Drugs that affect bleeding mechanisms

These drugs are only taken during bleeding. They include tranexamic acid (brand name Cyklokapron) and ethamsylate (brand name Dicynene). They have been shown to reduce blood loss with some women and can be used at any age.
Side effects can include headache, nausea, dizziness, rashes, vomiting and diarrhoea. Tranexamic acid should not be taken by women with a history of thrombosis. Drugs that stop the body from making prostaglandins
Examples of this kind of drug are aspirin and mefenamic acid (e.g. brand name Ponstan). Studies have shown that these drugs can cut down the blood loss in many women with heavy bleeding. They are taken only during menstruation, which is an advantage for women who don't want to take drugs all the time.

These drugs can be taken by women of all ages but shouldn't be prescribed for women with peptic ulcers. Side effects can include indigestion, diarrhoea, headache, dizziness, skin rashes, peptic ulcers and inflammatory bowel disease if used long term.

Contraceptive pill
The combined contraceptive pill is very effective in controlling heavy bleeding and is useful if you also want this form of contraception. The pill suppresses the menstrual cycle and stops ovulation (egg release).
At one time women over 35 were advised not take the pill but if a woman does not have any risk factors such as smoking or increased blood pressure, doctors now feel women can continue on the pill indefinitely.
Women of any age who are offered the pill should have a medical history taken and examination done before it is prescribed.

Progestogens
Treatment with these hormones is based on the theory that women with unexplained heavy bleeding are not ovulating (releasing an egg) and are thus not producing their own progesterone (the natural progestogen). Without enough progesterone, the lining of the uterus continues to build up until eventually it starts to break down, causing heavy bleeding. But most women with heavy bleeding and regular cycles are ovulating so this theory doesn't seem to stand up.

Progestogens are not as effective as tranexamic acid in reducing blood loss, but nevertheless they do seem to work for many women. Taking progestogen can cause side effects of weight gain, acne, breast tenderness, bloating and breakthrough bleeding, but not all women experience these. A high dose taken for a long time can increase the risk of heart disease especially in women who smoke heavily, are very overweight or have high blood pressure.

Different progestogens have been tried for differing numbers of days in the menstrual cycle. Common progestogens used are norethisterone (brand name Primolut N), medroxyprogesterone (brand name Provera) and dydrogesterone (brand name Duphaston). They may be given for five to 10 days starting somewhere between day 16 and day 25 of the menstrual cycle (counting day 1 as the first day of bleeding).


Mirena
Mirena, or the levonorgestrel intrauterine system, is a contraceptive device which is placed in the uterus like an IUD, and which releases a type of progestogen into the uterus. It has been shown to be more effective than tranexamic acid and TCRE in reducing heavy bleeding, although for the first two or three months it may cause a slightly heavier flow. In most women Mirena reduces the amount of blood lost during a period, and in some women periods stop altogether. It is not licensed as a treatment for heavy bleeding, but is useful if the woman also wants contraception.

Danazol (brand name Danol)
This is a synthetic hormone similar to the male sex hormone testosterone. It is used to treat endometriosis. It is not known exactly how Danazol works but it blocks and actually lowers natural hormone levels in the body and is very effective in cutting down menstrual blood loss.

However, it is a powerful drug and often has unpleasant side effects such as weight gain, muscle cramping, decreased breast size, hot flushes, acne, growth of facial hair, voice changes, depression and mood changes, oily skin and hair, and bloating. Some of these side effects such as voice changes may be irreversible.

If you begin to suffer from distressing side effects, it is better to go back to your doctor rather than waiting until the course is finished. In the doses given, Danazol is not effective as a contraceptive. A woman who needs contraception should not take the contraceptive pill while on Danazol but should use some other form of contraception.

GnRH angonists
These are powerful drugs (e.g. buserelin, goserelin and nafarelin) which are taken by injection or sniffing (intranasally). They act by stopping the ovaries from working, effectively reducing blood loss. Many women stop having periods altogether.

However, because a woman's oestrogen levels are also reduced, menopausal side effects are common. Therefore, GnRH agonists should not be used for more than six months.

Bioflavenoids
An alternative method of treating heavy bleeding which some women may be interested in trying is to take bioflavenoids. These are also known as flavones or hesperidin and used to be called vitamin P. Bioflavenoids found in cereals are called rutin and those found in the pith of citrus fruits are called citrin. They work with vitamin C to strengthen capillaries and other blood vessels.

Bioflavenoids can be taken in the diet where they always accompany vitamin C. The richest natural sources are fresh or tinned citrus fruits (particularly the pith), apricots, cherries, grapes, green peppers, tomatoes, broccoli and buckwheat. They can also be taken as tablets, combined with vitamin C or on their own. There is very little information about the safe doses of bioflavenoid tablets. It is wise to be as cautious about these tablets as about drugs.

Complementary therapies
While your doctor may say that your heavy bleeding results from a hormone imbalance or is unexplained, complementary medical practitioners will have a totally different understanding of your condition. These therapies treat the whole person, not just her symptoms.

Two women going to the same complementary therapist for heavy bleeding may well end up with completely different remedies. This makes it hard for controlled studies to be done comparing the effectiveness of complementary therapies. But the point is that there are a number of therapies to try before deciding that a hysterectomy is the only answer.

If you want to try a complementary therapy it's best to see a qualified practitioner, and to tell both the complementary therapist and your doctor about any other treatments you are taking.
Complementary therapies that offer treatment for heavy bleeding include herbalism, homeopathy, aromatherapy, and traditional Chinese medicine (acupuncture and herbalism).
Pelvic inflammatory disease is treated with antibiotics and bed rest, polyps usually by hysteroscopic removal, cancer of the lining of the uterus by hysterectomy and/or radio or chemotherapy, and hypothyroidism by hormone replacement therapy.

Surgical procedures;

Hysteroscopy
Hysteroscopy is a procedure which allows direct visual examination of the uterus. Although it is often done under a general anaesthetic, many gynecologists now carry out hysteroscopy as an out-patient procedure using a local anaesthetic. The procedure generally takes about ten minutes in the doctor’s office or outpatient section of the hospital, and may involve some discomfort.

Usually the woman lies in the lithotomy position, with knees bent and feet apart. The doctor inserts a narrow telescope-like instrument through the vagina and cervix into the cavity of the uterus (endometrial cavity). Gas or fluid is then passed into the uterine cavity so that the walls of the uterus are held apart, allowing them to be examined. The doctor looks through the protruding end of the hysteroscope into the uterus.This procedure shows whether there are any problems such as fibroids, polyps, or scar tissue in the uterine cavity. Some problems can be treated with operative hysteroscopy which involves placing instruments through the scope.
Hysteroscopy can be done alone or at the same time as dilation and curettage (D & C). Sometimes areas of abnormal tissue or growths can be missed during D & C or endometrial biopsy. Hysteroscopy may detect these missed areas.

D&C (Dilatation & Curettage)
This operation was the standard treatment for heavy bleeding, and is still offered to many women even though more effective and modern treatments are available. D&C is usually done as a day case under general anaesthesia, although it may involve an overnight stay in hospital. The cervix, which is normally tightly shut, is opened slightly to allow a spoonlike instrument into the uterus. The lining of the uterus (endometrium) is scraped away.

After the operation, there is often bleeding for a few days. It is advisable to arrange your day so that you are able to rest after your D&C. If possible, have someone come with you to the hospital and take you home afterwards.

The main purpose of the D&C is to investigate the causes of heavy menstrual bleeding and to screen for endometrial cancer. Endometrial cancer becomes more common in women over 40 but is extremely rare in women under 35. Even for women over 40, many doctors now question the widespread use of D&Cs for investigation when less invasive procedures (such as endometrial aspiration mentioned below) can be used just as effectively.

The first menstrual period after a D&C may be lighter but generally periods become heavier again. Some women do find that a D&C helps but it is hard to know whether this is because of the operation or is a coincidence. General anaesthetic carries some risks and with a D&C there is also a slight risk of perforation of the uterus (a chance of between 1 in a 100 and 1 in a 1000) and possible weakening of the cervix. Even though rare, these must be considered since there is doubt about the value of the D&C in treating heavy bleeding.


Endometrial aspiration

This is a simpler procedure than D&C for getting a sample of the uterine lining. Studies have shown that results are as reliable as from a D&C. Endometrial aspiration can be done in the gynaecologist's office.

A narrow tube is put through the cervix into the uterus and a specimen is sucked out. The procedure often causes cramps which can be painful. The advantage of endometrial aspiration is that it doesn't involve staying in hospital, having general anaesthesia or dilating the woman's cervix.

TCRE (Transcervical Resection of the Endometrium)
TCRE is a procedure in which the lining of the uterus is removed (also called resected or ablated) with a wire loop, roller ball or laser. The choice of instrument depends on the preference of the surgeon. The operation is performed using a hysteroscope, an instrument like a telescope which allows the surgeon to see the inside of the uterus. Special instruments can then be passed along the hysteroscope so that surgical procedures can be carried out.

After TCRE, periods usually become much lighter and in some cases stop altogether, depending on how much of the uterine lining has been removed. The choice is left to the woman to have either a partial resection, where some of the lining is left alone, or a total resection.

The effects of TCRE are long term so it is not a method that women who want any or more children should choose. If you have a TCRE you should still discuss contraception with your doctor as some women may still conceive following TCRE and there may be an increased risk of an ectopic pregnancy (pregnancy occurring outside the uterus, in the tubes leading from the ovary). Some doctors may suggest having a tubal ligation (sterilisation) at the time of the operation.

In the weeks leading up to the surgery, doctors may prescribe drugs to "thin" the lining of the uterus. These are usually GnRH agonists (see the section on these drugs on the previous page). The drugs make it easier to carry out the resection. TCRE can be carried out under general or local anaesthetic. Some doctors prefer to use a mixture of sedation and local anaesthetic. Women may be offered the choice.

Once sedated or asleep, the legs are placed in stirrups. An internal examination will be done and the cervix will be opened slightly, just as it is for a D&C. The hysteroscope will then be inserted in the uterus and a watery solution will be used to distend the uterus so the doctor can see the inside more clearly.

After checking for any possible problems, the lining of the uterus will be systematically removed. TCRE usually involves no incisions, stitches, drains or bladder catheters. Sometimes an intra venous drip may be needed and a balloon catheter may be left inside the uterus for a few hours. This may be necessary if bleeding is heavier than usual. There is a 6-7% incidence of complications during TCRE, such as injury to the cervix, perforation of the uterus, or absorption of the fluid used to distend the uterus, leading to a fluid overload in the body.

If local anaesthetic is used, you will probably be allowed home in a few hours but some women stay in hospital overnight. There will be some vaginal bleeding but this normally becomes light within 24 hours. Some women experience slight lower abdominal discomfort. Rest is recommended immediately after TCRE. Normally, women will be able to resume usual activities, including return to work, within 1 2 weeks. The vaginal bleeding will gradually change (usually within 10 days) to a discharge which will continue for several weeks to a month. Women will be asked to return to the hospital for a six-week post op check. As the cervix is not affected, regular smear tests will still be necessary.

Not all women can have TCRE. Sometimes there may be technical difficulties (such as where the uterus is severely tilted) and sometimes the tissue in the uterus may be found to be diseased and other treatment may be necessary.

Balloon therapy
Balloon therapy is a relatively new procedure to treat heavy periods. Like TCRE it removes the uterine lining, but a balloon filled with hot water is used to achieve this rather than manual removal using a laser, rollerball or wire loop. Because it does not rely so heavily on the skill of the doctor, complications during the procedure are rare. The recovery time after balloon therapy is quicker than after TCRE. The procedure is done under local anaesthetic and you usually go home the same day.

Hysterectomy
Hysterectomy is the most common major operation performed on women. 90,000 hysterectomies are performed every year in England. Half of these are carried out as a treatment for heavy menstrual bleeding.

Ideally, the decision to undergo any major operation is based on a two way discussion involving the doctor's expertise and advice and the woman's feelings and wishes. In the case of hysterectomy as a treatment for heavy bleeding, the surgery is usually 'elective'. That is, the woman is not suffering from an illness for which surgery is necessary to save her life, but is in a situation where she should be free to choose whether or not she wants to have surgery. The decision should be based on how the heavy bleeding is affecting her quality of life, rather than by the fact that she has heavy bleeding.

Although hysterectomy is common, it is still major surgery with all the risks such procedures involve. Some women feel fit two months after the operation, others need a longer time to recover (nine months to a year for many women). Women who have been experiencing severe problems in coping with heavy bleeding find that their quality of life improves dramatically.
Fibroids are the most common known cause of heavy bleeding. Fibroids are noncancerous growths made of bundles of muscle fibres that grow in the muscle wall of the uterus. Those that form just under the lining of the uterus are more likely to cause problems because they increase the surface area that is shed every month during a period. Even small fibroids in this position can increase the amount of blood lost.

You have several choices if you have fibroids: have no treatment, take tablets have a hysterectomy or myomectomy (an operation to remove the fibroid), or have the fibroid embolised (this is where the blood supply to the fibroid is blocked). Your decision will depend on how you feel about your heavy bleeding and how it is affecting you.

When no cause is found:
For more than half of all women with heavy bleeding, no cause is ever found. This is because the complex workings of women's bodies are still not completely understood. Once you have made sure there is nothing medically wrong with you, you may be better able to adapt to your increased menstrual blood loss, and your doctor may also agree that a 'wait and see' policy would be best.

If you are already sure that you cannot cope with your increased blood loss, there are two possible courses of action. You may be referred immediately to a gynaecologist, or your doctor may prescribe a course of tablets before referring you, to see if these help control the bleeding.

If you are referred to a gynaecologist straight away you may be given an appointment for a D&C and prescribed a course of tablets. Some consultants suggest having an endometrial biopsy which can be done under local anaesthetic. An instrument is passed through your cervix and takes tiny samples of tissue from the lining of your uterus. These can be examined to try and find the cause of the bleeding. Some doctors use an hysteroscope, a viewing instrument which can be passed through the cervix into the uterus, to examine the uterine lining, take samples and perform some procedures, such as TCRE (see surgical procedures).

After trying some or all of these, a hysterectomy will probably be considered. A major consideration in your gynaecologist's mind is your age. If you are under 35, and especially if you are still considering childbearing, you are less likely to be offered a hysterectomy. If you are over 40, you are more likely to be offered one. If you are over 45, your gynaecologist may prefer to do nothing because your approaching menopause will eventually cure the problem.