Treatment of Constant Vaginal Bleeding Close to Menopause
Frederick R. Jelovsek MD, MS
"I have had my period almost constantly for the last 13 months. I've gone to 2 doctors and they both seem to agree that I am too young to have a hysterectomy. I am 50 years old. I have always had a heavy period. In addition to the constant period I also have a prolapsed uterus and I have problems with my bladder sticking out slightly. I have a little pain (It would have to incapacitate me before I would complain). I have had back problems on and off for most of my adult life (the last 10 years being the worst). Another major problem is anemia caused by the constant loss of blood. I had a D&C 2 months ago. My period started approximately one month later and I've had it ever since (this past week it is almost back to normal (meaning heavy at times). I started PremPro® when my period started after the D&C. I thought the PremPro® was suppose to stabilize the period. I have approximately 1 week of pills left. How long should I wait before I tell the doctor that a hysterectomy is warranted? I was thinking that if I still have a constant period for the next several months would a hysterectomy be reasonable? At present I am using a pessary which is helping with the bladder/uterus problem. I am taking iron pills and vitamin B-12. " Lyn
It sounds as if you have had a diagnostic work-up for perimenopausal bleeding and at the D&C that was performed, I hope the doctor also looked at the inside of the uterus with a hysteroscope to make sure there were no anatomical causes of your continuous bleeding such as polyps or submucous fibroids. I cannot emphasize how important this is enough because there are still physicians performing D&Cs for abnormal uterine bleeding without using hysteroscopy. You would not want to go on to a surgical procedure or a prolonged unsuccessful hormonal treatment program just to find out there had been an endometrial polyp causing the bleeding all along.
Causes of Bleeding
Assuming the bleeding is just due to dysfunctional hormonal fluctuations and not to anatomical/mechanical causes. The next step is to try to regulate the bleeding with hormonal therapy. That is why the doctor started you on PremPro®. If you have already undergone menopause proven by an FSH (follicle stimulating hormone) blood measurement above 30 mIU/ml, then PremPro is a good choice. It has both estrogen and progestin in it continuously like a birth control pill but a smaller hormone dose than an oral contraceptive would be. In my experience, the PremPro® 0.625/5mg (blue pill) is more effective in preventing bleeding than is the PremPro® 0.625/2.5mg (pink pill). If you are on the lower dose, you might want to ask your doctor about trying the higher dose.
If you are not yet menopausal, ovulation may occur periodically and interfere with the hormonal regimen and cause continued abnormal uterine bleeding. Prior to menopause I think it is better to use a low dose oral contraceptive such as Alesse®, Levlite®,Loestrin 1/20® Fe, or Mircette® since they tend to block ovulation and may give you better control of the bleeding.
How successful is HRT at preventing menopausal bleeding?
Continuous combined hormone replacement such as that provided by Activella®, Combipatch®, FEMHRT® 1/5, Ortho-Prefest®, or PremPro® usually results in amenorrhea after about 3 months of use but intermittent bleeding during the first 3 months is common. By 6 months, about 2/3's of women will not have bleeding and at 1 year 80-85% will be without bleeding. Increasing the estrogen dose as well as the progestin dose may help stop some of the bleeding.
Thus hormonal replacement therapy is not always successful at stopping all uterine bleeding. It is especially unsuccessful if there is an anatomical cause of bleeding inside the uterus. In your case following the recent D&C, it is difficult to say if the bleeding will subside over time or whether it will continue.
How successful is endometrial ablation at stopping uterine bleeding problems?
There are different techniques for performing endometrial ablation. Originally physicians used a cautery "roller ball" technique or a Yag laser to burn the lining of the endometrium so it would not grow and slough each month. Recently a thermal balloon technique is the most popular because it seems to have less complications (1). In this technique a balloon in introduced into the endometrial cavity after hysteroscopy is performed and water is then injected into the balloon. The water is then heated and the lining of the endometrium is "scalded" so it does not keep growing under hormonal control.
The various techniques used for endometrial ablation may have slightly different outcomes but in general about 1/3 to 1/2 of women are completely without any bleeding afterwards (amenorrheic) while about 15-20% still have bleeding problems severe enough to warrant further surgery (2, 3). The overall satisfaction rate of endometrial ablation is about 65% (4).
Is hysterectomy a better treatment than endometrial ablation for bleeding problems?
The two procedures are somewhat difficult to compare. One involves an outpatient surgery with recovery in less than a week and the other involves a 6 week recovery and somewhat higher risk (about 3-4%) of serious complications. One randomized clinical trial has been conducted comparing hysterectomy with endometrial ablation (5). Further surgical treatment was required during the follow-up period of 4 years by 36% of the women having endometrial ablation and 24% of the women having hysterectomy. Satisfaction rates were high for both groups being 80% in the ablation group and 89% in the hysterectomy group. The difference in satisfaction was due to the different need for retreatment. Premenstrual symptoms improved more in the hysterectomy group. A review or several trials comparing ablation and hysterectomy also came to this same conclusion (6). Thus you can look at this one of two ways:
- Endometrial ablation allows about 75% of women to avoid hysterectomy
- Hysterectomy was more successful in the long run in treating the bleeding problems as well as premenstrual symptoms
Another study following women for 6.5 years found that 20% of women undergoing laser endometrial ablation need a hysterectomy at a later time (7). A study with a shorter follow-up felt endometrial ablation was successful almost 90% of the time (8). In spite of the success of endometrial ablation, it does not seem to be replacing hysterectomy as a treatment for bleeding on the national or international level (9). Hysterectomy performance continues at the same per capita rate and ablation is an additional procedure available. The reason for this may perhaps lie in other associated problems for which hysterectomy makes more sense in the long run.
Should prolapse be treated with a pessary or surgical therapy?
Prolapse of pelvic organs represents a detachment of the support of the uterus (uterine prolapse), vagina (vaginal prolapse), bladder (cystocele), bladder neck (stress incontinence) and rectum (rectocele). An artificial device made of polyurethane such as a pessary can be used to help support these defects so that a woman does not have symptoms. She or the doctor must place the pessary in the vagina to hold those structures up. Some pessaries must be removed daily and be cleaned while others can be left in the vagina longer and cleaned monthly or more. If a pessary supports the tissues and fits well and does not spontaneously fall out, its only long term problem is the inconvenience of cleaning and inserting the pessary periodically and also a slightly higher incidence of vaginal infection (10).
Pessaries are an excellent treatment to control symptoms while awaiting prolapse repair surgery or for women in whom surgery is extremely high risk because of medical problems. At age 50, however, the prospect of using a pessary for the next 25-40 years is not a pleasant thought if you are in good enough health to undergo surgical repair. As you can see from the multiple support defects possible, hysterectomy is not the cure for those problems although it may well be part of the solution; repair of the support defects is the key surgery you must undergo in order to have relief from your symptoms.
Does a hysterectomy cure the prolapse problem?
No. Hysterectomy is not necessary in order to repair pelvic prolapse problems. It is often performed along with the repair surgery especially if the cervix is protruding out the vaginal opening, but it does not have to be part of the procedure. As you can see from the various support defects, the hysterectomy has not much to do with the prolapse problems and you need to be more concerned about the proper fixing of the prolapse rather than the hysterectomy part.
In summary, you are not too young for a hysterectomy but that is not the issue. The options you have for the bleeding problem are to:
- continue with the HRT to try to control the bleeding
- have an endometrial ablation
- have a hysterectomy
For the pelvic relaxation problems, you can continue with the pessary but you should strongly consider surgical repair of the prolapse problems. You have many productive, useful years left that might well be spent not having to use a pessary each day.
With both the prolapse and the prolonged uterine bleeding problem, choosing to have a hysterectomy is very reasonable even at this point.
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