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Treatment options for heavy periods
The aim of this leaflet is to provide women with information about the various treatments that are available to treat heavy, painful and irregular periods. There are many different treatments for heavy periods. You should be aware that all treatments can have side-effects or complications and these are discussed below along with the likelihood of treatment success. I will take into account other symptoms such as pain, cycle irregularity and the future desire for pregnancy when advising you. Some treatments are not suitable for certain women. The list of side-effects and contra-indications is not complete - you should always read the information leaflet that comes with a medication and discuss any worries with me or your GP.
Option 1 - No treatment Many women seek medical help because they are concerned that a recent change in their periods is due to a disease in their womb. After investigation and reassurance, such women may be happy without medical treatment and so avoid side-effects.
Tranexamic acid (Cyclokapron)
This non-hormonal tablet is taken during the period. It works by preventing the breakdown of clots within the blood vessels of the womb. Women can expect a 50% reduction in blood loss. Side-effects include nausea and diarrhoea but are usually not severe. It should not be taken by women with a history of a deep venous thrombosis or pulmonary embolus.
Pros - Effective, non-hormonal, only taken during the period, few side-effects.
Cons - Little effect on pain.
Mefanamic acid (Ponstan)
This non-hormonal tablet is taken during the period. It works by acting against prostaglandins. It reduces blood loss by 20-40 % and is also a very effective pain-killer. Side-effects include diarrhoea and stomach irritation. It should not be taken by women with a history of allergy to aspirin or previous peptic ulcer.
Pros - Effective, non-hormonal, only taken during the period, good painkiller.
Cons - Not quite as effective or as well tolerated as tranexamic acid.
The Mirena coil is similar to a standard contraceptive coil but contains a progesterone hormone called levonorgestrel. The levonorgestrel is released slowly making the lining of the womb thin. This causes the periods to become light or even stop completely. Trials show that 80% of women treated with Mirena are satisfied with the resulting improvement in their periods. The effect on the periods lasts 5 years and sometimes longer. It is only suitable for women with a normal sized or mildly enlarged womb. The Mirena coil is now considered by the National Institute of Health and Clinical Excellence (NICE) to be the treatment of first choice for heavy periods in women with a normal sized or mildly enlarged uterus.
The side-effects / complications of Mirena include:
It is rare to get the effects of progesterone on the rest of the body because the amount absorbed into the blood stream is very low.
- Irregular bleeding (usually light) in the initial 2-3 months.
- Expulsion - this is most common in the first month after insertion.
- Perforation of the womb - this rare complication would require an operation to remove the coil.
- Pelvic infection - This usually only happens if a sexually transmitted infection (Chlamydia) is acquired.
Pros - Very effective, no need to remember to take tablets, no generalised hormonal side-effects, can easily be removed if desired, with rapid return of fertility.
Cons - Initial irregular bleeding, difficult to insert in women who haven't had children, Needs changing every 5 years.
Progestogens (Norethisterone, dydrogesterone and medroxyprogesterone acetate)
Progestogens are man-made versions of the natural hormone Progesterone. They work by delaying the period which will start 2-3 days after the tablets are stopped. They are useful for treating women with frequent periods and are usually given in the second half of the cycle. They may also help women who have very heavy infrequent (every 6 to 12 weeks) periods. They are not effective in women with a regular monthly cycle.
Side-effects are fairly common but are not always that troublesome. They include weight gain, fluid retention, breast discomfort and depression.
Pros - Can regulate the cycle.
Cons - Not effective if the cycle is regular, hormonal side-effects.
Combined Contraceptive Pill
The combined (oestrogen and progesterone) contraceptive pill is probably the most effective and well tolerated non-surgical treatment for heavy and painful periods. Possible side-effects include headaches, migaine, depression, weight gain or loss of libido. It should not be taken by smokers over the age of 35 years or women with a history of a deep venous thrombosis or pulmonary embolus. Its use in older women, especially those with risk factors for heart disease, eg obesity, needs to be balanced against the risks of alternative treatments.
Pros - Very effective and also reduces pain, contraceptive.
Cons - Hormonal, has to taken for 3 weeks out of every 4, not suitable for all women.
This operation involves the permanent destruction of the lining of the womb (known as the "endometrium"). This can be achieved by a number of methods. Balloon ablation involves the insertion of a hot water balloon into the womb for 8 minutes, usually under a general anaesthetic. Endometrial resection uses a combination of cauterising and shaving off the endometrium using special instruments that are inserted through the cervix along with a small telescope ("hysteroscopy"). Small fibroids indenting the cavity of the womb can often be removed at the same time as an endometrial resection.
Women can usually go home on the same day as the operation and can return to work a few days later. These techniques should only be considered by women who have completed their family because of the risk that subsequent pregnancies would suffer complications. They are only suitable for women with a normal sized or mildly enlarged womb. NICE considers endometrial ablation to be preferable to hysterectomy for suitable women.
80% of women are pleased with effect on their periods and about one third of these will not get any periods at all. It is possible to repeat the operation if the heavy periods recur.
Serious complications are very rare but include injury to the bowel if the womb is perforated, severe bleeding requiring hysterectomy, and fluid overload from the fluid used to distend the womb. Minor complications such as an infection of the lining of the womb may occur.
See information leaflet on Endometrial Ablation.
Pros - Good success rate without the need for major surgery.
Cons - Fails in 20% of women. Only for women whose family is complete. Contraception required afterwards if neither partner sterilised.
Hysterectomy means the removal of the womb. The cervix is part of the womb and this is usually removed as well ("total hysterectomy"). If the cervix is not removed, the operation is called a "subtotal hysterectomy". A hysterectomy can be performed through an incision in the abdomen ("Abdominal Hysterectomy"), through the vagina ("Vaginal Hysterectomy"), with keyhole surgery alone ("Laparoscopic Subtotal Hysterectomy") or with a combination of keyhole and vaginal surgery ("Laparoscopically-Assisted Vaginal Hysterectomy"). Depending on your symptoms and age, I may advise removal of your fallopian tubes and ovaries at the same time, but this will be discussed fully with you before the operation. It is usually necessary to stay in hospital for 3-5 days after the operation after an abdominal or vaginal hysterectomy. Women usually go home the day after a laparoscopic subtotal hysterectomy.
It is 100% successful at stopping periods but involves major surgery which may cause complications. Although minor complications are fairly common , they are usually easy to treat and do not result in lasting problems. Rarely, women have serious complications as a result of hysterectomy. These complications are listed below. They are not meant to frighten you but it is important that anyone having major surgery is aware of the range and nature of complications that may occur. Overall, 95% of women who have a hysterectomy are happy that they had the operation. Women are usually able to return to light work after 6-8 weeks, and heavy work after 10-12 weeks.
Minor complications of hysterectomy include wound infection or bruising, urinary infection, chest infection, difficulty passing urine, passing urine too often, painful abdominal wound, vault haematoma (bruising at the site of the womb) - this may occasionally cause prolonged abdominal pain.
Major complications of hysterectomy are not common but include complete wound separation, injury to bladder, ureter (tube from kidney to bladder) or bowel, deep venous thrombosis (clot in a leg vein) and pulmonary embolus (clot in the lung)
Pros - Most effective treatment of heavy periods with 95% satisfaction rate. Keyhole surgery sometimes possible.
Cons - Often a major operation with risk of complications, prolonged recovery time.
Fibroid Embolisation This is a new technique that can be used to shrink fibroids and treat heavy periods that are caused by fibroids. It is not used to treat small fibroids. Treatment involves passing a fine tube up an artery in the groin and injecting a substance that blocks the blood supply to the womb. It is not recommended for women who have not completed their family. The treatment is not without the risk of side-effects or complications. Further information can be found on the NICE and the RCR websites. This treatment is performed by a Radiologist and is not widely available at the present time and I usually refer suitable patients to London or Guildford for treatment.