Heavy, painful or irregular periods are very common complaints. The cause of these problems is usually either hormonal or physical (polyps, fibroids). There have been exciting new developments in this area recently, with many alternative treatment options now available. These are usually very effective.
One of the causes of heavy periods are fibroids. These are extra balls of muscle tissue located within the womb. They are common, affecting about 20% of women, many of whom have no symptoms. They are nearly always benign, with the risk of cancer being extremely small. As well as causing heavy periods, larger fibroids may cause pelvic discomfort or bowel & urinary symptoms due to direct pressure.
Most women experience some discomfort during their periods, often requiring simple painkillers such as Paracetamol or Ibuprofen. More severe pain may suggest the presence of fibroids, infection or endometriosis. Endometriosis is caused by deposits of glandular tissue around the pelvis, affecting about 6% of women. Endometriosis pain typically gets worse in the week before and during the period. It may cause pain with intercourse, and often periods are heavy or irregular too.
Periods commonly become irregular because of a disturbance of the hormonal cycle. Although the average menstrual cycle is 28 days, it is considered normal for it to last between 25 and 35 days. Recurrent bleeding in between periods (intermenstrual) or after intercourse (post coital) warrants investigation.
Investigations and treatments
Vaginal examination can reveal pelvic swellings and scarring, or some tenderness on movement of the womb. An ultrasound scan is often performed to look for fibroids, polyps or ovarian cysts, and to exclude other causes of heavy or irregular bleeding or pain. Hysteroscopy, the telescopic examination of the inside of the womb, or laparoscopy, the insertion of a telescope into the abdomen, may be recommended to investigate period problems or pelvic pain.
Heavy or painful periods without fibroids or polyps, can be treated with tablets. Those commonly used are tranexamic acid (cyclokapron), mefenamic acid (ponstan), progesterones (norethisterone, provera) or the pill.
The treatment of fibroids will depend on symptoms, age, desire for future pregnancies and the size and location of the fibroids. Most women with small fibroids need no treatment. Fibroids that protrude into the cavity of the womb may be removed during an operation known as hysteroscopic resection. Polyps within the womb can be removed at hysteroscopy too. Larger fibroids may be removed by an open operation known as a myomectomy, especially if future pregnancies are desired. If a hysterectomy is sensible, this can often be performed vaginally, after some treatment to transiently shrink the fibroids. New treatments such as embolization and focused ultrasound are currently being evaluated.
Another very helpful treatment of period problems is called a Mirena (IUS). This is a coil like device, inserted into the womb, which releases progesterone locally. The device is contraceptive, and also very effective in reducing period problems. It can be inserted in outpatients, and will work well for between 3 and 5 years.
The lining of the uterus (womb) can be removed or destroyed to treat heavy periods, leaving the womb behind. This is called endometrial resection or ablation (ie. Novasure). It is a day case operation, and may be an alternative to a hysterectomy. Most patients have lighter periods or no periods at all after these procedures.
If a hysterectomy is thought to be best this can be performed vaginally in most cases. Recovery from a vaginal hysterectomy is generally quicker than for an abdominal operation, with a hospital stay of 2 or 3 nights. Although often regarded as a last resort, women are usually delighted with the benefits after a hysterectomy, and very rarely regret the operation. Contrary to rumour, after a hysterectomy women do not need HRT unless the ovaries are removed for good reason at the same time.