Heavy Menstrual Bleeding

Edward Lichten, M.D.,PC
555 South Old Woodward Ave. Suite #700
Birmingham, MI 48009 
248.593.9999

Email: drlichten
@yahoo.com

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Diagnosis	Medications	Operative Hysteroscopy
Anovulation	Lupron	Thermal Ablation
Adenomyosis	Synarel	Endometrial Ablation
Fibroids-Leiomyomata	Provera, Megace	Resectoscopy
Menopause	Laboratory Tests	D&C dilitation curettage

Introduction:
The number one reason for hysterectomy is abnormal bleeding. Most causes of abnormal bleeding can be determined with a few simple questions:

Diagnosis
Question #1: When was the woman's last menstrual period?

Is she menopausal (last menstrual period more than 6 months ago)?
Is she anovulatory (irregular menses imply a uterine build up or polyps)?
Is she pregnant (missed menses after have near regular monthly flows)?

Menopause?
It is sometimes quite difficult to determine if a woman is menopausal. Yes, she is usually in her late forties or early fifties. Many of these women have had tubal ligation and have had their last child more than 10 years previously. But with our active lives and healthy living, women in their fifties are "not old anymore." As a physician, it is relatively easy to determine if a woman is menopausal. We can draw the appropriate laboratory blood tests. The tests we run are the FSH (follicle stimulating hormone) and the LH (luteinizing hormone) serum assays. These measure these two hormones that are released from the pituitary in the middle of the brain. Their function is to stimulate the woman's ovaries to release female hormones of estrogen and progesterone. When the ovaries are not functioning properly, the pituitary increases the release of FSH and LH. Their normal values are under 5; menopause will find both the FSH and LH over 20. In-between, doctors use the term perimenopause.

Laboratory Tests
The only special case is at ovulation: the FSH and LH are quite elevated. Therefore, to determine if a woman is menopausal, a physician may draw two blood samples two weeks apart. If they both are elevated, there is no doubt in the diagnosis of menopause. The other laboratory blood tests are the serum progesterone on day 23 and the beta-HCG (urine or blood pregnancy test) to determine if a pregnancy has occurred.

Anovulatory
Some women can tell that they are ovulating by the pain they experience at the middle of their menstrual cycle. This pain is usually one sided, but may affect both sides. The cramping pain may be associated with a small amount of mid-cycle uterine bleeding. But many women do not experience this pain. The purpose of ovulation is to release the egg for fertilization. After ovulation, the ovary produces the hormone progesterone which makes the lining of the uterus conducive for the implantation of the fertilized egg. The production of progesterone also raises the woman's body temperature.

Therefore, there are four methods used to determine ovulation: 1) The presence of the ovarian cyst at midcycle, 2) elevated basal body temperature the 10-14 days after ovulation, 3) elevated progesterone in the blood on day 21-24, and 4) changes in the lining of the uterus (endometrium) prior to her next menstrual period.

The most consistent method of determining ovulation in a woman who wishes to conceive is the serum progesterone assay. If the level is less than 2, she is not ovulating. If the level is over 10, there is very strong evidence of ovulation. If the levels are in-between, then the production of progesterone is less than adequate.

Pregnant? Even before a woman is "late" she can determine if she is pregnant with the EPT or home pregnancy tests. These measure the hormone beta-HCG produced only by the placenta (after-birth). Therefore, the diagnosis of pregancy is quite easily confirmed or eliminated from the medical diagnosis of "causation of bleeding."

D&C(Dilitation & Curettage)
Question #2: What does the physician "feel" during the D&C?
If the woman is not miscarriaging from an incomplete pregnancy, then the result of the dilitation and curettage will tell the physician much about the conditions in the uterus and the state of the uterine lining. Since most D&Cs are now performed in the doctors' office, he can compare his physical examination with what he "feels" when doing the curettage (scraping). He may feel irregularities that correspond to "bumps" on the uterus. This implies fibroid tumors also called leiomyomata (medical term). During the curettage, he may feel that the uterine cavity is quite large. This may correlate with a soft, boggy manual examination. This implies Adenomyosis which is often seen in older women who have had multiple pregnancies. The deep glands in the lining are the cause of irregular and heavy uterine bleeding.

Question #3: What is the result of the pathology of the D&C?
The three most common findings on the pathology report are:

1. Thin or atrophic endometrium (compatible with menopause).
   
2. Out-of-phase endometrium (compatible with not ovulating).
   
3. Products of conception (compatible with an incomplete miscarriage).

Rarely do we find cancer of the endometrium, called "endometrial carcinoma." A thick piece of tissue that is out-of-phase is called a polyp. Tissue that has a "Swiss-cheese" appearance is called cystic hyperplasia. This is not cancer. When the term "adenomatous hyperplasia" is used, this implies a crowding of the endometrial glands. When the term used is "adenomatous hyperplasia with atypia," this is considered pre-malignancy.

Question #4: Does the D&C and medical treatment correct the bleeding problem?

If the problem is anovulation, then the D&C usually corrects the immediate problem. Treatment of anovulatory bleeding can be either birth control pills or pregnancy. If the woman is 14 to 54 years of age, she can be treated with a low dose OC, oral contraceptive (birth control), to regulate her menstrual cycle. This corrects the problem of anovulation (too thick endometrium) by adding the OCs progestin and the atrophic (too thin endometrium) by adding the OCs estrogen. If the woman wishes to conceive, the use of Clomiphene can induce ovulation. Fertilization and pregnancy are effective treatments for bleeding disorders for at least nine months.

Not every woman's bleeding responds to oral contraceptives. They are contra-indicated in women with blood clots, a history of smoking and those with hypertension. But there are other medications that can control almost all bleeding problems.

The medications luprolide acetate or Lupron and Synarel are Gn-RH agonists. That means they prevent the release of FSH and LH from the brain. This creates a state of very low estrogen. And not only does the uterine bleeding usually cease, but also, the fibroids and polyps shrink and might disappear over time. These drugs are usually used for short periods of time, up to 9 months. Further use is associated with osteoporosis and bone thinning. The other choice is Megesterol acetate (Megace). Megace is a drug from the save family as Provera called progestins. Megace is unique in that a low dose of oral Megace is successful in minimizing bleeding while having minimal effects on bone loss. Depoprovera may cause continuous bleeding.

But no medication or out-patient surgery will work for every case of abnormal uterine bleeding!

What then are the options for a woman who has completed her childbearing and needs to stop heavy, irregular and prolonged menstrual periods?

READ ON ABOUT OUT-PATIENT and IN-PATIENT SURGICAL PROCEDURES

Out-patient and In-office Surgery  

1. Hysteroscopy
2. Operative hysteroscopy
   
   1. Endometrial Ablation
      
   2. Thermal Ablation
      
   3. Resectoscopy

In-Patient Surgery

1. Hysterectomy
2. Hysterectomy with a 'Tummy Tuck'