Heavy periods are a common problem among women, especially women in their 30’s and 40’s. It is estimated that 20% of women in their 40’s suffer with periods heavy enough to be considered “abnormal.” Studies show that women are deeply affected by heavy periods: 60-80% of women with heavy periods report missing social events or avoiding intercourse because of heavy bleeding, and one third indicate that they have missed work because of their bleeding. Many women with heavy periods report moodiness, depression, anxiety, or lack of confidence as a result of their periods.
It is estimated that 20% of women in their 40’s suffer with periods heavy enough to be considered “abnormal.”
Generally, your period is considered “abnormal” if the flow is enough to interrupt your lifestyle. Typically, women with abnormally heavy periods report:
- Soaking through pads or tampons
- Changing frequently
- Having embarrassing “accidents”
- Carrying lots of feminine hygiene products
- “Doubling up” with two pads, or a pad and a tampon
Certainly, if you period is heavy enough to sometimes miss work, or if your period lasts longer than 7 days, it is abnormal. Also, if you’ve been told of being anemic and have heavy periods, treatment may be indicated.
Treatment Options for Women with Heavy Periods
There are a variety of treatment options for women with heavy bleeding. Combined oral contraceptives (“birth control pills”) have been used for decades to control heavy periods. The pill is frequently effective, but many women have concerns about side effects and consequences of long-term exposure to these hormones. Moreover, oral contraceptives are not be safe for many women: Women over 35 who smoke, or women who are very overweight, have high blood pressure, or diabetes are not ideal candidates for the pill.
A progesterone-containing intrauterine device (IUD) is also sometimes used for control of heavy periods. The levonorgestrel-containing Mirena, for example, is easily placed during an office visit. For the first 3 to 6 months with Mirena, many women will report some disorganized bleeding; usually this consists of periods which are a bit prolonged—but not heavy—or persistent light staining between periods After 3 to 6 months, women with Mirena generally fall into one of two groups: Either they get light regular periods, or they get no periods at all. Some women are uncomfortable with the idea of a foreign body inside their uterus, and others are concerned about the small amount of hormones contained in the Mirena device. It does, however, provide an effective control of heavy periods in some women.
In addition to oral contraceptives and the levonorgestrel-containing IUD, there are medications which can be used to control heavy periods. Recently, Lysteda (tranexamic acid) received FDA approval for the treatment of heavy bleeding. The drug is taken with your period, and has been shown to reduce flow in most women. Use of Lysteda, however, has been significantly associated with an increased risk of blood clots; moreover, because the medication is relatively new, there are few data available on long-term safety and side effects.
Many women are understandably reluctant to commit to long-term use of hormones and other medications; many worry about side effects and long-term safety. Some of these options also can be quite costly: With many birth control pills now costing $70 per month, a 40-year-old woman who starts the pill will spend close to $10,000 on birth control pills before she stops getting her period!
In the last decade, endometrial ablation procedures have become extremely popular among women with heavy periods. In this 10-minute procedure, a special instrument is guided into the womb through the vagina, and used to permanently inactivate the inner lining of the uterus (the endometrium). The procedure takes just 10 minutes to perform, and is usually performed with light anesthesia; some mild cramps are expected for a day or two, but women can expect to return to work the day after the procedure.
Even if your period stops after endometrial ablation, it doesn’t make you “menopausal.”
Results of the endometrial ablation procedure are truly remarkable. Patients previously accustomed to excessive menstrual bleeding, with flooding, clots, and cramps find that after ablation, their periods consists of just a few days of light staining; for some women, their period just “fizzles out” altogether. (Remember: Even if your period stops after endometrial ablation, it doesn’t make you “menopausal.” Your body still goes through a natural hormonal cycle each month…there’s just no flow of blood at the end of it.) Women who have severe period cramps—especially those with their worst cramps on their heaviest days—typically have dramatic relief after ablation. Interestingly, there is evidence that endometrial ablation even improves symptoms of PMS. The results of endometrial ablation are expected to be permanent. This really represents a revolutionary option for women with heavy menstrual flow: A 10-minute procedure which can safely permanently reduce menstrual flow, with no hormones whatsoever.
The NovaSure® Procedure for Endometrial Ablation
In Fig. 1, the device is inserted.
In Fig. 2, the array is opened.
In Fig. 3, radiofrequency energy is then used to inactivate the endometrium.
Finally, in Fig. 4, the device is removed.
A Clinical Message from Dr. Andre Saad
I performed my first endometrial ablation twenty years ago. Back then, endometrial ablation was technically very challenging and, frankly, out of the reach of most practicing gynecologists. With early “rollerball” and “resectoscopic” procedures, the surgeon operated through a narrow telescope inserted into the uterus. We would pass an instrument through a channel in the telescope, and manually roll back and forth over the inner lining of the uterus with an electrified rollerball, or shave off the inner lining with a wire loop attached to electric current. Results were good, but the procedure was time-consuming, the equipment was temperamental, and the technique was highly dependent on the surgeon’s skills. As might be expected for this specialized, advanced procedure, complications occasionally occurred, and were sometimes serious.
Over the last two decades, “rollerball” and “resectoscopic” ablations have been largely abandoned, because several devices have been developed which “automate” the procedure. These “global endometrial ablation” devices certainly remove some of the technical demands of the procedure, and probably make the procedure safer and more effective as well. The American College of Obstetricians and Gynecologists—a national organization which gives guidance on standards of practice—now recommends endometrial ablation as a first-line option for women who perceive their periods to be too heavy.
One of the most common devices used for endometrial ablation is NovaSure®. With Novasure, an electrical “net” is opened inside the uterus, and radio waves are passed through its fibers, inactivating the surrounding uterine lining. I was an early adopter of endometrial ablation, and I have performed literally hundreds of endometrial ablation procedures over the years. Novasure is associated with high success rates, low rates of complications, and very high rates of patient satisfaction.
Is Endometrial Ablation Right for You?
Endometrial ablation is truly revolutionary, and is a terrific procedure—for the right candidate. Having performed hundreds of ablations over the years, I can offer some insight into which women are best served by endometrial ablation.
First, endometrial ablation is only appropriate for women who have completed their families. Because the inner lining of the womb is inactivated by this procedure, women cannot safely get pregnant and carry a child after ablation. If you have not completed your family, or if you are not certain if you want more children, you should not have an endometrial ablation.
It is true that endometrial ablation makes it very difficult for women to conceive, but it also makes conception extremely inadvisable. Pregnancy after an ablation—whether the pregnancy is continued or terminated—is a risky endeavor. Endometrial ablation procedures are not intended to be used as contraception, and are only appropriate for women who will reliably take precautions against pregnancy.
The women who get the best results from endometrial ablation are those who have a normal or nearly-normal uterus. Women with a very large uterus have less predictable results. Also, if the inner cavity is distorted by fibroids, or if women have an abnormally-shaped uterus, they may not be suitable candidates.
Like any procedure, ablation does carry some risks. Depending on the method of ablation used, cramps and nausea may occur on the day of the procedure, and sometimes require treatment. Postoperative infection is uncommon, but occasionally occurs. Rare complications include perforation of the uterus, anesthetic complications, and injuries to other organs.
At The Woman’s Health Pavilion, we enthusiastically support minimally invasive solutions like endometrial ablation, which improve women’s quality of life with minimal down-time. Our practice experience with endometrial ablation is quite positive, and I know that I would have no hesitation to recommend these procedures to a friend or family member. If you would like to discuss endometrial ablation, or other options for treatment of heavy bleeding, I would welcome the opportunity to meet with you in consultation.
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