Heavy bleeding, while usually not medically serious, can cause major disruption in a woman's life. It can cause embarrassment and result in a decrease in exercise and other beneficial activities. If severe enough, it can also result in anemia.
Dysfunctional Uterine Bleeding (DUB) refers to excessive bleeding that is not related to fibroids, polyps, endometriosis, adenomyosis, pregnancy, cancer or other identifiable causes. It is usually related to hormone imbalance or changes and is more likely to occur during perimenopause when women often do not ovulate regularly. About half of the cases are women between 40 and 50 and 20% are adolescents. Some of the common imbalances are excessive estrogen, lack of progesterone or an imbalance of these hormones.
Hypothalamic dysfunction, pituitary or adrenal hyperplasia (which is usually associated with excessive hair growth or other signs of virilization) or thyroid problems can also cause heavy bleeding. Drugs such as steroids and psychopharmacologic agents can inhibit ovulatory function and result in bleeding problems. But because bleeding can be an indication of cancer, fibroids, endometriosis, polyps or pregnancy, it is important to have it evaluated by your health care provider. An abnormality of the arteries supplying the uterus can also cause bleeding, but this is rare.
Dr. Winifred Cutler has found that for some women, excessive bleeding may be a consequence of having intercourse during menses. Obesity, polycystic ovary syndrome, stress, crash diets, and excessive exercise can all disrupt ovarian function. Those on hormone replacement therapy may experience bleeding problems but it is rarely a cause of heavy bleeding.
Diagnosis
The most important step is to determine what is causing the bleeding. Dilatation and Curettage (D&C) involves scraping the interior of the uterus and may still be used for diagnosis,. However, a procedure which reduces the risk of uterine puncture and is less expensive, is aspiration curettage which removes a thin layer of the endometrium with suction.
While an endometrial biopsy (a sample of the uterine lining is taken to determine if suspicious cells are present) has been standard procedure to check for precancerous conditions, the use of ultrasound which shows the thickness of the uterine lining is becoming more common. Studies reported in both the American Journal of Obstetrics and Gynecology and the Journal of Reproductive Medicine found that ultrasound was an effective screening tool for the presence of uterine abnormalities. It identifies those who need further diagnostic evaluation such as a biopsy if the test is abnormal or inconclusive. This procedure allows a view of the whole uterus. A biopsy may not be representative of the condition of the entire endometrium.
If abnormalities are found further procedures such as Magnetic Resonance Imaging (MRI) which uses a magnet to create images of live tissue, Computerized Axial Tomography (CT or CAT) which takes X-ray pictures of slices of a region, and hysteroscopy which allows the physician to look at the inner walls of the uterus and cervix may be used.
Treatments
One of the key questions in dealing with DUB is recognizing whether you are dealing with life-threatening bleeding (causing severe anemia, or caused by cancer) or lifestyle-threatening bleeding which is the most common cause of hysterectomies in this country. (See issue 3.3 on hysterectomy.) While heavy bleeding can be very disruptive to your daily activities, the safest approach is appropriate diagnosis and therapy beginning with the least invasive procedures.
While DUB is the reason given for 20% of hysterectomies in this country, there are less drastic measures available that may solve the problem. Nonsteroidal anti-inflammatory drugs such as Advil may work for some women. These are to be started one week before menses and continued through the flow.
For perimenopausal women, oral contraceptives or natural hormone therapy may be effective. Cyclic progesterone treatment or hormone replacement therapy are additional options. For more severe cases Danazol or injections of Depo-Provera or Depo-Lupron have been used, but Depo-Provera and Lupron have their own set of problems and many women have complained of horrific side effects. (D&C) may stop the bleeding, but it may return and is seldom used. Endometrial ablation (burning away or vaporizing the uterine lining) with laser or electrocautery is also often an effective alternative to hysterectomy.
A recent report in the New England Journal of Medicine reported that after five years 79% to 87% of women were happy with this surgery and it controlled bleeding in at least 85% of the women. During five years of follow up, only 9% underwent hysterectomy and 10% had another ablation. One possible down side to this treatment is future endometrial cancers may be harder to diagnose due to scar tissue in the uterus.
A procedure which uses a catheter with a balloon attached is being studied. The catheter is inserted into the uterus. The balloon is inflated with sterile solution so it fills the uterus and takes its shape. Then a heating element raises the temperature to 189 degrees. This destroys the endometrial lining. This is still an experimental procedure but new techniques will be evolving.
Self-Help
If you have consulted with your health care provider, you are dealing with heavy bleeding and no cause has been identified, here are some things you can do for yourself.
Diet: If you are losing a lot of blood, you want to protect yourself from anemia by getting extra iron. Liver is a good animal source. A non-animal source is legumes, but you should take vitamin C (75mg.) with it because it aids absorption. Seeds, nuts, blackstrap molasses, some fruits such as raisins, dates, and prunes and some vegetables such as beets, corn, spinach, sweet potato, and dandelion greens, are also good. Fresh, dark green, leafy vegetables are a good source of Vitamins K and C and iron. Deficiencies in these may contribute to heavy bleeding.
Many of these vitamins and herbs can be found on the Recommendations page.
Herbs: Lady's mantel, vitex, wild yam root, uva ursi, raspberry leaves, garden sage, black haw bark, golden seal, yellow dock, turmeric, silymarin and pau d'arco.
Bioflavonoids: Citrus fruit inner peel, buckwheat, elder, hawthorn, horsetail, shepherd's purse.
Essential Fatty Acids: Oils: flax seed, borage seed, black currant, and evening primrose.
Homeopathy: Lachesis, sepia, belladonna, ipecacuanha, secale, sabina, china, crocus sativa, natrum mur, sulfur.
Supplements: Zinc, Copper, Iodine, Vitamin B6 Warning: Large doses of vitamin C may thin the blood and increase bleeding.
Acupressure, yoga: Some women find specific yoga positions or acupressure points helpful.
The belief is that these approaches balance the body and stabilize energy flow, allowing the body to heal. See Heavy Menstrual Flow & Anemia by Dr. Susan Lark for further information.
For some women hysterectomy is the only solution. However, this surgery is too often used for problems that are not life-threatening. Because it is so common, we may not recognize its seriousness and too many women are not told of the possible side effects such as reduced sex drive, urinary problems, constipation, or back pain. If you consider surgery, be sure you are fully informed.
Related articles: Abnormal Pap Smears, Colposcopy, Cryosurgery
And Other Treatments
