics. Controlled trials (Q33-26) would be required to evaluate the potential benefit of antibiotics for dysfunctional uterine bleeding.

K: Hyoscine butylbromide, (Buscopan)

This agent relaxes smooth muscle and therefore reduces uterine contractions. It may be considered in the management of dysmenorrhoea.

L: The levonorgestrel intrauterine system (Mirena)

This device was developed primarily for contraception (Q14.26). It steadily releases a tiny amount of the progestogen levonorgestrel within the cavity of the uterus – equivalent to two progestogen only tablets each week. This results in the lining of the uterus (endometrium) staying in a thin underactive (hypoplastic) state. As the endometrium is thin, the menstrual loss is reduced. There may be initial spotting through the first weeks after insertion but this will almost invariably settle. The device may be introduced in the clinic or at completion of hysteroscopy and D & C (Q24.8).

M: Depo-Provera

This provides contraception and often periods become light or absent (Q14.19).

References:

Randomised comparative trial of the levonorgestrel intrauterine system and norethisterone for treatment of idiopathic menorrhagia. (1998) 24-17-3114

Q 24. 18 What would be reasonable initial treatment for a teenager or young woman with heavy periods?

        Teenagers and young women wishing to retain their fertility generally require medical treatment. The combined oral contraceptive pill is frequently an effective first choice for younger patients particularly when there is need for contraception. Teenagers with heavy periods may be having anovulatory (eggs are not being released) cycles; progestogens taken in the second half of the cycle may be effective and are frequently favoured by parents with understandable concerns about starting their young daughter on the pill. Tranexamic acid, two or three tablets taken three or four times daily, on the usually heavy period days is otherwise a sensible first choice. When pain accompanies the heavy loss, a non-steroidal anti-inflammatory agent may be appropriate. Mefenamic acid 500 mg three times daily is a popular selection. 

Q 24. 19 What is a hysterectomy?

        Hysterectomy (Greek, hystera – womb; Greek, ektome  - excision) is the removal of the womb. It is a frequently performed operation. There are 625,000 hysterectomies performed annually in the USA and 90,000 in the UK. These figures for hysterectomy do not seem to be falling despite the advent of endometrial ablation (the lining of the womb is destroyed - Q24.28).

RSS News Feeds On Hysterectomy:-

www.delawareonline.com ¦ The News Journal ¦ HEALTH ¦ Less-invasive alternative to hysterectomy (Delaware Online)
For two years, Sonja Bey dealt with the excessive menstrual bleeding and pain associated with problematic uterine fibroids. Drugs proved effective for a time, until the side effects became too much. Bey’s gynecologists recommended a hysterectomy to remove her uterus.

A remarkable life, a remarkable death (Pittsburgh Post-Gazette)
Everyone had a hand on Laura Mankamyer last Monday evening. Her closest friends and relatives gathered around her bed in the living room, stroked an arm, massaged a foot, caressed her forehead as they read scripture, told her they loved her, sang hymns.

WICAB corrects imbalance and more (Wisconsin State Journal)
Cheryl Schiltz pulls on her coat and strides out of the Middleton office where she works to drive to the class she’s taking at UW-Madison. That may not sound unusual to most of us. But for Schiltz, 46, it’s pretty amazing.

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The indications for hysterectomy. 24-20

Risks of hysterectomy. 24-21

Types of hysterectomy. 24-23

Sub-total hysterectomy. 24-24

Conservation of the ovaries at hysterectomy. 24-24

Time in hospital for hysterectomy. 24-26

Smear tests after hysterectomy. 24-27

Surgical alternatives to hysterectomy. 24-28

Hysterectomy and endometrial ablation compared. 24-29

Psychological effects of hysterectomy. 24-30

Q 24. 20 What are the indications for hysterectomy?

        Hysterectomy may be indicated for a variety of reasons including:

• heavy periods and other vaginal blood loss problems that do not respond to medical treatment. This is the most frequent reason that hysterectomy is performed whether there is a suspected cause such as fibroids or not.

• pelvic pain associated with the womb, ovaries or Fallopian tubes, is another common indication. This may be related to fibroids, endometriosis or pelvic inflammatory disease.

• large fibroids when fertility is not required.

• premenstrual syndrome. Removal of the ovaries and uterus may prove to be the last resort in treatment for severe premenstrual syndrome.

• an ovarian tumour in a woman who has reached her later forties. Hysterectomy including removal of both the ovaries and Fallopian tubes (Q24.23) is usually recommended as the chance of malignancy increases with age. The exact nature of an ovarian tumour cannot be determined without microscopic examination. When an ovarian tumour is removed in younger women, it is appropriate to try to conserve fertility.

• cancer of the endometrium and cervix.

• utero-vaginal prolapse. The uterus may need to be removed vaginally as part of surgery for prolapse (vaginal hysterectomy – Q30.6).

• on rare occasions, there may be uncontrollable bleeding following childbirth or miscarriage and an obstetric hysterectomy may be life-saving if other treatments are proving ineffective.

References

The epidemiology of hysterectomy: findings in a large cohort study. (1992) 24-20-959

Treatment of menorrhagia before hysterectomy in a district general hospital. A retrospective review (2001) 24-20-3290

Q 24. 21 What are the risks of hysterectomy?

        The risks of surgical procedures in general are discussed in Q4.21. The urinary tract (bladder and ureters) are closely related to the uterus and may be damaged. The bowel is normally free from the uterus but may be adherent to it if there has been infection, endometriosis or previous surgery.

        Infection in the urinary tract is a relatively common complication requiring antibiotics. Thromboembolism (Q4.21) has been reduced by encouraging early mobilisation after surgery and the use of anticoagulants.

        Bladder symptoms are common following hysterectomy. Antibiotics will help if there is infection. Otherwise these symptoms usually settle with time.

References:

24-21-3522 The VALUE national hysterectomy study: description of the patients and their surgery.

24-21-1164 The effect of hysterectomy on the age at ovarian failure: identification of a subgroup of women with premature loss of ovarian function and literature review. (1987)

Q 24. 22 What is vault granulation?

        Granulation is wet scar tissue, which may cause bleeding or discharge. The vaginal vault is the top of the vagina following total abdominal hysterectomy. During this operation, the cervix is removed and the top of the vagina is sutured (stitched). The granulation may be cauterised with silver nitrate by your gynaecologist in the clinic at your postoperative visit. This is a painless procedure taking just a few seconds.

Q 24. 23 What are the different types of hysterectomy?

        Unless there is uterine prolapse, most gynaecologist’s remove the womb through the abdominal wall (abdominal hysterectomy). A vaginal hysterectomy indicates that the uterus has been taken out through the vagina. When there is prolapse of the uterus and heavy periods, vaginal hysterectomy and pelvic floor repair (Q30.6) may solve two problems.

        Figure 24.4 shows the options available at abdominal hysterectomy. A total hysterectomy is when all of the womb, including the neck of the womb (cervix), is removed (Q24.24). In subtotal hysterectomy, the body of the uterus is removed but the neck of the womb is left in place. Bilateral salpingo-oophorectomy is the removal of the ovaries and tubes (Q24.25).

        More complex surgery may be required when the hysterectomy is performed for malignancy. Lymphadenectomy is the removal of the local lymph glands. During a Wertheim’s hysterectomy, required for some women with early cancer of the neck of the womb (cervical cancer), connective tissue adjacent to the uterus is removed together with lymphadenectomy.

        Some gynaecologists have been trained to remove the uterus vaginally with the assistance of  laparoscopy (laparoscopically assisted vaginal hysterectomy). As with all ‘minimally invasive’ procedures (Q4.23), we are only just coming out of the pioneering stages. Usually, three or four small incisions are required to introduce all the instruments that are necessary. It has, however, been shown that if the uterus is not enlarged, an abdominal scar of no more than 10cm is required to perform a conventional hysterectomy and many gynaecologists remain comfortable with this approach. Laparoscopic hysterectomy may require less pain relief after surgery but the operation lasts one hour longer.

References:

• Three methods for hysterectomy: A randomised, prospective study of short term outcome (2001) 24-23-3403

• A randomised comparison and economic evaluation of laparoscopic-assisted hysterectomy and abdominal hysterectomy. (2000) 24-23-3404

• Total versus subtotal hysterectomy: The last great controversy in gynaecological surgery? (1998) 24-23-2904

• A randomised prospective trial comparing laparoscopic and abdominal hysterectomy. (1996) 24-23-1258

Q 24. 24 Is it essential to remove the neck of the womb at hysterectomy?

        It had become routine practice to remove the cervix when performing abdominal hysterectomy in the United Kingdom and in the majority of other countries.

        The arguments in favour of removing the cervix are:-

• cancer of the cervix cannot develop later.

• the cervix may be the cause of pain or discharge if it is not removed.

• there is a greater chance of a blood collection (haematoma) in the pelvis soon after surgery with the subtotal hysterectomy complicating recovery – a concept that does not seem to have strong foundation.

• if the cervix is not removed, there is a greater chance of prolapse in years to come – there are no comparative trials to demonstrate this.

        There are, however, times when it may be safer to conserve the cervix. Occasionally, it may be densely adherent to the bowel (usually the rectum) particularly if there is severe endometriosis in the area. If the gynaecologist believes the risks to the bowel or urinary tract may outweigh the advantages, it may be decided during the operation that leaving the cervix in place (sub-total hysterectomy) is in the patient’s best interest.

        Many French women prefer to have the cervix conserved at the time of hysterectomy as there is a suggestion that this prevents reduction of sexual satisfaction. The argument in favour of removing the cervix pre-dates cervical smears. If smears have been abnormal removing the cervix would seem appropriate but if there have been regular smears showing no abnormality sub-total hysterectomy should cause less anxiety.

        Some believe that conserving the cervix (sub-total hysterectomy) reduces the likelihood of bladder symptoms in the long-term.

      A woman of forty presented with heavy periods and premenstrual syndrome. She had always been keen on a conservative approach. Endometrial ablation had provided temporary improvement but within a couple of years she felt that further surgical intervention was required. She had read extensively and elected to have a sub-total hysterectomy with removal of the ovaries and tubes. Her cervical smears had been normal. The operation was uneventful and she was home on the fourth day. She elected to take HRT tablets (oestradiol 2mg daily). She returned to her work with children by the third week and when we saw her six weeks after surgery she felt “like a new woman – absolutely wonderful.” She will continue to have her routine cervical smears as her cervix has not been removed.

         In the late 1990’s, gynaecologists in the UK have become increasingly inclined to discuss the question of the subtotal procedure with their patients when counselling them with regard to hysterectomy.

References:

Subtotal abdominal hysterectomy: A surgical advance or a backward step? (2001). 24-24-3402

Supravaginal hysterectomy – a less invasive procedure.(1995). 24-24-929

Subtotal hysterectomy revisited. (1995). 24-24-1122

Q 24. 25 Should my ovaries be removed or conserved during hysterectomy?

If the hysterectomy is undertaken abdominally, there is a choice of conserving or removing the ovaries (Figure 24.4). When the hysterectomy is undertaken vaginally as part of treatment for prolapse, the ovaries are not usually removed.

In a young woman, the ovaries are likely to have longer remaining function than in a woman around the age of fifty. There is, therefore, more advantage in conserving the ovaries in a young woman compared to a woman approaching her menopause. Some women, even beyond the age of fifty are very keen to keep their ovaries, if they appear healthy. Provided they have had the opportunity to make an informed choice, their decision must be accepted.

In recent years, it has been found that following hysterectomy, ovaries that have not been removed lose their function, usually within five years. This observation may be partially explained by the fact that some women develop heavy periods within the few years leading up to the menopause and the ovaries appear to lose their function early after the hysterectomy because the menopause was imminent anyway.

Even if there is no history of pelvic pain before hysterectomy, many women (about 1 in 20) will develop pain if their ovaries are conserved and return to have a second operation to remove the offending ovaries later.

Statistically we now know that when the ovaries are conserved at the time of hysterectomy, one woman out of every two hundred and fifty is likely to develop cancer of the ovary at some time in her life. This is not as a result of the hysterectomy but simply reflects the chance of a woman developing this disease. Once or twice each year I see women in their fifties or sixties with ovarian cancer who have had their ovaries conserved at the time of hysterectomy.

Cyclical symptoms (premenstrual syndrome Q25.1) are usually improved or cured when the ovaries are removed and hormone replacement therapy is commenced.

Finally, hormone replacement therapy has advanced to the stage that, with few exceptions, an entirely satisfactory treatment is available following removal of the ovaries. Every patient undergoing hysterectomy should give these facts careful consideration and indicate at the time of signing consent for operation whether she wishes to keep her ovaries if they appear healthy. If the ovaries appear unhealthy the gynaecologist would generally wish to remove them.

References:

Long-term results of bilateral oophorectomy for the treatment of chronic pelvic pain: Relief of pain and special hormone replacement therapy requirements. (1996) 1664

Relation between hysterectomy and subsequent ovarian function in a district hospital population (1994) 366

Bilateral oophorectomy and hysterectomy in the treatment of intractable pelvic pain associated with pelvic congestion (1991) 140

Q 24. 26 How long will I be in hospital when I have my hysterectomy?

• Patients undergoing abdominal hysterectomy have traditionally stayed in hospital for at least 6 days. It is increasingly recognised that early discharge from hospital has several advantages:

• Patients, understandably feel more comfortable in their own environment.

• There is probably less risk of infection away from the hospital.

• Early mobilisation reduces the risks of deep venous thrombosis (a blood clot developing in the deep veins of a leg or in the pelvis) or pulmonary embolism (the clot in the vein breaks away and travels to the lung).

• Early discharge allows optimum utilisation of hospital staff and facilities.

        The majority of our patients are home within  four or five days and many patients are back to full activity including work within three or four weeks.

References:

Early hospital discharge following abdominal hysterectomy (1996) 1463

Early discharge after hysterectomy for benign diseases by mini-laparotomy (1995) 931

Q 24. 27 Do I still need to have smear tests after hysterectomy?

        If there have been smears showing moderate or severe abnormality before the hysterectomy, further smears for up to five years are advisable even if the cervix has been removed; these smears are taken from the vaginal vault. If the cervix has been removed and there were no smear test problems before hysterectomy further smears are not justifiable. If the cervix has been conserved (sub-total hysterectomy) smears should continue along the same programme as for women who have not had a hysterectomy.

        If you have had a vaginal hysterectomy, the cervix will have been removed.

Q 24. 28 What are the other surgical alternatives to hysterectomy?

 Fibroids can be removed surgically (myomectomy - Q23.17) and the uterus conserved. This is beneficial if you have large fibroids, particularly if the fibroids are distorting the cavity of your womb. It has been estimated that during one per cent of myomectomies, hysterectomy has to be performed, as there may be uncontrollable bleeding. Medical suppression of the menstrual cycle with a gonadotrophic releasing hormone agonist (Q33.16) may be employed pre-operatively to produce  a  temporary menopause-like state. This reduces the size of the fibroids and also their blood supply. Myomectomy is generally undertaken for younger women who wish to retain their fertility.

 Since the late 1980s, some gynaecologists have been removing or destroying the lining of the womb (endometrial ablation). The advantage of this new technique is that patients are only in hospital for one or two days and are often back to work after two or three weeks. Following endometrial ablation, the majority of patients experience reduced blood loss. However, at least 70% continue to have periods and even the most successful and experienced surgeons have shown that 20-25% of their patients will require a second operation (repeat ablation or hysterectomy) within two years. Endometrial ablation may not destroy all the endometrium so that sterilisation is not guaranteed and contraception is still required. Endometrial ablation is generally only recommended if there is dysfunctional uterine bleeding. Patients must have a D and C and hysteroscopy before the ablation. There has been no reduction in the incidence of hysterectomy resulting from the introduction of endometrial ablation suggesting that ablations are additional procedures to hysterectomy rather than a replacement.

 There are several techniques for ablating the endometrium. My own preference is to use a special fluid filled latex balloon which is heated in a controlled manner for eight minutes (Figure 24.5). Others destroy the endometrium with laser, or resect it under direct hysteroscopic visualisation. Special training is required for hysteroscopic surgery, whereas the latex balloon technique is remarkably simple to use.

 The late effects of endometrial ablation are not known. We do not know how women having endometrial ablation will be affected when they go into their fifties, sixties, seventies and eighties: It will take another forty or fifty years before we have the answers.

References:

Has endometrial ablation replaced hysterectomy for the treatment of dysfunctional uterine bleeding? National figures.(2000) 3553

Goserelin acetate (Zoladex) plus endometrial ablation for dysfunctional uterine bleeding: A 3-year follow-up evaluation (2001) 3255.

Cavaterm thermal balloon ablation for the treatment of menorrhagia. (1999) 2888

Microwave endometrial ablation: Development, clinical trials and outcomes at three years. (1999) 2712

A randomised trial of endometrial ablation versus hysterectomy for the treatment of dysfunctional uterine bleeding: Outcome at four years. (1999) 2262

Uterine thermal balloon therapy for the treatment of menorrhagia: The first 300 patients from a multi-centre study. (1998) 3119

A national survey of the complications of endometrial destruction for menstrual disorders: The MISTLETOE study (1998) 2077

A randomised comparison of medical and hysteroscopic management in women consulting a gynaecologist for treatment of heavy menstrual loss (1997) 2078

Uterine thermal balloon therapy under local anaesthesia for the treatment of menorrhagia: A pilot study (1997) 2062

Goserelin acetate (Zoladex) plus endometrial ablation for dysfunctional uterine bleeding: A large randomized, double-blind study (1997) 1788

A pragmatic randomised comparison of transcervical resection of the endometrium with endometrial laser ablation for the treatment of menorrhagia (1997) 1746

Experience with the first 250 endometrial resections for menorrhagia (1991) 11

Q 24. 29 How do endometrial ablation and hysterectomy compare?

 Ablation has the advantage of speed of recovery. If patients are advised before admission for hysterectomy that early discharge home is likely, all domestic arrangements can be made. For those women who feel that they need surgical treatment for their heavy periods but who are reluctant to lose their uterus, the ablation techniques are attractive. Even with relatively short follow-up, it has become apparent that a significant number of patients undergoing ablation require further surgery. This means that the overall difference between hospital admission times between ablation and hysterectomy may be less than original estimates and this is also true when comparing economic differences.

 The risks of surgical procedures in general, and hysterectomy in particular have been presented (Q4.21  and Q24.21). Complications can occur with ablation particularly if the uterus is inadvertently perforated (punctured).

 In a randomised trial between hysterectomy and transcervical resection (ablation), the effect on health–related quality of life at an average of 2.8 years after surgery was evaluated. Those women allocated to hysterectomy had better scores in seven out of eight parameters. The greatest difference was for pain. Twenty eight per cent of those allocated to endometrial resection required a second resection or hysterectomy.

References:

Why do women choose endometrial ablation rather than hysterectomy? (1998) -2203

Hysterectomy following failed endometrial resection (1997) -1668).

Randomised trial comparing hysterectomy with endometrial ablation for dysfunctional uterine bleeding:Psychiatric and psychosocial aspects (1996) -1098).

Hysterectomy vs. resectoscopic endometrial ablation for the control of abnormal uterine bleeding: A cost-comparative study (1994) -925).

An economic evaluation of transcervical endometrial resection versus abdominal hysterectomy for the treatment of menorrhagia (1993) -923

An economic evaluation of transcervical endometrial resection versus abdominal hysterectomy for the treatment of menorrhagia (1993) -335

Randomised controlled trial comparing endometrial resection with abdominal hysterectomy for the surgical treatment of menorrhagia (1993) -220

Q 24. 30 Are there any psychological effects following hysterectomy?

        In a randomised trial of 204 women with dysfunctional uterine bleeding, 99 were allocated to hysterectomy, 52 to transcervical resection and 53 to laser ablation of the endometrium. There was no evidence that hysterectomy led to psychiatric disturbance. There was no difference in libido (sex drive) between the groups.

Q 24. 31 How do we decide the best treatment for my period problems?

        It is essential that you should be aware of the options available. Age and fertility requirements are the first concern. Clearly hysterectomy must be avoided until the family has been completed. The severity of the problem and its duration must be taken into account. Other factors, such as pelvic pain or premenstrual syndrome may influence the decision.

        Some women feel that hysterectomy is “unnatural” or “defeminising” or there may be cultural influences making hysterectomy unacceptable. For others with a family history of ovarian or uterine cancer, hysterectomy may provide reassurance.

        Your treatment should be influenced by your requirements. Only you can determine how much your periods are affecting you. Frequently there is a combination of problems  e.g. heavy periods and premenstrual syndrome or a requirement for sterilisation. Ultimately, the choice of treatment is yours to make from the full information provided by your doctor.

        On one operating list recently there were three patients with heavy periods. One aged 39 elected to have hysterectomy with removal of only her right ovary (she had right sided pelvic pain). The second, aged 42, chose insertion of a Mirena IUS at the time of hysteroscopy and D & C and the third aged 37 had requested thermal balloon ablation of the endometrium.

Q 24. 32 Could I have some useful Web sites?

Evaluation of the quality of Web sites is discussed in Q4.27. You may find that several general women’s health sites may help you (Q4.28). The following are more specialised Web sites on topics found in this chapter:-

This page was last updated: May 25, 2002

Q 24. 33 Are there any support groups?

HystereCity

The Hysterectomy Association

Women’s Health – Home Page

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