Abnormal Bleeding and Fibroids
A normal menstrual cycle (period) usually occurs monthly every 25-31 days and lasts from 3-7 days. The total blood loss is on average 30mL (2-3 tablespoons), but is no more than 80mL. A normal sized uterus usually weighs 1-2 ounces (50-75 grams) and is not bigger than a peach.
Abnormalities in the menstrual cycle
Abnormalities in the menstrual cycle are common and are defined here. Amenorrhea is defined as absence of menses for greater than 6 months. However a work-up is recommended if 3 periods in a row are missed. Oligomenorrhea is defined as less frequent menstrual cycles that occur at least 35 days apart. Menorrhagia is defined as prolonged or excessive uterine bleeding that occurs at regular intervals, total blood loss is more than 80mL or bleeding lasts for more than 7 days. Metrorrhagia is defined as irregular menstrual bleeding or bleeding in between periods. Polymenorrhea is defined as frequent menstrual bleeding that occurs every 21 days or less. Menometrorrhagia is defined as frequent menstrual bleeding that is excessive and irregular in amount and duration. Dysmenorrhea is defined as painful menstrual periods and is caused by prostaglandin release in the uterus causing painful uterine contractions. It is the most common menstrual disorder, affecting up to 90% of young women.
Heavy Bleeding and Cramping
Many women experience persistent, heavy uterine bleeding and pelvic pressure or cramping. There are many causes for irregular bleeding, including anovulation (not ovulating each month), uterine fibroids, uterine polyps, endometrial hyperplasia (uterine pre-cancer) or carcinoma, cervical or vaginal neoplasia, endometritis (inflammation/infection of uterine lining), adenomyosis, bleeding associated with pregnancy or post-partum, coagulopathies (blood thinning problems such as von Willebrand’s disease, platelet abnormalities, and thrombocytopenic purpura), systemic diseases, iatrogenic causes and medication side effects. Common causes of anovulation include normal physiologic conditions, such as adolescence, perimenopause, lactation, and pregnancy, as well as pathologic conditions such as hyperandrogenic anovulation (eg, polycystic ovary syndrome, congenital adrenal hyperplasia, androgen-producing tumors), hypothalamic dysfunction (eg, secondary to anorexia nervosa or exercise-induced), hyperprolactinemia, hypothyroidism, primary pituitary disease, premature ovarian failure, and iatrogenic (eg, secondary to radiation or chemotherapy). Persistent heavy bleeding can significantly affect a woman’s quality of life, require frequent bathroom trips/clothing changes and/or double protection, and even cause weakness or fatigue due to iron-deficiency anemia. Here we will discuss the two most common causes of persistent heavy bleeding: fibroids and adenomyosis.
Fibroids, also known as leiomyomas, are benign tumors originating from uterine tissue. They can vary greatly in size and number, and they are classified according to location: subserosal, submucosal, intramural, pedunculated, or combined. Symptoms and treatment options are affected by the size, number, and location of the leiomyomas. The incidence of uterine fibroids is unknown. Since fibroids are very common and most of the time they do not cause bothersome symptoms, they go undetected. However, some studies report leiomyomas in greater than 50% of women age 50 years. While the majority of women usually have no symptoms, 1 in 4 women end up with symptoms severe enough to require treatment. Symptomatic patients may experience heavy bleeding, irregular bleeding, painful periods, as well as pelvic pressure and urinary frequency from an enlarged uterus. Usually premenopausal women are the patients who seek out treatment. This is because when menopause occurs and estrogen production declines, fibroids usually shrink and abnormal bleeding significantly improves. However, a minority of postmenopausal women will still be symptomatic and seek out treatment.
Adenomyosis and Endometriosis
Adenomyosis is a certain type of endometriosis (abnormal location of uterine lining cells) that develops inside the uterine walls. It causes pelvic pain and bleeding. Adenomyosis prevents effective uterine contractions during a period making it more painful and prolonged. In the majority of cases, adenomyosis and endometriosis are present and symptomatic at the same time. As is the case of women with fibroids, if a woman reaches menopause, her symptoms from adenomyosis tend to improve due to decreased estrogen production, and it is less likely that she will need treatment. Fibroids and Adenomyosis may coexist in the same uterus. This may exacerbate the already severe symptoms.
The work-up for persistent, heavy uterine bleeding typically includes blood work to check for anemia (low hemoglobin and hematocrit), platelet dysfunction, and thyroid dysfunction, as well as performing a Pap test, endometrial biopsy, and pelvic ultrasound. The physicians at AMIGS can perform their own ultrasounds at your visit. Thus there is no separate appointment needed. Sometimes we also need to perform an in-office diagnostic hysteroscopy to help us decide on the best management plan. A diagnostic hysteroscopy involves inserting a slender flexible hysteroscope into the uterus via the vaginal canal. Only a small amount of sterile saline is needed to expand the uterine cavity so we can see if any polyps or fibroids are visible. Since the scope is so slender usually only oral or intramuscular pain relieving medications and local anesthesia to numb the cervix are needed. The procedure only takes about 5-10 minutes. There is no significant recovery time needed and patients can resume normal activities immediately. Patients can expect some cramping and discharge for a couple days. Sometime an endometrial biopsy or diagnostic hysteroscopy cannot be performed in the office, usually due to a very narrow cervical canal that will not allow passage of the instrument. In these cases, a Hysteroscopy with Dilation and Curettage (D&C) is advised as an outpatient procedure in the operating room under anesthesia. This procedure is similar to the diagnostic hysteroscopy described above except dilation of the cervix is needed to place the hysteroscope into the uterus and a uterine specimen is collected to rule out cancer. This procedure can also help decrease abnormal bleeding since a thickened uterine lining, uterine polyps and small submucosal fibroids (fibroids that extend into the cavity) can be removed at the time of the procedure.
Once the work-up is complete and cancer has been ruled out, conservative treatment should typically be attempted first and is the same for both uterine fibroids and adenomyosis. First-line therapy is prescribing a hormonal agent, if no contraindications exist. Hormonal agents may contain either a combination of an estrogen and a progestin medication or may contain a progestin-only compound; choices include birth control pills, vaginal rings, transdermal patches, intrauterine devices (IUDs), and injection progesterone. If this is not successful, then estrogen-eliminating treatment is offered in the form of Lupron injections (GnRH-a, gonadotropin releasing hormone agonist). Lupron treatments take several months and may produce severe side effects, especially menopause-like symptoms. Usually, the therapeutic impact only lasts as long as these agents are given. If pelvic pain occurs with the abnormal bleeding, usually non-steroidal anti-inflammatory medications are given as well.
If conservative hormonal treatments are contraindicated or unsuccessful, then usually a Minimally Invasive option is offered next. For small submuscosal fibroids (ones inside the uterine cavity) and uterine polyps, an Operative Hysteroscopy is offered. This has been discussed above. Uterine Endometrial Ablation is one of the most effective options for persistent, prolonged, and heavy uterine bleeding/cramping, symptomatic small fibroids, and adenomyosis. The procedure is designed for patients that do not desire future fertility/pregnancies or surgery/operation. It is an excellent alternative to hysterectomy in appropriate candidates. There are no hormones or surgery involved. An endometrial ablation destroys the lining of the uterus by using either a freezing (cryoablation) or heat energy (thermal ablation) technique.
Cryoablation (Her Option®)
Cryoablation (Her Option®) is a minimally invasive, safe, in-office procedure that destroys the lining of the uterus via freezing. It is performed in the convenience of our office with minimal to no discomfort. It can accommodate different uterine sizes and shapes, and is highly effective with a patient satisfaction rating of greater than 90%. About one hour before the procedure, pain relief and relaxation medications (toradol and ativan) are administered. Local anesthesia is sometimes used if needed to numb the cervix just prior to the procedure. When anesthesia is adequate, a slender probe is inserted through the vagina into the uterine cavity, where it creates an ice ball that freezes the uterine lining and most of the uterine wall tissue creating a permanent effect. Cold temperatures have a natural pain relieving (analgesic) effect, reducing pain associated with the procedure. During the procedure, your doctor will monitor the progress of the treatment using an abdominal ultrasound. The procedure takes about 25-35 minutes, and the recovery time is less than one hour. Vaginal discharge is expected to last for about two weeks. Post-procedure discomfort is mild and usually adequately treated with using over the counter pain killers, such as advil, motrin, or tylenol. Patients usually return to work in1-2 days.
After three months, patients’ periods are expected to be absent or lighter with shorter duration and significantly less cramping. This effect is typically permanent. This procedure is not a sterilization procedure and patients still need to use birth control after the procedure. If permanent birth control is desired, an In-office Tubal Occlusion (Essure®) Procedure can be performed at the same or later time.
Thermal Endometrial Ablation
Thermal Endometrial Ablation is similar to Uterine Cryoablation, but the uterine lining is destroyed with a device supplying heat energy instead of using a freezing probe. Sometimes this method is limited by the size and shape of the uterus. Patient satisfaction and therapeutic effects are similar. Usually this method is performed in an Outpatient Surgery Center under general anesthesia. There are some doctor’s offices that can perform this procedure under conscious sedation in the office with appropriate monitoring. On average, over a 5 year period, endometrial ablation techniques are about 85% effective. About 15% of patients will require additional treatment or hysterectomy.
If the above more conservative options are unsuccessful, contraindicated, or not desired, then surgery is offered. For patients with fibroid tumors who wish to keep their childbearing potential (they want to have children), a Myomectomy is a possible option. A Myomectomy is a surgical procedure which removes only the fibroid tumors from the uterus. If incisions are made into the uterine wall, then they are closed with sutures, and the uterus is left intact. If a major incision is made into the uterine wall, this will heal forming a scar and usually a Cesarean Section is recommended for future deliveries if the patient becomes pregnant.
There are a variety of ways this procedure can be performed and the approach depends on the number, location and size of the fibroids, as well as the surgeon’s level of skill and comfort. A Hysteroscopic Myomectomy involves placing a hysteroscope into the uterus via the vaginal canal and removing small submucosal fibroids. An Abdominal Myomectomy involves making an incision in abdominal wall and removing the fibroids through this incision. This is the standard of care for intramural and subserosal fibroids, especially large fibroids. Patients stay in the hospital for 2-3 days. A Laparoscopic or Robotic Myomectomy, removes intramural and subserosal fibroids laparoscopically from the uterus. They require a highly skilled surgeon specializing in minimally invasive surgery. The advantages of a laparoscopic procedure are many. Patients usually go home the same day, the recovery time is faster and less painful, and the cosmetic outcome is better. Most of our cases here at AMIGS are performed laparoscopically or robotically.
If patients have completed childbearing, the surgical procedure recommended to remove fibroid tumors is a Hysterectomy, which is a surgical procedure to remove the uterus without removing the ovaries. In addition, the only way to remove adenomyosis (unless it is an adenomyoma), is to perform a hysterectomy. The main reason a hysterectomy is the surgery of choice for fibroid tumors is due to the nature of fibroids. Even with the most skilled surgeon, it is usually difficult to remove all of a patient’s fibroids for various reasons. Retained fibroids may continue to grow after a myomectomy and new fibroids can form. Thus the patient’s symptoms may return. In addition, the amount of blood loss is usually more with a myomectomy than with a hysterectomy, and the recovery is usually longer with more discomfort. With a hysterectomy, all of the fibroids are removed and since the uterus is removed no new fibroid tumors can grow. Fibroids, adenomyosis, menstruation and painful periods are essentially eliminated. Also patients who have a hysterectomy do not need any future birth control.
There are a variety of ways a Hysterectomy procedure can be performed (in the absence of cancer) and the approach depends on the size of the uterus, patient’s history of previous abdominal surgeries, indications for the procedure, as well as the surgeon’s level of skill and comfort. Abdominal Hysterectomy and Vaginal Hysterectomy are the standard of care and involve a 1-2 night stay in the hospital. The definitive minimally-invasive solution is provided by out-patient Laparoscopic Hysterectomy or Robotic Hysterectomy. Most of our cases here at AMIGS are performed laparoscopically, even when the uterus is very large. The advantages of a laparoscopic procedure are many. Patients usually go home the same day, the recovery time is faster and less painful, and the cosmetic outcome is better. After April 2010 we will also have the option of performing Robotic Surgery.
Uterine Fibroid Embolization (UFE) and Magnetic Resonance guided Focused Ultrasound (MRgFU)
Finally, there are two additional options to treat symptomatic fibroids: Uterine Fibroid Embolization (UFE) and Magnetic Resonance guided Focused Ultrasound (MRgFU). These procedures are performed by an interventional radiologist. Prior to these procedures a patient must have an updated Pap test, endometrial biopsy, and an MRI (Magnetic Resonance Imaging) test. Based on the MRI results, the radiologist will determine if the procedure is a possible option. These procedures aim to shrink the fibroids in hopes of improving the patient’s symptoms. They do not eliminate fibroids. UFE blocks the blood supply and makes the fibroid tumors inactive or less active. UFE is not recommended for patients desire pregnancy/children, have adenomyosis or submucosal fibroids. UFE requires IV sedation and is associated with significant pain (days or weeks) after the procedure. MRgFU is performed on a MRI table. The patient is lying on her abdomen for three hours with a catheter in her bladder. High frequency ultrasonic energy is applied on the fibroid causing it to become inactive or less active. MRgFU is associated with pain and requires sedation and pain medications. A follow-up MRI is usually ordered 3-6 months after these procedures. The rate of recurrence depends on the nature of the fibroids. The existing fibroids can grow again and new fibroids can form, causing symptoms to return. Also if there is adenomyosis present as well, this will continue to cause symptoms. Lastly, this is not a sterilization procedure, thus patients need to continue to use birth control until they reach menopause.