"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.
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. |
