Heavy Menstral Bleeding

Dealing with fibroids and uterine polyps

QUESTION: I am a 53-year-old woman who has had fibroids for some time. Recently, I have had heavy menstrual bleeding. An ultrasound showed polyps. My doctor suggested treatment choices, including a new procedure that involves freezing the fibroids and polyps. I'm not sure what to do.

ANSWER: As you probably know, you're almost certainly in perimenopause, the four to eight years leading up to menopause (the complete cessation of menstruation). Each woman follows a different path to menopause, but it's very common for the menstrual cycle to be irregular and the amount of blood flow to vary.

Although perimenopause may contribute to your heavy bleeding, your fibroids and uterine polyps may also be responsible. Fibroids are growths of muscle and fibrous tissue in the wall of the uterus. They often develop in women between the ages of 35 and 50. They can make menstrual bleeding heavy and full of clots, before and during perimenopause.

Uterine polyps, on the other hand, are overgrowths of the endometrial tissue that lines the uterus. Fibroids and uterine polyps can be cancerous, but the chance of that is less than 1 in 1,000 for fibroids and about 1 in 100 for uterine polyps. Both are benign growths and, unlike cancerous tumors, they cannot spread to other parts of the body. In fact, neither problem increases a woman's risk for developing uterine cancer.

The blood loss from heavy menstrual bleeding can make women anemic. So you should have a blood test that measures your level of red blood cells, especially if you are feeling run down. Even though the chances of endometrial cancer are low, an endometrial biopsy should be done to rule out cancer. This is usually a quick office procedure that involves removing a very small piece of endometrial tissue.

Beyond these initial, precautionary steps, the question of how aggressively to treat heavy bleeding during perimenopause comes down to how much it's interfering with a woman's quality of life. Unless it is causing anemia, the bleeding itself is not harmful. And it rarely indicates a serious underlying problem.

So let's go through some of the choices. (There are many, so this isn't an exhaustive list by any means.)

• You could defer active treatment and just have your gynecologist continue to monitor you. You're not that far away from menopause, and any bleeding should stop once you are no longer having periods. The fibroids will shrink once you are menopausal.

Acute heavy menstrual bleeding « Cambridge Medicine

Blog Post  by Malcolm G. Munro MD, FACOG, FRCS(c), Professor, Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Director of Gynecologic Services, Kaiser Permanante, Los Angeles Medical Center, Los Angeles, CA, USA

Recently a young healthy woman presented with acute heavy menstrual bleeding (HMB) and was placed on a multidose combination estrogen-progestin oral contraceptive (COC) regimen. As the bleeding stopped she developed central neurological symptoms and findings and was diagnosed with internal jugular venous thrombosis that resulted in profound neurological sequellae. Investigation identified the presence of a previously undiagnosed case of von Leiden factor deficiency. This case provides a suitable backdrop for discussion about acute heavy uterine bleeding, the role for medical therapy, and the potential consequences of high dose estrogenic interventions.

The entity of acute HMB has only recently been defined as heavy uterine flow not associated with pregnancy that is of sufficient volume to require urgent or emergent medical intervention.  Although research evaluating the causes of this recently defined entity is necessary, it is likely that ovulatory disorders (AUB-O) are the most common cause. However, coagulopathies may also contribute (AUB-C), and, particularly in adolescents with von Willebrand disease, may augment the heavy bleeding associated with perimeharcheal anovulation (AUB-C, -O). Arteriovenous malformations are yet another but admittedly rare entity that can also cause acute HMB.

The management of acute AUB/HMB frequently requires utilization of urgent care, emergency, and/or operating room resources to control the bleeding. Fortunately, there exist a number of nonsurgical approaches that may control the acute problem without the need for operative intervention that include administration of gonadal steroids, and intrauterine tamponade.

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Heavy Menstrual Bleeding

A gynecologist's second opinion, the questions and answers you need to take charge of your health