Menstrual Disorder Treatment


Abnormal Uterine Bleeding Treatment Options

Treatment recommendations for abnormal uterine bleeding (AUB) depend on the diagnosis. Both medication and surgery are used to treat AUB. Typically, less invasive therapies should be considered first. Treatment choices depend on your age, your desire to preserve fertility and the cause of the bleeding (dysfunctional or structural). Other treatments may reduce your menstrual bleeding to a light to normal flow.

Medication for bleeding caused by hormonal imbalances include low-dose birth control pills (oral contraceptives), progestins and nonsteroidal anti-inflammatory drugs (NSAIDs).

Oral contraceptives (OCs) and contraceptive patches (CPs) are almost 100 percent effective in restoring cyclic menstrual periods. Pills containing less estrogen tend to work better to reduce bleeding. OCs or CPs can reduce menstrual flow, improve and control menstrual patterns and relieve pelvic pain during menstruation. They can be considered for PMS treatment if symptoms are mostly physical, but they may not be effective if mood symptoms are the primary symptom. However one newer brand of OCs containing a form of progesterone called drospirenone has been shown in clinical studies to reduce some mood-related symptoms such as anxiety, irritability, tearfulness, and tension among others.

Birth control pills may not be an appropriate treatment choice if you smoke, have a history of pulmonary embolism (blood clots in your lungs) or are highly sensitive to side effects of this medication.

Progestins used to manage dysfunctional bleeding include oral Provera, norethindrone and Depo-Provera, an injectable form of the progestin, Provera, which is an oral preparation. Progestins may reduce menstrual bleeding by up to 20 percent. The Mirena or the Progestasert IUDs may help to decrease heavy bleeding for some women by slowly releasing progestin into the uterus for up to five years. It may help to reduce menstrual flow by up to 40 percent. This device, however, may increase the risk for ectopic pregnancy, and hormonal side effects, such as bloating.

Menstrual Disorder Treatment: NSAIDs & Dilation and Curettage

Nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce menstrual bleeding by up to 30 percent, particularly when they are taken with oral contraceptives. These medications include ibuprofen, naproxen and mefenamic acid. Common side effects of NSAIDs include stomach upset and gas. Medication therapy is often successful and a good option if you want to preserve your fertility or avoid surgery. The benefits last only as long as the medication is taken, so if you choose this route, you should know that medical treatment is a long-term commitment.

These surgical options may be recommended if drug therapy fails:

  • hysteroscopic treatment of anatomic abnormalities (such as polyps or fibroids)
  • hysteroscopic endometrial ablation or endomyometrial resection (EMR)
  • global or blind endometrial ablation
  • hysterectomy

Except for hysterectomy, in each of these options the uterus is preserved and only the uterine lining is destroyed to reduce excessive bleeding. However, though these options preserve the uterus, fertility is destroyed with some of the procedures and childbearing after the procedure is not an option. There are other important considerations for each of these treatment options. Risks common to all surgical options include infection, hemorrhage and other complications, some of which are described below.

Dilation and curettage (D&C): once a mainstay in the treatment of excessive menstrual bleeding, newer options are now considered more effective. During a D&C, which is performed on an outpatient basis using general anesthesia, your uterine lining is scraped away. No viewing mechanism is used, so the procedure is done "blindly." Many health care professionals no longer recommend a D&C because it's simply not effective.

Menstrual Disorder Treatment: EMR

Hysteroscopic endometrial ablation or endomyometrial resection (EMR): during endometrial ablation the uterine lining is viewed through a hysteroscope and cauterized with an electrosurgical tip called a "rollerball" or with a laser. It's considered outpatient surgery and normally takes about 20 to 40 minutes. It is performed under general anesthesia and it should take you one to two days to recover, in most cases. Because the uterine lining is destroyed with this procedure, it is not recommended if you want to have children. Endomyometrial resection (EMR) is also a hysteroscopic technique. However, in this procedure the uterine lining and a quarter-inch of its underlying muscle is actually removed. EMR is generally associated with far better outcomes in terms of menstrual blood flow. Its main disadvantage is that it requires considerable technical expertise and should only be performed by highly qualified hysteroscopists.

Hysteroscopic procedures (rollerball and EMR) are acquired skills that and not every physician possesses. Make sure to ask yours about past experience in this procedure before agreeing to it. Rollerball thermal ablation and EMR require that your uterus be filled with fluid so that its contours may be visualized on a monitor. While viewing your uterus, the physician moves the rollerball or wire-loop electrode, which delivers an electrical current, from top to bottom of the uterus until the entire surface of the uterus has been cauterized or removed.

Risks associated with this procedure include uterine perforation, and fluid overload. Because the fluid pumped into your uterus is kept under pressure during the procedure, there is a slight risk that distention fluid may escape into the uterine blood vessels, upsetting the concentration of electrolytes, such as sodium, in your blood stream. This imbalance may be life threatening. However, the risk of fluid overload is rare in the hands of an experienced physician.

Recently approved by the U.S. Food and Drug Administration (FDA) in April 2001, the Hydro ThermAblator® is a computer-controlled device that utilizes a hot saline solution to destroy specific tissue inside the uterus. After the patient has received anesthesia, the doctor inserts a hysteroscope and tubing through the vagina into the uterus. The heater canister, which is located outside the body, heats saline fluid (salt water) to a temperature of 194°F (90°C). With the aid of the pump and valves, the heated fluid is circulated through the HTA system and uterus for 10 minutes. The heated fluid directly contacts the innermost layer of tissue (endometrium) of the uterus. The exposure to heated fluid acts to destroy the endometrium.

Menstrual Disorder Treatment: Therapy & Treatment Systems

Uterine Cryoblation Therapy: The FDA also recently granted marketing approval for HerOption™ Uterine Cryoblation Therapy System. The therapy system involves a slender probe attached to a cooling unit. The probe is inserted through the cervix into the uterus. The tip of the probe is brought to a very low temperature to freeze and eliminate the uterine lining responsible for the excessive bleeding. Her Option is the first FDA-approved technique that uses hypothermia to destroy the endometrium. Because the procedure can be controlled through the use of ultrasound guidance, a thorough level of ablation may be safely achieved.

The NovaSure Impedance Controlled Endometrial Ablation System is a new, FDA-approved device for the treatment of excessive menstrual bleeding (menorrhagia); the device works by ablating, or destroying, the lining of the uterus using radiofrequency energy. The procedure is performed with a handheld catheter that delivers radiofrequency energy for about 90 seconds, significantly less time than for other endometrial ablation treatments, according to Novacept, NovaSure's Palo Alto, California-based manufacturer.

Blind endometrial ablation/uterine balloon therapy: a relatively new device (marketed as ThermaChoice®) is safer than the rollerball thermal ablation procedure because your uterus is not filled with fluid during the procedure. Because no visualization is necessary, the instrument is smaller, and requires no special skill. The major drawbacks of uterine balloon therapy are that it cannot be used in many uteri (those that are larger than normal, have an abnormal shape, or contain fibroids or polyps) and that it appears to be less effective than either of the hysteroscopic techniques in experienced hands. During this procedure, a soft, flexible balloon attached to a thin probe is inserted into your vagina through the cervix and placed in your uterus. The balloon is inflated with sterile fluid and expands to fit the contours of your uterus. Then, the fluid is heated to 87 degrees Celsius. This treatment lasts for eight minutes and thermally destroys your uterine lining. Afterwards, the fluid is withdrawn, the balloon deflates, and the device is removed from your uterus through your cervix and vagina. Nothing remains in your uterus after the procedure is complete.

During this procedure, a soft, flexible balloon attached to a thin probe is inserted into your vagina through the cervix and placed in your uterus. The balloon is inflated with sterile fluid and expands to fit the contours of your uterus. Then, the fluid is heated to 87 degrees Celsius. This treatment lasts for eight minutes and thermally destroys your uterine lining. Afterwards, the fluid is withdrawn, the balloon deflates, and the device is removed from your uterus through your cervix and vagina. Nothing remains in your uterus after the procedure is complete.

You should note that the balloon therapy cannot be used if you have uterine polyps, fibroids or if your uterus is irregularly shaped (also known as septum). These conditions affect about 35 percent of all women who are treated for abnormal uterine bleeding.

Uterine balloon therapy is designed as an outpatient procedure and may be performed under local or general anesthesia. Most women take less than one day to recover. You may experience some cramping during the procedure and a watery, pink discharge for about two weeks, which are symptoms common to any ablation or D&C procedure. The procedure is recommended only for women who have completed their families, as it destroys the uterine lining and therefore, fertility. Following treatment, you must use contraception. Although thermal ablation destroys the uterine lining, there is a small chance that pregnancy could occur, which can be dangerous to both mother and fetus.

Risks associated with this technique are considered much smaller than other thermal ablation techniques. However, risks may include uterine perforation, fluid leakage from the balloon, blood loss and burning of internal structures. Thermal balloon ablation appears to have substantially less efficacy than the hysteroscopic methods (rollerball and EMR).

About 15 percent of women treated with thermal balloon actually stop having periods (called amenorrhea). With hysteroscopic endometrial ablation (rollerball), about 40 percent of women can expect to become amenorrheic. With hysteroscopic EMR, about 85 percent of women can expect amenorrhea.

 

Menstrual Disorder Treatment: Hysterectomy

Hysterectomy: this is one of the most common surgical procedures recommended to stop certain types of AUB. About 20 percent of all hysterectomies are performed to stop AUB and it's the only treatment that completely guarantees the bleeding will stop. But, this is a radical surgical intervention that removes your uterus. You will no longer be able to have children after this procedure. Several factors make elective hysterectomy a serious consideration: it is major surgery and includes all the risks associated with any surgical procedure. A lengthy recovery period, often four to six weeks, may be necessary for some women. Fatigue associated with the procedure can last much longer.

Hysterectomy refers to several types of procedures. In a supracervical hysterectomy, the body of your uterus alone is removed above the cervix. A total hysterectomy removes your uterus and cervix. In either of these surgeries, your ovaries and fallopian tubes may be preserved.

The uterus may be removed through either an incision in the abdomen (abdominal hysterectomy), or through an incision in the vagina (vaginal hysterectomy). Another option is the laparoscopically assisted vaginal hysterectomy (LAVH), in which a surgeon uses a laparoscope (a small telescope) inserted through the abdomen to see the entire pelvis. Other tiny incisions are made in the abdomen so the surgeon can perform parts of the hysterectomy there, with the remainder of the procedure completed through the vagina. A LAVH utilizes smaller incisions than abdominal hysterectomy, but is more invasive than a vaginal hysterectomy. The type that makes most sense for you depends, in part, on the size of your uterus, your medical history, and the consultation with your physician and his/her experience with the procedure(s). The risk of ureteral injury (damage to the tube that moves urine from the kidney to the bladder) is, however, increased with LAVH.

When your ovaries are removed, you will undergo surgical menopause and may experience all the symptoms associated with an abrupt decrease in estrogen. To manage symptoms, estrogen therapy is often prescribed following surgery.

Menstrual Disorder Treatment: Hormone Therapy

The safety of postmenopausal hormone therapy, which includes estrogen therapy and combination estrogen-progestin therapy, for short-term use to relieve menopausal symptoms, as well as to reduce the long-term effects of estrogen depletion — such as osteoporosis — is now under intense scrutiny by the Federal government. This scrutiny was triggered by major studies of postmenopausal therapy published in 2002 that found significant health risks associated with its use.

In January 2003, the U.S. Food and Drug Administration (FDA) announced that it would require a new, highlighted "black-box" warning on all estrogen products for use by postmenopausal women. The warning indicates an increased risk for heart disease, heart attacks, stroke and breast cancer from supplemental estrogen — risks identified by one section of the Women's Health Initiative study, which was abruptly halted when the risks were identified. The "black-box" warning advises health care professionals to prescribe estrogen products at the lowest dose and for the shortest possible length of time.

New, lower-dose versions of the hormone therapies used to treat symptoms of menopause are currently being developed. The U.S. Food and Drug Administration recently approved a low-dose version of the combination estrogen-progestin treatment sold as Prempro, which is expected to be available in the summer of 2003.

Other medical and nonmedical options are available and may be appropriate for you to manage symptoms triggered by removing your ovaries with hysterectomy. Discuss your options with your physicians.

Menstrual Disorder Treatment: Fibroids

Treatment Options for Fibroids

If you've been diagnosed with fibroids, there are a number of treatment options available. They include:

Hysterectomy: this is the most frequently recommended treatment for fibroids. It offers the only real cure for fibroids since they don't recur after the surgical procedure. However, removing the uterus to stop bleeding caused by fibroids is not an option some women wish to consider. If you are considering future pregnancies, this procedure is not an option for you.

Myomectomy: The myomectomy procedure removes only the fibroids, leaving your uterus intact, which can preserve fertility. The procedure is performed either through an open incision in your abdomen or by electrosurgical "resection," which uses electrical current instead of a knife to cut away fibroid tissue. Fibroids located on the outside of your uterus are usually removed by open surgery, though small fibroids in this area may also be removed using a laparoscope. Fibroids on the inside of your uterus are removed with a hysteroscope with an electrode attached to it. This tool shaves away the fibroids.

Open myomectomies are considered major surgery, require a lengthy recovery, and can involve substantial blood loss. As with any surgery to the reproductive tract, this procedure may cause scar tissue that may impair your fertility. Both types of myomectomies are performed under general anesthesia. With hysteroscopic myomectomy, the cervix must be dilated to accommodate the surgical instruments.

This procedure is frequently more complicated than hysterectomy and the risks of myomectomy procedures should not be understated. Myomectomy takes as long and often longer than a hysterectomy and it may involve greater blood loss and a greater need for transfusion than hysterectomy. Also, when a hysterectomy can be performed vaginally, recovery is less than for either hysterectomy or myomectomy.

If a fibroid protrudes into the uterine cavity it may be accessible by hysteroscopic myomectomy. In this procedure a loop electrode is used to cut away the fibroid. This procedure is best done under ultrasound guidance in which an ultrasound transducer is placed onto the abdomen in order to minimize the risk of uterine perforation. One of the risks of hysteroscopic myomectomy is that your fertility may be compromised.

Myomectomy may also involve a more difficult postoperative course than hysterectomy and there is the risk of damage to ureters and other structures, as with hysterectomy. Scarring of the uterus following myomectomy may also affect fertility. And the procedure doesn't prevent further fibroids from growing. In fact, they often grow back and may require more surgery.

Fibroid vaporization: fibroid vaporization is performed by inserting a small hysteroscope into the uterus through the vagina and cervix. A small electrode is inserted through the hysteroscope and electrical energy is use to vaporize the fibroid instead of shaving it away. Local anesthesia may be used because the cervix does not need to be dilated as much to accommodate the smaller hysteroscope. Fibroid vaporization may affect fertility because the endometrium will not regrow where the fibroid was attached.

 

Menstrual Disorder Treatment: Fibroid Treatment

There are some innovative surgical techniques now being considered for fibroid-related bleeding. While these treatments may be effective, only small numbers of women have undergone these procedures and there have been no long-term follow-up studies. Some procedures include the following:

  • Myolysis: this involves delivering electric current via needles to a fibroid at the time of laparoscopy
  • Cryomyolysis: involves using a freezing probe in a similar manner to myolysis
  • Uterine artery embolization (UAE) is a radiological alternative to surgery that involves placing a catheter into an artery in the leg and guiding the catheter via x-rays to the arteries of the uterus. Once the catheter gets there, it is used to deliver agents that block off the blood vessels that supply the fibroids. With the blood supply blocked, the fibroids should rapidly diminish in size. This procedure is relatively new and long-term data is still lacking in terms of complications, future need for hysterectomy and recurrence of fibroids. The recovery time from UAE can be weeks, and the long-term effect of leaving dead tissue behind is still unknown.

Some women with fibroids opt for medical treatment as the first stage before surgery, or as a way to delay surgery for women who are close to menopause, when fibroids shrink naturally. The most common treatment is called GnRH agonists (gonadotropin-releasing hormone), which is a class of hormones that have been shown to help temporarily shrink fibroids by blocking estrogen production that stimulates their growth. Lupron, Synarel, Supprelin and Zoladex are drugs often recommended to treat endometriosis and may also be suggested as a strategy for pre-treatment of fibroids prior to surgery.

GnRH agonists used to be considered a short-term treatment because side effects include menopausal symptoms triggered by estrogen deprivation, such as hot flashes, vaginal dryness, and significant bone loss. Typically, low doses of estrogen and progestin are prescribed with GnRH agonists to lengthen the therapy in a safe manner and tolerable manner.

Menstrual Disorder Treatment: Surgical Techniques

There are some innovative surgical techniques now being considered for fibroid-related bleeding. While these treatments may be effective, only small numbers of women have undergone these procedures and there have been no long-term follow-up studies. Some procedures include the following:

  • Myolysis: this involves delivering electric current via needles to a fibroid at the time of laparoscopy
  • Cryomyolysis: involves using a freezing probe in a similar manner to myolysis
  • Uterine artery embolization (UAE) is a radiological alternative to surgery that involves placing a catheter into an artery in the leg and guiding the catheter via x-rays to the arteries of the uterus. Once the catheter gets there, it is used to deliver agents that block off the blood vessels that supply the fibroids. With the blood supply blocked, the fibroids should rapidly diminish in size. This procedure is relatively new and long-term data is still lacking in terms of complications, future need for hysterectomy and recurrence of fibroids. The recovery time from UAE can be weeks, and the long-term effect of leaving dead tissue behind is still unknown.

Some women with fibroids opt for medical treatment as the first stage before surgery, or as a way to delay surgery for women who are close to menopause, when fibroids shrink naturally. The most common treatment is called GnRH agonists (gonadotropin-releasing hormone), which is a class of hormones that have been shown to help temporarily shrink fibroids by blocking estrogen production that stimulates their growth. Lupron, Synarel, Supprelin and Zoladex are drugs often recommended to treat endometriosis and may also be suggested as a strategy for pre-treatment of fibroids prior to surgery.

GnRH agonists used to be considered a short-term treatment because side effects include menopausal symptoms triggered by estrogen deprivation, such as hot flashes, vaginal dryness, and significant bone loss. Typically, low doses of estrogen and progestin are prescribed with GnRH agonists to lengthen the therapy in a safe manner and tolerable manner.

Menstrual Disorder Treatment: Menstrual Cramps

Treatment Options for Menstrual Cramps

If you are experiencing severe menstrual cramps (called dysmenorrhea) on a regular basis, there are some things your health care professional might suggest you try for relief, including over-the-counter and prescription medications and exercise, among other strategies.

Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) can be purchased without a prescription. If you take your medication at the earliest sign of cramping, you are likely to feel a dramatic improvement, sometimes even complete relief of your symptoms.

Other ways to relieve symptoms include applications of heat on your abdominal area and mild forms of exercise.

Danazol (Danocrine) is a synthetic drug that resembles a male hormone, and is sometimes used to reduce severe menstrual cramps, menorrhagia, fibroids and symptoms of endometriosis. Occasionally, it is used in conjunction with an oral contraceptive. The drug works by suppressing menstruation and estrogen levels. Side effects may include facial hair, deepening of the voice, weight gain, acne, dandruff and elevated cholesterol levels. Pregnant women and those seeking to become pregnant are not advised to take this medication due to potential risk of birth abnormalities.

Menstrual Disorder Treatment: PMS and PMDD

Treating PMS and PMDD

To help manage PMS or PMDD symptoms, try exercise and dietary changes suggested here and ask your health care professional for other options.

Dietary options:

  • cut back on alcohol, caffeine, nicotine, salt and refined sugar, which can make PMS and PMDD symptoms worse
  • increase the amount of calcium in your diet from sources such as low-fat diary products, soy products, dark greens like turnip greens, and calcium fortified orange juice. Increased calcium may help relieve some menstrual cycle symptoms.
  • increase the amount of complex carbohydrates in your diet; these include fruits, vegetables, grains and beans
  • increase the amount of water you drink to help flush out fluids from your body and make you feel more comfortable

Menstrual Disorder Treatment: Supplements

Exercise is another good way to relieve menstrual cycle symptoms. Even taking a 20 to 30 minute walk three times a week can:

  • increase brain chemicals that give you more energy and improve mood
  • decrease stress and anxiety
  • improve deep sleep at night

Some of the medical therapies your health care professional might suggest include:

  • antidepressants such as Paxil, Effexor, Zoloft, and Prozac or Xanax (anti-anxiety) for mood-related symptoms
  • GnRH agonists (Lupron), in combination with estrogen or estrogen-progestin hormone therapy
  • diuretic medications, as prescribed by a health care professional, help rid your body of excess water, water weight gain and bloating. Spironolactone (Aldactone) is the only diuretic that has been shown to be of benefit for reduction of premenstrual fluid-retention
  • Nonsteroidal anti-inflammatory drugs (NSAIDs), which can relieve premenstrual pain. A variety of NSAIDs are available, including over-the-counter ibuprofen products such as Advil and Motrin, or naproxen sodium (Aleve)
  • oral contraceptives to help regulate your menstrual cycle

Nutritional supplements such as zinc, vitamin E and magnesium have not been shown in scientific studies to relieve PMS symptoms. Other remedies, such as oil of primrose and other herbal remedies also are unproven. Discuss these and other strategies with your health care professional before taking any dietary supplement.