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A taboo topic: heavy menstrual bleeding…Do you have heavy menstrual bleeding? There are lots of ways to fix this.  The most effective method is to remove the uterus (a hysterectomy) but this method comes with surgical risks and (of course) infertility.

What is considered heavy menstrual bleeding?  By textbook, it is more than 80 milliliters of menstrual blood loss per cycle.  This affects nearly 20% of menstruating women.

What are all the options for decreasing menstrual blood loss?

• Hysterectomy
• endometrial ablation
• levonorgestrel-releasing intrauterine system (IUD), or
• daily birth control pills.

There was a study with over 1200 women who received various of the above treatment options and the results showed that patients who chose surgery (including both hysterectomy and endometrial ablation) had greater satisfaction at 6 months.  At 2 years, the higher level of satisfaction was with those with endometrial ablation. But, by five years the satisfaction with both surgical groups was the same to those who took oral birth control pills. This five-year finding is confounded as more than 50% of the oral medication group had changed their therapy within the five years and had a surgical intervention to decrease bleeding.

So, what do the guidelines tell us?

• The National Institute for Health and Care Excellence states that “pharmaceutical treatment should be considered where no structural or histological (cell-type) abnormality is present, or for fibroids less than 3 cm in diameter which cause no distortion of the uterine cavity.”
• Alternately the Americal College of Obstetricians and Gynecologists suggests that medical management be done first and then surgical options (ablation or hysterectomy) be done if medical management is not effective or contraindicated.
• My job as a family physician is to inform the patient of all her options and to let her know that if conservative measures (oral birth control pills or levonorgestrel IUD) fail, then a gynecologist can help them further with a possible endometrial ablation or hysterectomy.

Want more information?  www.cochrane.org/CD003855.