MiddletownJournal.com

After a diagnosis with your health care profession, treatments for menstrual disorders may range from taking over-the-counter medication for relief of PMS to considering a hysterectomy to end abnormal uterine bleeding.

Abnormal Uterine Bleeding

Medication and surgery are used to treat AUB. Typically, less invasive therapies should be considered first. Treatment choices depend on your age, your desire to preserve fertility and the cause of the bleeding (dysfunctional or structural). Other treatments may reduce your menstrual bleeding to a light to normal flow.

Medication

Medication therapy is often successful and a good option if you want to preserve your fertility or avoid surgery. The benefits last only as long as the medication is taken, so if you choose this route, you should know that medical treatment is a long-term commitment.

Low-dose birth control pills, progestins and nonsteroidal anti-inflammatory drugs (NSAIDs) may help control bleeding caused by hormonal imbalances. If your periods have stopped, oral contraceptives (OCs) and contraceptive patches are almost 100 percent effective in restoring regular bleeding. Both can also help reduce menstrual flow, improve and control menstrual patterns and relieve pelvic pain during menstruation.

They are considered for PMS treatment if your symptoms are mostly physical, but may not be effective if your primary symptom is mood changes. However, a newer brand of oral contraceptive containing a form of progesterone called drospirenone may reduce some mood-related symptoms such as anxiety, irritability, tearfulness and tension.

Birth control pills may not be an appropriate treatment choice if you smoke, have a history of pulmonary embolism (blood clots in your lungs) or have bothersome side effects from this medication. The risk of these side effects is even higher if you use the birth control patch or vaginal ring, because they have higher levels of estrogen.

Progestins, either oral or injectable, are also used to manage heavy bleeding, particularly that resulting from a lack of ovulation. Although they don't work as well as estrogen, they are effective for long-term management.

The levonorgestrel IUD (Mirena) may also help decrease heavy bleeding for some women by slowly releasing progestin into the uterus for up to five years. Studies find that it may reduce menstrual blood loss as much as 97 percent after one year.

Nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce menstrual bleeding by up to 20 to 50 percent. These medications include ibuprofen, naproxen and mefenamic acid. Common side effects include stomach upset and gas.

Surgery

Except for hysterectomy, surgical options for heavy bleeding preserve the uterus, destroying just the uterine lining. However, most of these procedures result in the loss of fertility, ending your ability to have children.

There are other important considerations for each of these treatment options. Risks common to all surgical options include infection, hemorrhage and other complications.

• Dilation and curettage (D&C). During a D&C, your uterine lining is scraped away. No viewing mechanism is used, so the procedure is done "blindly." Many health care professionals no longer recommend a D&C because it's simply not effective. However, it does provide good tissue samples that can be evaluated for any abnormalities. It is performed on an outpatient basis under local anesthesia.

• Endometrial ablation. These procedures are recommended only for women who have completed their families, as they destroy the uterine lining and therefore, fertility. However, following treatment, you must use contraception. Although thermal ablation destroys the uterine lining, there is a small chance that pregnancy could occur, which could be dangerous to both mother and fetus.

The main types of ablation are:

• Hysteroscopic endometrial ablation or endometrial resection (EMR). During hysteroscopic endometrial ablation, the uterine lining is viewed through a hysteroscope and cauterized with an electrosurgical tip called a "rollerball" or with a laser. It's considered outpatient surgery and normally takes about 20 to 40 minutes. It is performed under epidural or general anesthesia and it should take one to two days to recover, in most cases.

  EMR is also a hysteroscopic technique. However, in this procedure the uterine lining and a quarter-inch of its underlying muscle are removed.

  Hysteroscopic procedures (rollerball and EMR) are acquired skills that not every physician possesses. Ask yours about past experience in this procedure before agreeing to it. Both procedures also require filling your uterus with fluid so its contours can be visualized on a monitor and so it remains open during the procedure. While viewing your uterus, the physician moves the rollerball (which resembles the type of tool you might use to smooth wallpaper) or wire-loop electrode, which delivers an electrical current, from top to bottom of the uterus until the entire surface of the uterus has been cauterized or removed

  Risks associated with this procedure include uterine perforation and fluid overload. Because the fluid pumped into your uterus is kept under pressure during the procedure, there is a very slight risk that fluid may escape into the uterine blood vessels, upsetting the concentration of electrolytes, such as sodium, in your blood stream. This imbalance may be life threatening. However, the risk of fluid overload is very rare in the hands of an experienced physician and with the new fluid monitoring equipment available.

  Forty percent of women can expect their periods to stop after hysteroscopic endometrial ablation (rollerball), and about 50 percent after EMR. About 40 percent will experience very light periods and only 10 percent will not be satisfied with the results of these treatments.

• Hot water ablation. This method of ablation uses a computer-controlled device with a hot saline solution to destroy specific tissue inside the uterus. A computer monitors the uterus to make no fluid leaks through uterine walls or tubes. It is performed under local anesthesia. The surgeon inserts a hysteroscope and tubing through the vagina into the uterus. The heater canister, which is located outside the body, heats saline fluid (salt water) to a temperature of 194 degrees F (90 degrees C). With the aid of the pump and valves, the heated fluid is circulated through the HTA system and uterus for 10 minutes. The exposure to the heated fluid destroys the endometrium.

• Uterine cryoblation therapy. This therapy system uses freezing to destroy the lining of the uterus. It involves a slender probe attached to a cooling unit. After receiving local anesthesia, the probe is inserted through the cervix into the uterus. The tip of the probe is brought to a very low temperature (-20 degrees C; -4 degrees F) to freeze and eliminate the uterine lining.

• Electrical energy ablation. This system works by ablating, or destroying, the lining of the uterus using electrical energy. The procedure is performed with a handheld catheter that delivers radio frequency energy to the uterine lining for about 90 seconds, significantly less time than for other endometrial ablation treatments.

• Uterine balloon therapy. During this procedure, a soft, flexible balloon attached to a thin probe is inserted into your vagina through the cervix and placed in your uterus. The balloon is inflated with sterile hot fluid and expands to fit the contours of your uterus. Then the fluid is heated to 87 degrees Celsius. This treatment lasts for eight minutes and thermally destroys your uterine lining. Afterwards, the fluid is withdrawn, the balloon deflates, and the device is removed from your uterus through your cervix and vagina. This is an out patient procedure usually performed under general anesthesia.

  With this procedure, no visualization is necessary, the instrument is smaller, and it requires no special surgical skill. The major drawbacks of uterine balloon therapy are that it cannot be used if you have uterine polyps, fibroids, or abnormally shaped uteri (those that are larger than normal, have an abnormal shape, or contain fibroids or polyps) and appears to be less effective than hysteroscopic techniques in experienced hands.

  About 13 percent of women treated with thermal balloon stop having periods.

• Microwave ablation. Performed under local anesthesia, this procedure uses microwave technology to destroy the uterine lining. A long, slender tube is inserted into the uterus to deliver the microwaves. The painless treatment lasts one to four minutes.

• Hysterectomy. This is one of the most common surgical procedures performed to end heavy bleeding. It is the only treatment that completely guarantees bleeding will stop. But it is also a radical surgery that removes your uterus.

  Several factors make elective hysterectomy a serious consideration: It is major surgery and includes all the risks associated with any surgical procedure. A lengthy recovery period, often four to six weeks, may be necessary for some women. Fatigue associated with the procedure can last much longer.

  Several types of hysterectomy are available. For more on this surgical procedure, see the hysterectomy topic elsewhere on this Web site.

Menstrual cramps

If you are experiencing severe menstrual cramps (called dysmenorrhea) on a regular basis, your health care professional might suggest you try over-the-counter and prescription medications and exercise, among other strategies, for relief.

Medications such as non-steroidal anti-inflammatories (NSAIDs), like ibuprofen and naproxen, can be purchased without a prescription. Treatment works best if started hours before the onset of cramping. If you wait until you have pain, it doesn't work as well. This will also help reduce heavy bleeding.

Other ways to relieve symptoms include putting heat on your abdominal area and mild exercise.

PMS and PMDD

To help manage PMS symptoms, try exercise and dietary changes suggested here and ask your health care professional for other options. If you suffer from PMDD, however, don't try to treat on your own; make sure you talk to your health care professional.

Dietary options for PMS include:

• cutting back on alcohol, caffeine, nicotine, salt and refined sugar, which can make PMS and PMDD symptoms worse
• increasing the amount of calcium in your diet from sources such as low-fat dairy products, soy products, dark greens such as turnip greens and calcium fortified orange juice. Increased calcium may help relieve some menstrual cycle symptoms.
• increasing the amount of complex carbohydrates in your diet; these include fruits, vegetables, grains and beans
• increasing the amount of water you drink to help flush out fluids from your body and make you feel more comfortable

Exercise is another good way to relieve menstrual cycle symptoms. Even taking a 20- to 30-minute walk three times a week can:

• increase brain chemicals that give you more energy and improve mood
• decrease stress and anxiety
• improve deep sleep at night

Other medical therapies your health care professional might suggest include:

• Antidepressants such as Paxil (paroxetine ), Effexor (venlafaxine), Zoloft (sertraline) and Prozac (fluoxetine)
• Anti-anxiety medication such as Xanax (alprazolam)
• GnRH agonists (Lupron), in combination with estrogen or estrogen-progestin hormone therapy for short term (less than six months) treatment. This treatment has numerous side effects, however, including hot flashes and vaginal dryness.
• Diuretic medications, such as Aldactone (spironolactone) to help with water weight gain and bloating.

Nutritional supplements such as zinc, vitamin E and magnesium have not been shown in scientific studies to relieve PMS symptoms. Other remedies, such as oil of primrose and other herbal remedies also are unproven. Discuss these and other strategies with your health care professional before taking any dietary supplement.