Female Reproductive and Sexual Health

The commonest problems that any gynaecologist will have to deal with in his/her career will be to do with menstruation. Menstrual problems range from unexplained absent periods (amenorrhoea) through irregular periods, frequent periods, erratic infrequent periods to heavy and or prolonged periods. Squeezed somewhere in between is the problem of inter-menstrual bleeding. Not infrequently, a woman will have a combination of any number of the described menstrual problems. There is no uniform explanation for menstrual problems and a proper work-up to identify the underlying cause is necessary in order to offer the appropriate solution.

Heavy Menstrual Bleeding (Menorrhagia)

The commonest menstrual problem is heavy periods or excessive menstrual loss. The old medical term for Heavy Menstrual Bleeding (HMB) that remains cyclical and regular is menorrhagia.

Heavy Menstrual Bleeding (HMB) affects roughly 1 in 5 women of child-bearing age. In fact, some studies put the figure at around 1 in 3 (33%). It is therefore quite common. Prevalence in any society is heavily influenced by the use of hormonal contraception such as the combined pill, injectable contraceptives (Depo-Provera) and the Mirena intrauterine contraceptive device. These contraceptive measures tend to have a major influence on menstruation with the pill producing regular, usually normal or light ‘periods’ and the other mentioned contraceptive methods tend to stop periods altogether during the duration of use. In some societies, availability and uptake of any form of hormonal contraception is patchy at best and here, the problem of heavy periods would be expected to be comparatively more prevalent.

Many women take heavy periods as something that happens, that cannot be influenced and where one has simply got to get on with it. That is, of course, not the case. Heavy periods are a common problem but one that is relatively easy to manage effectively. There are many options and we will come to these in this chapter in due course.

HMB: Causes and risk factors

In many cases of heavy periods, no obvious underlying cause can be identified. However, for some patients there are identifiable risk factors, the management of which can help alleviate the problem.

•Age: Heavy periods affect women of all ages, from the early teens soon after menarche to women in the peri-menopause, in their late 40s and early 50s. However, it is the case that this problem is more prevalent in the later years, typically from the mid-30s onwards. When a woman starts experiencing heavy periods at that time of her life, the problem tends to get worse with passing time. Spontaneous resolution is rare. A medical intervention is often necessary. Age is very important because it does heavily influence the choice of treatment options.

•Blood disorders: Studies show that anything up to a quarter of women with severe menorrhagia will have an underlying blood disorder. The commonest is a condition called von Willebrand’s disease (vWD). This is a condition where there is a deficiency of a blood protein called von Willebrand factor. This protein is essential for effective blood clotting and its deficiency means the person is prone to excessive bleeding. People with this condition may otherwise present with frequent unprovoked nosebleeds and/or easy bruising. In other cases, heavy menstrual loss is the only clinical feature. A blood test will usually clinch the diagnosis. The name comes from the Finnish doctor who first described the condition in the early 20th century. Because this condition is not rare, it is important for a doctor to try to rule it out in a woman presenting with heavy periods especially in the absence of any other possible underlying cause.

Haemophilia is a condition where Clotting Factor VIII (Haemophilia A) or Factor IX (Haemophilia B) is deficient. Haemophiliacs will therefore have bleeding tendencies and, for a woman sufferer, heavy periods will be a prominent feature of the condition. However, because of the nature of its inheritance, haemophilia is overwhelmingly a male condition. Women sufferers are quite uncommon.

•Fibroids: Fibroids or uterine myomas as they are medically known are very common benign tumours, usually presenting in women in their 30s onwards. However, they can be seen in women who are much younger than that. Fibroids tend to grow slowly over several years but, occasionally, fairly rapid growth has been observed in some women. In most cases, fibroids do not cause any problems at all and most women would remain oblivious of their presence until discovered incidentally during routine imaging investigations for other reasons such as pregnancy. An ultrasound scan of the pelvis will easily identify a fibroid, its exact location in the uterus and its size. Fibroids can be found jutting into the uterine cavity. These are known as sub-mucosal fibroids. They can also grow within the wall of the uterus. Those are called intra-mural. The third type is sub-serosal and those are the fibroids that grow on the outer wall of the uterus projecting into the pelvic or abdominal cavity and away from the uterus itself. Some women will have several fibroids, encompassing all three types. Location of the fibroid is important. Fibroids that project into the uterine cavity could cause or worsen heavy periods. Likewise, large or multiple intra-mural fibroids have been associated with heavy periods. However, fibroids that grow from the outer wall of the uterus, projecting outwards, are not usually associated with heavy periods. It is important therefore to be careful not to rush to a judgement of identifying the cause of a woman’s menorrhagia simply on the basis of seeing a fibroid on a pelvic scan. Quite often it is not to blame.

Options for HMB treatment: Medication

It is important to reiterate the fact that in many patients there will not be any identifiable underlying cause or predisposing factor for the Heavy Menstrual Bleeding (HMB). Treatment will therefore be generic and tailored to suit her circumstances. What may be offered to a 20 year old college student yet to start a family may differ significantly to a 44 year old mother of teenage children who has long completed her family and is probably already sterilised.

•NSAIDs: When we refer to medical treatment we mean using medication to the exclusion of any form of surgery. There are a number of options that fall in this category. One of those is Non-Steroidal Anti-Inflammatory Drugs or NSAIDs. The logic behind deploying NSAIDs for heavy periods is because of their anti-prostaglandin properties. It is a recognised fact that, in menorrhagia, there is often higher than normal levels of prostaglandins that promote blood vessel dilatation thereby increasing blood loss.

By using medication with anti-prostaglandin activity, this effect is curtailed. Experience shows that, for some women, this medication produces sufficient reduction in menstrual flow thereby solving the problem. However, it is also true that NSAIDs do not work for everybody. Some women barely see any reduction. Moreover, for it to be effective, the medication has got to be used with every period. There is no residual benefit for subsequent periods. The timing is also important. The tablets need to be taken from the time of onset of the period. A delay of even a few hours would normally render the treatment ineffective. The types of NSAIDs that are used for this condition are Mefenamic Acid (brand names Ponstan® and Ponstel®) and Naproxen (brand names Naprosyl®, Feminax Ultra®, Aleve® and many others). Many of these brands are available in many countries without a prescription.

NSAIDs used for heavy periods may be a preferred option for women who, apart from heavy loss, suffer from painful periods as well. NSAIDS can be effective in dealing with the pain. These drugs will also be ideal for a woman suffering from heavy periods but who is actively trying to conceive. Other treatment options discussed below, which, by and large, are more effective; are not compatible with a concomitant quest for pregnancy.

•Tranexamic acid: This medication works by enhancing the natural clot-formation mechanism thereby helping to stem the heavy bleeding. In many cases of heavy periods, the problem has been identified to be a rapid breakdown of the tiny clots that are formed to plug the broken down blood vessels in the womb cavity. Those clots are the natural mechanism through which menstrual bleeding is limited.

Drugs like Tranexamic acid limit the excessive breakdown of those clots therefore aiding the natural mechanism. Such drugs are called ‘anti-fibrinolytic agents’. Tranexamic acid is taken during the period itself starting at the onset. It should not be taken by women with a history of deep vein thrombosis (DVT). Women with chronic renal (kidney) disease also ought to exercise caution mainly by reducing the dose. The standard dose is 1gram taken four times a day. Tranexamic acid can be safely and effectively combined with NSAIDs discussed above because the two work through different mechanisms.

•Hormonal treatment: Hormonal preparations can and are often used to deal with heavy periods. The combined contraceptive pill can be quite effective in sorting out heavy periods. For a woman who does not have contra-indications for the pill and who does not have identifiable risk factors, this is one option that is available to her. This is ideal for a woman who is also in need of an effective and reliable contraceptive. For a woman who does not need contraception, either because she is not sexually active or has another form of contraception already in place, the use of the combined pill solely for dealing with periods could be outside the licence and therefore unavailable.

Another commonly used hormonal treatment option is the use of cyclical progestogen tablets. A typical course will involve taking tablets from the fifth day of the cycle and continuing for 21 days. That means the tablets are taken from Day 5 to Day 25 of every cycle. This treatment is quite effective but many women are not enthusiastic about it because of the intense nature of the treatment. This is usually used as a short term measure, not lasting more than a few months. There are many types of progestogen. The type commonly used for this purpose is Norethisterone (also found in the pill Microgynon® and Seasonale®). Another progestogen used is Medroxy-progesterone acetate or MPA (brand names Provera®; Cycrin®; Amen®).

Progestogen medication is sometimes poorly tolerated with problems of feeling bloated, fluid retention and breast tenderness. These preparations, even though not contraceptives in the true sense of the word, would reduce a woman’s chances of conceiving during the duration of use (not beyond). They are therefore unsuitable for a sufferer who is actively trying to conceive.

•Mirena® IUS: Strictly speaking, this is also a hormonal option. Even though the mode of delivery of the hormone is different from the options described above, Mirena works via a similar mechanism. The device is inserted and left to stay in the womb cavity (image below). It contains a reservoir of the Levonorgestrel progestogen hormone which is continually released at a steady rate and in minute amounts to suppress the lining of the womb from proliferating.

This intra-uterine device is extremely effective in dealing with heavy periods. After 6-12 months, menstrual blood loss is reduced by about 96%. Many users attain complete absence of periods (amenorrhoea) in the medium term. It is that good. The device which is roughly the same size as a standard intra-uterine contraceptive device or ‘coil’ is effective for up to 5 years.

In addition to this benefit, it is an extremely effective contraceptive; more effective than the contraceptive pill or even female sterilisation. It is therefore quite ideal for a woman suffering from heavy periods but who also wants long term reliable contraception and is probably undecided yet on whether she would want a permanent form of contraception (sterilisation). Mirena is easy to insert, the procedure taking a couple of minutes in a normal clinic setting, is practically devoid of any medium or long term side effects and, more crucially, works for over 90% of users.

Surgical treatment options

Many women with long standing heavy periods will be started on medications as detailed in the options above. Depending on the individual’s circumstances, that may be all she requires. However, in some cases, the woman in question may not wish to try the medication options or the Mirena IUS. In other cases those options may not work or could simply be unsuitable for her. In such situations, there are effective surgical options to consider

•Endometrial ablation: These are procedures where the lining of the womb is removed usually using devices which deliver heat energy to burn it away. There are numerous ablation methods, all of which have the same end result: The destruction and removal of the lining of the womb.

Endometrial ablation is a very effective way of dealing with heavy periods. Long term satisfaction rates are consistently in the 80-90% range. Most endometrial ablation procedures can be carried out in the outpatient setting using a local anaesthetic and standard pain-killers only. However, depending on facilities and expertise, this outpatient/office setting option may be unavailable in some places and the procedure may have to be done in an operating theatre with a short general anaesthetic. The image below shows the Novasure™ ablation wand deployed inside the uterine cavity. This is the way it would be during the ablation procedure. Novasure™ is just one of a number of ablation techniques available.

A woman undergoing endometrial ablation can expect instant benefits. There is usually a period of two or three weeks, immediately after the procedure, where she will experience a vaginal discharge as the debris from the destroyed lining is shed. After that, there is usually no periods for a couple of months. When the periods come back, they are usually very light and short, typically lasting no more than a couple of days in every cycle. In 30-40% of those receiving the treatment, periods disappear altogether.

Endometrial ablation is absolutely contra-indicated in anybody who might want to have children in the future. It is therefore rarely an option for young women in their twenties who may be suffering from heavy periods. Since most women with this problem will be in their late 30s onwards and most would have completed their families, this does not tend to be an issue. However, for doctors, it is imperative that this aspect of the treatment is thoroughly discussed and understood. This is regardless of a woman’s age.

•Myomectomy: Myomectomy is the name for the surgical procedure to remove fibroids (myoma). If a woman is found to have fibroids that are deemed significant, she can have myomectomy performed as a way of relieving the problem. Fibroids inside the womb cavity (sub-mucosal) can be resected via the vaginal route. However, fibroids that are within the wall of the uterus will require an abdominal approach. Traditionally, this has been performed through an open procedure. Increasingly, myomectomy is performed via the minimal access (laparoscopic) approach. Where the necessary surgical expertise is available, this tends to be the preferred route as recovery from surgery is a lot quicker and hospital stay is dramatically shortened, rarely lasting more than 24 hours. Myomectomy is an especially attractive option for a woman who is suffering from heavy periods but who is keen to preserve her fertility.

•Hysterectomy: Hysterectomy is the surgical removal of the uterus. This is, of course, guaranteed to cure the problem of heavy periods (menorrhagia). However, it is a major operation and, in modern practise, it is regarded as an option of last resort. It is rarely, if ever, justified to offer a hysterectomy as a first option in a case of menorrhagia in the presence of much less radical options which are quite effective. A hysterectomy has a potential for major complications, some of them irreversible and should be reserved for where other methods (above) are either unavailable, unsuitable or have failed.

Dysfunctional Uterine Bleeding (DUB)

The term ‘dysfunctional uterine bleeding’ refers to any form of abnormal vaginal bleeding during the reproductive years. Vaginal bleeding occurring after the menopause falls outside this category.

Dysfunctional uterine bleeding can take many forms including:

•Irregular and frequent ‘periods’. In