Management of

Heavy Periods


At the time of puberty, the ovary will start producing eggs, one each month. If the egg gets fertilized, you become pregnant. The growing egg will produce hormones to prepare the uterus for this pregnancy. If you do not get pregnant, the uterus loses its lining, and this will form part of the menstrual blood that females lose every month.

At different stages of life, menstruation, or periods, may be less regular, they may become unpredictable, may be associated with cramps, pain, passing blood clots, etc. If you think you are bleeding too much, or you think your bleeding has changed, this is enough reason for us to check and see if all is well.

The first step is usually a blood test to check your Hemoglobin and Iron levels, and usually an ultrasound to check on the uterus and ovaries. You may also get tested for Thyroid gland function. Your family physician will usually order these before you are referred to see us. If not, we will arrange them.

Now, depending on how old you are, whether you plan on getting pregnant soon or later on, and depending on the results of the blood tests and the ultrasound, we have different options for management.

The thing that you need to do before you start looking into options is actually talk to your family physician. They will usually check your blood levels and may be request an ultrasound. Then you will probably be referred to a gynecologist. If you are 40 years old or more, it is recommended to have a biopsy, or taking a sample of the inside lining of your uterus, just to make sure that you do not have any abnormal cells. If you do have abnromal cells, , your choices may be restricted.
The biopsy is done in the office, kind of similar to a pap test. It may be a bit uncomfortable, the uterus may give you cramps like your period cramps. You may need to take a couple of Advils before you come. Tylenol is not as effective for this cramping. The results typically come back in 28 days.

The options that are available include: (not everything is suitable for everyone)

1- Expectant: or just wait and see. This may make sense if you just had the odd heavy bleeding, ultrasound is normal and if an endometrial biopsy was done and it came back normal. Another example is if the result of the endometrial biopsy came back saying you had a polyp that was removed, and you had no heavy bleeding since then.
This is more stuitable may be if you are 50 year old or so. The average age of menopause being 51 in North America. So, if the bleeding is not too heavy, and you are close to menopause, this may be an option.

2- Medical Treatment: This is not a long term solution, only to try to make you lose less blood to give time for your body to bump up your hemoglobin and iron levels until we decide on a more definitive treatment. This is basically a medicine (tranexamic acid)  that you take by mouth every 6 hours while you are bleeding. You will notice a difference, but do not expect the blood to totally stop only on this medication.
There is a newer medication Fibristal that may be used to stop bleeding caused by fibroids. Again, it may be very useful in stopping bleeding, and fast. It is not a long term solution, though.

3- Hormonal Treatment: Usually the female hormone estrogen will stop vaginal bleeding. This is present in birth control pills, and this is why you may be given Birth Control pills to try to control your bleeding. Even if you have your tubes tied already, you will still benefit from the pills.

If you are bleeding heavily, for example soaking a pad/hour, we recommend you go to Emergency Department. You will probably be given Estrogen by IV. You may then continue on with birth control pills. There are a few conditions that may not be appropriate to take birth control pills with. We will go through them if you think you want to try to take pills to control your bleeding.

4- Mirena: This is a brand of IUD's or Intra Uterine Devise. When they were first used, they were meant to prevent pregnancy. They are still mainly used for that reason. But with the progress in medicine and manufacturing technology, they came up with a great idea. Why not put the medication that decreases the bleeding in the the IUD? And they did, and the result is Mirena.

So, this is an IUD that has a hormone that prevents bleeding. You are also protected against pregnancy, and it is used for both reasons. It is a relatively simple procedure, we insert it in the office and you can go back to work after visiting us. It lasts up to five years.

Two things to say about IUD. One: Things have changed a lot. Your mom may tell you her story with an IUD in the past. Things have changed, and we now recommend and use IUD's more and more, with great success. Two: They are very effective to the extent that we use them to treat heavy periods even in women who already had their tubes tied.
One last thing about Mirena. It costs about CAD 400. Even, if you have insurance, this is still how much it cost. So, the manufacturer will give you your money's worth of packaging. Seriously now, you do get your money's worth of a good product. But the warning still holds true. The box is big. It contains an introducer, some educational material, and a sterile package. So, do not worry about the size of the box, the IUD itself is alittle but larger than a Toonie, but is T shaped.

5- Ablation, also called Endometrial Ablation. This is a special procedure that we do in the hospital with you sleeping under anesthesia. It is not complicated, and in the US they will actually do it in physician's offices. The idea is simple. A special medical instrument goes into the uterus and then we attach it to a machine. It runs a special treatment cycle, heating up the inside lining of the uterus enough to destroy the lining, but not enough to hurt you in any way. This should prevent any further bleeding, and some people may not even menstruate again after this procedure.

Now, since we destroy the lining of the uterus, this method is not recommended if you plan on having any more children. The lining may not be good enough to carry a baby through pregnancy. Or when pregnant, may cause problems with the placenta. At the same time, this is not a method of preventing pregnancy. You will still need to use another form of birth control. Some women choose to have their tubes tied at the same time for this reason.

This is a surgical procedure, and carries some of the risk of surgery in general. It is done as a day surgery procedure. This means you spend about half a day in hospital and go home after the procedure is done. You need someone to come with you to the hospital to drive you home.

You should usually expect 10-14 days of watery discharge after you have this procedure, sometimes enough to require a pad.

About 80-90% of those who chose this option are happy with the results, whether it is much less bleeding or no periods at all. The remaining 5-10% who are not satisfied with the results may then either choose a Mirena IUD, or actually usually taking their uterus out.

6- Hysterectomy (or taking the uterus out):

Clearly, you should only chose this option if you do not plan on having any more babies.
The uterus is an internal female organ that its 'only' use is to carry babies. If you do not plan on having any more babies, you are paying the 'monlthy lease' for an organ you have no use for. Now, if the bleeding is too heavy, we start evaluating how useful it is and what are our options. It is understandable that some poeple prefer to have all their organs intact. Other feels that the uterus us part of their femininity.
The point we want to raise is: the uterus has no relation to your hormones, or your menopausal status. Your hormones come form the ovaries. Many times over, in younger women, we remove the uterus and we leave the ovaries. Their hormonal production remain at the same level as before the surgery. They will not necessarily need hormone replacement therapy. At least not becasue of the surgery. They may eventually needed hormones, but this would be at the time they were detsined to need them, even if they had no surgery.

A hysterectomy is done in the hospital. Until may be 2012 or 2013 most of the hysterectomies done in Oshawa were done by the open techinque, very much like a C section. Then started to switch. Laparoscopic hysterectomy was introduced in the past by Dr Norman and his colleagues at the time. For a while, this procedure was not being offered any longer. Then recently. Dr Abdel Hadi re-introduce the laparoscopic technique. This is similar to taking your gall bladder or appendix out. A camera goes through your belly button, and 2-3 other small incisions allow for pencil sized instruments to go inside your tummy and perform the surgery.
Laparoscopic hystrectomy has great advantages: less pain, less scarring, easier recovery, earlier return to life activities, work, etc. You may go home the same day of the surgery, or may be the following day in the morning. A week after the procedure, no one will even notice you had surgery done.
Rarely, however, this may not be a suitable option for you. Examples include if you have a large uterus (example, with firboids), large ovarian masses that need biopsy, were never pregnant before, etc. In these cases, an examination and detailed discussion may offer you other options (example: having open surgery).

A hysterectomy does not mean that we necessarily will take your ovaries out at the same time. Depending on how old you are and what other conditions there are, we may take the ovaries out or leave them behind at the time when we take the uterus out.  I do not like to use the words partial, complete and total.  I will clearly say whether we are taking the ovaries out or not, especially on the consent form.

One more option: This option is not offered by Gynecologists, rather by Interventional Radiologists. These are X-Ray physicians who had special training in performing procedures under X-Ray screens. To help you stop your heavy bleeding, or sometimes prevent bleeding at all, they will inject a special material that will block the blood supply to the uterus. It has good success rates. You will still have your uterus, but this procedure is not recommended if you plan to have more children in the future. It is done in the hospital, as a day procedure; you go home the same day.
As things are currently in Lakeridgehealth, this procedure take a long time to arrange, between arrange an MRI for you in teh hsopital, seeing the Doctor and eventually having it done. It is not a great option if you plan on having children in the future.

As I always say, there are side effects to everything we do in life. You will need to talk to the Interventional Radiologist for more information about the procedure and any possible side effects.