Throughout history, menstruation has been associated with myth and superstition. Menstrual blood was felt to cure leprosy, warts, birthmarks, gout, worms and epilepsy. It has been used to ward off demons and evil spirits. Menstruating women have been separated from their tribes in order to prevent a bad influence on the crops or the hunt. As recently as 1930, the cause of abnormal menstrual bleeding was felt to be an undue exposure to cold or wet just prior to the beginning of the period.
In modern times we have learned that menstruation is the end of the monthly cycle a woman's body goes through if conception has not occured, allowing the uterine lining to start over again for the next cycle. We have made quantum leaps towards understanding the role menstruation plays in preparing a woman's body for reproduction. And we have learned a great deal about the treatment of many of the problems of abnormal periods. Science has thankfully dispelled the myths and superstitions that surrounded menstruation and sexuality, but the mystery and wonder of these processes stays with us still.
Since the days that I studied the female hormone system in medical school, new research has revealed an astonishingly complex system of hormones and nerve transmitter proteins that interplay to regulate the monthly menstrual cycle. The system is balanced, but in certain situations - such as times of stress, when body weight changes, when taking medications - it is easily upset. Once the balance is upset, bleeding can occur that is outside of the normal pattern. Also, cells that form abnormal growths within the uterine lining - polyps, hyperplasia, cancer- can cause bleeding as they develop. In the first part of this chapter, we will deal with the circumstances and solutions for problems with your periods. The second part of the chapter will deal with painful periods and the new ideas and treatments for this common, bothersome and, sometimes, incapacitating problem.
The onset of menstrual periods occurs between the ages of 9-17 with the average age being 13. Adolescents tend to have periods that are far apart and then establish more regularity over the subsequent few years. Most adult women will have a menstrual cycle, measured from the first day of any bleeding to the next episode of bleeding, about every 21-35 days. Although women expect to bleed every 28 days, only 15% of women actually have cycles that length. Bleeding usually lasts 4-6 days with some women bleeding a few days longer or shorter. Most women lose about 6 teaspoons of blood each month. Interestingly, the number of days between periods changes over time, with periods becoming further apart as women reach their forties.
Abnormal bleeding is said to occur if you have a period more often than every 21 days, less often than every 35 days, or if you have bleeding or spotting in between periods. Very heavy bleeding, saturating a pad or tampon every hour or two for more than a few hours, is also abnormal. There are a number of causes of abnormal bleeding, and the good news is that almost all of them are benign and easily treatable. The most common causes are hormonal changes, ovarian cysts, uterine or cervical polyps, overgrowth of the uterine lining cells (hyperplasia), fibroids, and, rarely, precancer or cancer of the uterus. The following sections will explain each of these problems in detail.
As menopause approaches, most women will experience lighter and less frequent periods. However, the likelihood of bleeding from other causes such as hyperplasia (lining overgrowth), polyps, or precancer or cancer of the uterus increases at this time of your life. Bleeding that is irregular, very heavy (need to change a pad every hour or two) or prolonged (more than seven days) is abnormal and it is important to establish the cause. The best way to accomplish this is with a sampling of the cells from the uterine lining. The diagnostic methods available include hysteroscopy, endometrial biopsy, and D&C. These methods are fully described in this chapter.
This test allows the doctor to look inside the uterus by placing the hysteroscope, a small telescope, through the vagina and into the opening in the cervix. Once inside the uterus, the lining cells can be inspected. Polyps, fibroids, hyperplasia and cancer can all be seen with the hysteroscope. The procedure, called hysteroscopy, can be done in the office in about 5 minutes and usually does not require any anesthesia. The information the doctor can get from this procedure is invaluable. Because many problems can be clearly seen, the diagnosis is often certain. A number of studies have shown that the diagnosis made by hysteroscopy followed by scraping the visualized abnormal area of lining cells is more accurate than when a D&C is performed blindly without the hysteroscope.
The hysteroscope is a telescope that allows us to look inside the cavity of the uterus
A polyp seen inside the uterine cavity
A fibroid seen bulging into the uterine cavity (submucous).
MOLLY'S PERSISTENT BLEEDING
Molly is a 66-year-old woman who had been having bleeding after her menopause. She had already undergone three D&Cs and a varuety of hormonal treatments, yet the bleeding persisted. Her examination was normal, but I suggested that we do a hysteroscopy in the office. This had never been done, and we really needed to see why the bleeding was not going away. She agreed, and we scheduled it for the next day. After using local anesthesia, the hysteroscope was inserted, and it was immediately apparent that a large polyp was inside the uterine cavity. The polyp was loosely attached to the uterine lining by a stalk, so that it flopped back and forth. Without knowing exactly where it was, the previous D&Cs had missed it entirely. After placing a polyp forceps into the uterus in the exact location of the polyp, the polyp was easy to remove. Another inspection of the uterine cavity with the hysteroscope now showed that the polyp was gone. Molly has not had abnormal bleeding again.
Endometrial ablation is an outpatient surgical procedure used to stop or decrease bleeding from the uterus. The traditional method of performing endometrial ablation uses electrical energy passed into the uterus at the end of a telescope in order to burn and destroy the lining of the uterus The uterus is filled with fluid and the doctor is able to look through the telescope and watch to make sure the entire lining is destroyed. This technique is very effective, but does require special training and skill on the part of the doctor. As a result, many doctors never learned how to perform endometrial ablation and do not offer the procedure to their patients as an alternative to hysterectomy.
Newer methods of ablation have recently been developed that should allow most gynecologists to perform the procedure without involved special training. Some of these devices may even be able to be used in a doctor’s office, avoiding anesthesia and the added costs of a hospital. In addition, neither of the new methods uses fluid to hold the uterus open during surgery and thus avoids the extremely rare chance that extra fluid might get absorbed into the bloodstream and cause complications. One of these methods uses an expandable metal device that is inserted into the uterus like an IUD, Once the device is expanded inside the uterus, a gentle suction pulls the uterine lining close to the instrument and an electrical current burns the lining cells. This procedure only takes 90 seconds and the results have been excellent. Another device circulates hot water inside the uterus to burn the lining cells. This device has been specially engineered to keep the water at a low pressure so that it cannot escape through the tubes. If the device senses a leak it automatically shuts off. Because the water circulates freely throughout the entire uterine cavity, the shape of the cavity will not affect the results. As a result, the device is very effective for women with fibroids, enlarged or abnormally shaped uterine cavities. This procedure takes about 10 minutes and results have been comparable to the other methods. Other devices are in development and, hopefully, endometrial ablation will become more available to women as an alternative to hysterectomy for heavy bleeding.
An attachment for the hysteroscope uses heat from an electrical generator to cauterize the uterine lining cells.
To manage heavy bleeding, the small (1/4 inch) rolling metal bar can
be used to cauterize and eliminate the uterine lining cells.
Photograph of an ablation in progress.
An attachment for the hysteroscope can shave out fibroids from within the uterine cavity (hysteroscopic myomectomy).
Photograph of a hysteroscopic myomectomy in progress.
After endometrial ablation, the ovaries continue to make normal amounts of hormone, but without lining cells, bleeding cannot occur. In 50% percent of patients, all the lining cells have been destroyed, and these women never have another menstrual period again. In an additional 40% percent of women, a few lining cells have been left behind, and these women will experience a light flow for a few days each month. For 10% of women, no improvement is noted. Still, 90% of the women who have this procedure are extremely happy not to have to tolerate the severe and debilitating monthly bleeding they had previously had. Women who have had an endometrial ablation are among the most satisfied patients in my practice. After surgery, they are able to return to normal activity and life unencumbered by the fatigue and inconvenience associated with heavy bleeding.
Endometrial ablation may only be performed on women who do not wish to have any, or any more, children. Once the lining cells of the uterus are destroyed by the procedure, there is no place for a developing fetus to attach within the uterus. Despite this, it is best to use some form of contraception after the procedure. If some cells remain following endometrial ablation, there exists the rare possibility of pregnancy. In the few cases where pregnancy has occurred, termination of the pregnancy has been recommended. Doctors have been concerned that without adequate cells lining the inside of the uterus, the placenta would grow abnormally, directly into the muscle wall of the uterus and take hold like the roots of a tree. As a result, the placenta would not be able to separate at the time of delivery, and hemorrhage could occur.
Dysmenorrhea refers to the pain accompanying a period. Most menstruating women have uterine contractions of moderate strength that each last for less than thirty seconds and occur about every 3 to 5 minutes. However, women who experience severe dysmenorrhea have cramps that last up to 90 seconds with only a few seconds of rest in between. And, the strength of the contraction may be up to 5 times greater than normal.
We now know that dysmenorrhea results from the release of a chemical substance, called prostaglandin, from the lining cells of the uterus at the time of the menstrual period. The prostaglandin causes contractions of the muscle wall of the uterus, "menstrual cramps". In fact, if you give prostaglandin to a woman by injection, severe menstrual cramps result. Along the same lines, prostaglandin is now used to help start the contractions of labor in women who, for medical reasons, need to deliver their babies promptly.
Women who have dysmenorrhea have been found to produce more prostaglandin in the lining cells of the uterus than woman who do not have cramps. And, when the increased amount of prostaglandin is released at the time of the period, stronger uterine contractions are the result. As we will discuss, new medications are now available that prevent the formation of prostaglandins in the uterus and thus can prevent or decrease menstrual cramps.
|Order A Gynecologist's
Second Opinion directly from Amazon.com by
or visiting the Amazon.com web site.
Disclaimer: The ideas, procedures and suggestions contained on this web site are not intended as a substitute for consulting with your physician. All matters regarding your health require medical supervision.