Regular and Heavy Menstrual Cycles

Menstrual cyles - what's normal and what's not? Dr. Ashley Hill discusses heavy periods  in this video and Dr. Gargey Patil discusses painful periods in this video.   

Causes of heavy and regular menstrual cycles

Most cases of heavy and regular menses are caused by a problem with the uterus, including common conditions like uterine polyps, fibroids, or adenomyosis. Although much less common, in some cases, especially in women older than 50, abnormal uterine bleeding may be caused by uterine pre-cancer or cancer. 

Endometrial polyps

Endometrial polyps are small growths in the lining of the uterus.  Think of a tall weed growing in the middle of a yard.  The polyp irritates the normal uterine lining around it, causing abnormal bleeding.  This bleeding can be spotting, heavy bleeding during a regular cycle or bleeding during sex.  While most are benign,  the risk of cancer is as high as 1 in 15 in some studies.  Tests such as saline infusion sonograms or office hysteroscopy are used to diagnose this common condition. Fortunately, treatment is straightforward and involves an office or outpatient procedure to remove the polyp.

Learn more about polyps in this short video.

Uterine fibroids

Uterine fibroids are very common and benign growths within the uterus ranging in size from microscopic to the size of a watermelon.  Many women have fibroids and do not know it since they may be small and do not cause any symptoms.  However, a large fibroid, or many fibroids may cause the  uterus to enlarge to the point where it causes pressure on surrounding organs, or the fibroids cause heavy bleeding.

Adenomyosis

Adenomyosis is a condition where the inner uterine lining grows into the outer muscular layer.  This can cause a swollen, painful uterus and heavy bleeding  A vaginal ultrasound or an MRI is used to diagnose this condition.

Inherited bleeding disorders

Although uncommon, some adolescents and women inherit a bleeding disorder that leads to heavy menses.  One disorder, von Willebrand Syndrome,.  is more common to diagnose in adolescents who have extremely heavy bleeding, to the point of needing a transfusion.  There are several specialized blood tests that help diagnose this condition.  Treatment usually consists of one or more medications and perhaps an IUD.  If you or your daughter has this condition we will work in collaboration with a hematologist to treat it.

Uterine cancer

There are about 42,000 new cases of uterine cancer each year in the United States. The most common symptom is postmenopausal bleeding.  Fortunately, most women who have postmenopausal bleeding do not have uterine cancer, but it is important that all menopausal women with bleeding have a gynecological evaluation to rule out cancer.  Most menopausal women with abnormal bleeding will need a gentle exam and perhaps a vaginal sonogram or endometrial biopsy.

Tests used to diagnose heavy menstrual cycles

Vaginal Sonogram

A vaginal sonogram, sometimes called an ultrasound, is a fast, painless test that uses an internal probe which allows for closer access to the areas that need evaluation. A sonogram allows physicians to see disorders like uterine fibroids and other problems with the muscular uterine walls, ovarian cysts, and early pregnancies. You will be asked to empty your bladder prior to this procedure.

Saline Infusion Vaginal Sonogram

When looking for uterine polyps, physicians will sometimes add a small amount of sterile water into the uterus.  The fluid helps provide better images of the cavity and lining of the uterus than a conventional transvaginal ultrasound. You may experience some cramping or spotting during or after this procedure.  Most women do not need any additional pain relief to have this procedure but it may be helpful to take ibuprofen before and after your procedure.

Endometrial Biopsy

We may recommend a biopsy of the uterine lining in order to rule out cancer or pre-cancer.   Similar to a Pap smear, we place a small speculum in the vagina, clean the opening to the uterus, and then place a thin “straw” into the uterus to take a small sample of the uterine lining.  The biopsy portion of the procedure usually takes under 30 seconds.  You may experience some cramping or spotting during or after this procedure.  Most women do not need any additional pain relief to have this procedure but it may be helpful to take ibuprofen before and after your procedure.

Office Diagnostic Hysteroscopy

Hysteroscopy is an office procedure in which your physician will place a very thin, lighted scope through the vagina and into the cervix in order to see the inner uterine lining.  Several common conditions can be diagnosed with this relatively fast procedure, including polyps, fibroids, and abnormal (possibly cancerous) areas within the uterus. You may experience some cramping or spotting during or after this procedure.  Most women do not need any additional pain relief to have this procedure but it may be helpful to take ibuprofen before and after your procedure.  

Dr. Boone discusses how the physicians at the Center for Menstrual Disorders use hysteroscopy to diagnose and develop treatment options for abnormal uterine bleeding in this video.

Treatment options for heavy menstrual bleeding

Our goal is to individualize treatment to your condition and needs.  There are surgical and nonsurgical options for most types of heavy uterine bleeding. Mainstays of nonsurgical treatment include birth control pills, NSAIDs (a class of medications including ibuprofen) and the levonorgestrel (Mirena®) IUD.  Surgical options might include removing a polyp or fibroid from the uterus, cauterizing the uterine lining (called an endometrial ablation), or performing a minimally-invasive fibroid removal or hysterectomy.

Hormonal Medications

As described above, hormonal medications often help treat abnormal uterine bleeding.

NSAIDs

Contrary to popular belief, medications like ibuprofen decrease uterine blood loss by squeezing the uterine blood vessels.  We may use these in conjunction with other medications to help treat heavy vaginal bleeding.

Hysteroscopic polypectomy or myomectomy

Hysteroscopic polypectomy or myomectomy is a procedure in which uterine fibroids are surgically removed while preserving the uterus in women of childbearing age or in women who want to avoid hysterectomy.  The procedure is done in the office or as outpatient surgery. For this procedure,  we would like someone to drive you to and from the office or hospital.  

Uterine fibroid embolization (UFE)

Some women, particularly those who are not candidates for major surgery, may benefit from uterine fibroid embolization (UFE), which is performed by an interventional radiologist.  UFE is a  minimally invasive treatment for fibroid tumors of the uterus..   The radiologist uses an x-ray camera called a fluoroscope to guide the delivery of small particles to the uterus and fibroids. UFE is typically offered to women who no longer wish to become pregnant.

Endometrial Ablation

Endometrial ablation is a relatively fast outpatient procedure that uses a lighted viewing instrument (hysteroscope) and other instruments to destroy (ablate) the uterine lining, or endometrium. In the past, many women with heavy bleeding underwent hysterectomy.   Modern minimally invasive options also include a global endometrial ablation.  The goal is to completely end all menstrual cycles.  However, some women who have this procedure will still have menstrual cycles, but they usually are much lighter than prior to the procedure.  Do not consider this procedure if you plan to become pregnant in the future. Although this surgery usually causes sterility by destroying the lining of the uterus, pregnancy may still be possible if a small part of the endometrium is left in place. This can lead to severe pregnancy problems. Birth control of some form is needed if you have not finished menopause.

Dr. Michael Cacciatore discusses a minimally invasive ablation procedure for eliminating heavy menstrual bleeding in this video.  

Minimally Invasive Hysterectomy

At the Center for Menstrual Disorders, more than 80 percent of  hysterectomies are performed with a minimally invasive approach.  Recent national surveys reveal that the majority of physicians in the United States perform most hysterectomies using a “bikini cut” instead of laparoscopically or via the vagina.. The advantages of minimally invasive hysterectomy are much smaller incisions,  faster recovery, and decreased scarring.