Medical investigations and treatment for irregular and heavy periods

Contents

• How are irregular or heavy periods investigated medically?
• What are the latest treatment options for irregular or heavy periods?
• Treatment for irregular or heavy periods caused by a hormone imbalance
• Treatment for Irregular or Heavy Periods when the cause is not obvious
• Surgical options for the treatment of irregular or heavy periods

How are irregular or heavy periods investigated medically?

When a woman with heavy and/or irregular periods sees a doctor the first step will be the taking of a detailed medical history. Important aspects in the history are age, the duration of the problem, the length of the cycles and duration of bleeding, whether there are associated symptoms such as pain, whether contraceptives or precautions are used to prevent pregnancy, the history of smear tests and the possibility of pregnancy.  Some women may feel lumps in the lower part of their abdomen or experience frequent urination due to fibroids. A history of other medical problems such as any bleeding/clotting problems, history of easy bruising, known hormonal conditions and any medication used would also be important.

Following the history taking an examination will usually be carried out. This examination will generally look for signs of systemic or hormonal conditions such as obesity, excessive hair growth and acne. Examination of the abdomen will check for the presence of lumps or tenderness in the lower part of the abdomen. Pelvic examination assesses the neck of the womb, the womb and the ovaries. Polyps on the neck of the womb may be seen or an enlarged womb due to fibroids may be felt during this examination. If the smear test is due, or if there are symptoms such as bleeding after sex or bleeding in between periods, a smear test may be taken.  Occasionally a biopsy from the lining of the womb bay be obtained during this examination using a fine, ‘straw-like’ tube without much discomfort.

If the symptoms of irregular bleeding have occurred relatively recently a pregnancy test may need to be carried out.  It is quite common these days to also carry out a pelvic ultrasound scan to assess the womb, ovaries and the other pelvic structures.  Internal (transvaginal) ultrasound examination usually provides better views of the pelvic organs than transabdominal scans.  Fibroids, polyps, adenomyosis, and thickened lining of the womb can usually be diagnosed with ultrasound scans. Occasionally MRI or CT scans may be carried out to obtain further information.

When an ultrasound scan shows a condition inside the cavity of the womb, when there is uncertainty about the diagnosis or when there is a concern about cancer or pre-cancer of the womb, an endoscopic examination of the inside of the womb (hysteroscopy) may be carried out.  A diagnostic hysteroscopy or to remove minor problems such as small polyps or fibroids may be carried out in the outpatients unit without a general anaesthetic.  However, when a woman chooses to be asleep during the procedure or if there are larger growths that require removal a general anaesthetic would be more appropriate. 

What are the latest treatment options for irregular or heavy periods?

If the initial medical investigations reveal a clear explanation for the heavy periods then further medical procedures will focus on the treatment of that condition. For example, if fibroids are inside, or protruding into, the cavity of the womb (submucosal) or polyps are found, these can usually be removed using an endoscope. This is a medical device that consists of a thin, flexible tube containing a camera that is linked to a screen and enables doctors to examine the inside of the body. This is usually a simple procedure which may be carried out as a day procedure or even in the outpatients unit and tends to resolve the bleeding problem very effectively.  

Treatment for irregular or heavy periods caused by a hormone imbalance

If there is a hormonal imbalance such as polycystic ovary syndrome the subsequent treatment would usually include weight loss if the woman is overweight or obese and the use of hormonal medication. If the woman is not trying to get pregnant and has no risk factors or objections to the use of the contraceptive pill, this is an option that can effectively regulate the periods and that tends to make them lighter as well. For premenopausal women with irregular and/or heavy periods due to a hormonal imbalance, the use of the progestogen hormone can effectively regulate the cycles and this may prevent excessive blood loss.

Treatment for irregular or heavy periods when the cause is not obvious

In the absence of an obvious explanation for the heavy/irregular periods an effective form of treatment is the Mirena Intrauterine System (IUS).  This is a contraceptive device which contains the progestogen hormone.  This hormone is released locally and it makes the lining of the womb thinner. As a result, blood loss becomes lighter in most women and in a small proportion there is no significant bleeding at all. As the levels of the progestogen hormone with Mirena IUs are very low, hormonal side effects such as bloatedness, breast tenderness or weight gain tend to be rare or very mild. Mirena is also an effective contraceptive and would be ideal for women who do not want to get pregnant. It is effective for five years but needs to be replaced after that. Mirena can also be used for women who have adenomyosis or uterine fibroids when the cavity of the uterus is not very large or distorted.

Similarly, the combined oral contraceptive pill may also be used to treat heavy periods in the absence of an obvious explanation. The pill is known to cause light periods, as explained above. Depo Provera injections, which are given as three-monthly injections, and hormonal implants such as Implanon, may stop periods and be beneficial treatment options for some women who have heavy periods and who are in need of an effective contraceptive as well.

Other forms of medical treatment for heavy but regular periods is Tranexamic acid and Mefenamic acid tablets.  These do not contain any hormones and achieve a modest degree of reduction in blood loss.  The main side effects are related to stomach irritation such as indigestion or diarrhoea.  They are taken only at the time of periods and do not need to be taken at other times, unlike hormonal treatment options.

Surgical options for the treatment of irregular or heavy periods

For women who have not benefited from the above medical treatment options or when the medical treatment options are not acceptable to them, surgical treatment options may be considered. In addition to the endoscopic removal of polyps or fibroids some women may choose to have the lining of the womb removed or burnt away (endometrial ablation). The removal of the lining of the womb (endometrial resection) is an endoscopic procedure and is usually carried out as a day procedure.  There are a number ways of burning away the lining of the womb but they all use a form of energy such as heat, microwave, radiofrequency or laser. The majority of women after these procedures have either light periods or no periods. They may be carried out either as outpatient or day procedures.

For women who have large or multiple fibroids, removal of fibroids (myomectomy) may be an effective treatment.  As explained above, fibroids inside the cavity of the womb (submucosal fibroids) may be removed endoscopically through the next of the womb (hysteroscopic myomectomy or hysteroscopic resection of fibroids).  Other forms of fibroids require removal through the abdomen.  When the fibroids are not too many or too large they may be removed by key-hole (laparoscopic) surgery, but when this is not possible their removal is carried out through an incision, usually in the bikini line (open myomectomy, laparotomy or abdominal myomectomy).

Other alternatives for uterine fibroids include uterine artery embolisation (when the blood supply to the fibroids is blocked) or high frequency ultrasound treatment.  These cause some degree of shrinkage of the fibroids and may help with the bleeding symptoms as well.

When other treatment options fail and when there is no longer a need or desire to preserve the uterus a hysterectomy may be considered. Hysterectomy may also be recommended when there is pre-cancer of the next of the womb (endometrial hyperplasia with atypia, see above) and is the required treatment for cancer of the womb. In most circumstances hysterectomy may be carried out as key-hole surgery (laparoscopic hysterectomy), unless the uterus is extremely enlarged. For women who have not gone through the menopause the removal of the ovaries is not required. Some women may choose to have a subtotal hysterectomy when the next of the womb is preserved. This is suitable for women who have never had any smear abnormalities and it can be carried out as key-hole (laparoscopic) surgery as well.

For further information on the author of this article, Consultant Gynaecologist, Mr Ertan Saridogan, please click here.