F,40, a mother of two walked into my consultation room with a wobbly gait. Her face looked as white as a sheet. She had to pause frequently to catch some breaths while talking.
“Doc, I have been having heavy periods with clots for a year. But it is manageable as the bleeding would stop after 5 days. But for this month, it is terrible. I have to change the menstrual pad every hour and the bleeding does not seem to stop. I have bled for the past 10 days and I feel very week and giddy now.”
F’s pulses were rapid, weak and thready at 112 /min. Her blood pressure was low at 80/50mmHg. Fresh blood was oozing out from the vagina. Her uterus and ovaries were normal. Ultrasound examination of the pelvis did not reveal any fibroid or ovarian cyst. She was anaemic with a low haemoglobin of 6.7g/dL (normal range 11.5-13.5g/dL). She was admitted to hospital straight away and was transfused with blood. When her condition was stable, a hysteroscopy was performed. This is a procedure in which a thin telescope is inserted through the cervix into the uterus to examine its cavity. The tissue lining the uterus (endometrium) was sampled for microscopic examination. F’s heavy bleeding was due to the shedding of a thickened endometrium from hormonal imbalance.
Many women of reproductive age have heavy menstrual bleeding but a large number do not seek treatment until severe anemia sets in, causing symptoms like breathlessness and giddiness.
Hormonal imbalance is one of the common causes of heavy periods. In a normal menstrual cycle, there is a balance between the hormones secreted by the ovary. These hormones regulate the endometrium, which is shed during menstruation. If hormonal imbalance occurs (which may be due to the ovary not producing and/or releasing the egg), the endometrium grows thicker and finally sheds by way of heavy bleeding.
Other common causes of heavy menses include uterine polyps , fibroid, ovarian cyst, endometriosis and pelvic infection. Medications are usually given first to treat heavy menstrual bleeding. They include hormones, oral contraceptive pills, clot promoters (tranexamic acid) and hormone manipulators (Gonadotropin releasing hormone, GnRH agonists)
Other modes of treatment include:
Insertion of hormonal intrauterine device (IUD) commonly known as Mirena. This is a hormone impregnated IUD which releases a hormone to thin the endometrium and reduces menstrual flow,
Endometrial ablation in which the endometrium is destroyed with heat using hysteroscope or other devices,
Surgery: This includes removal of uterine fibroid(myomectomy), polyp (polypectomy) ovarian cyst (ovarian cystectomy) or the uterus (hysterectomy).
F had been sterilized by tubal ligation previously. She was not in favor of taking hormones. She opted for endometrial ablation using Thermablate. (fig. 1) This is a non-hysteroscopic technique in which a heat shielded catheter is inserted into the uterine cavity. At the tip of the catheter, there is a soft tipped silicone balloon. A heated sterile liquid flow through the catheter and into the balloon which is inflated and conformed to the contour of the uterine cavity (fig. 2). It is less invasive and is done under a short general anesthesia. Patient has a short recovery time and can assume normal activity within a day or two. Mild side effects include cramping, nausea and vomiting, spotting and/or discharge after theprocedure.
F had the procedure done 8 months ago. Her menstrual flow had reduced significantly. Her hemoglobin returned to normal and she was happy with the outcome.