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Should I have an Endometrial Ablation for Heavy Bleeding?

Question

I recently read an article in More magazine about extreme bleeding, fibroids and endometrial ablation. The author had heavy bleeding and ended up having the fibroids removed and an endometrial ablation. I'm a healthy 45-year old yet I've been having gushing and flooding for several months. Should I have the lining of my uterus scraped away?

Answer

Thank you for your good question. The short answer is-not yet. You need to know the following things:

  1. Perimenopausal heavy bleeding (eventually) stops.
  2. You may be sufficiently helped by easy-to-take over the counter things help (like ibuprofen for heavy flow and iron for low blood count).
  3. A number of different medical therapies are effective for heavy bleeding, especially progesterone.

Although endometrial ablation sounds easy, quick and (compared with hysterectomy) inexpensive, in the long run it is not.

I just read that More magazine article, "Private parts," from the September 2009 issue, and found it troubling. It gives a totally wrong idea about fibroids (they aren't cancer), a rosy picture of endometrial ablation (it is small but it is surgery) and, except for mentioning the progestin-soaked IUD (Mirena®), doesn't discuss any of the common things women with heavy menstrual flow can do to help themselves or the assistance that a family doctor can provide.

In 40 years of clinical practice, only once did one of my perimenopausal patients with fibroids and heavy bleeding require surgery-it was because the fibroids were so large that she looked six months pregnant and the fibroids were pressing on her bladder. Nor do you require two surgeries (removal of a small fibroid and endometrial ablation) if you have cured the heavy bleeding with a progestin-soaked IUD. Instead of "shopping for surgery", as the More author does, take charge of your health by seeking for, and carefully evaluating, all the women's health information you find.

The truth about fibroids

Fibroids rarely ever cause heavy bleeding. They are harmless nubbins of muscle that commonly grow in the wall of the uterus. Officially known as "leiomyoma" (leio for smooth, myo for muscle), they arise in the smooth muscle that is the major part of the uterus. They are not "cancer nests" as the More article stated, but totally benign. The very rare cancers that come from uterine muscle (less than 1/1000 woman) don't arise from ordinary fibroids.

The lining of the uterus, which sheds with menstruation, and is the source of heavy bleeding, is not near the uterine muscle and fibroids. Less than 10% of fibroids are even close to the endometrium. Although heavy bleeding and fibroids commonly occur together, it is because the higher estrogen and lower progesterone of perimenopause causes both.

Thoughts about endometrial ablation

Endometrial ablation is a kind of surgery. I think that surgery is necessary and important, but because it is invasive, I would recommend surgery only if all other options have been tried and found unsuccessful. There are many ways to deal with heavy flow. Because removing the endometrial lining doesn't change the hormones of perimenopause, women often need to have repeat endometrial ablation surgeries. Also, almost 20% of women who have had an endometrial ablation eventually require a hysterectomy. Finally, and important for self-knowledge is that, if endometrial ablation is successful and totally removes your flow, you won't know when you graduate into menopause. Menstrual flow (or its absence) is a marker of your progress through perimenopause.

What you can do for perimenopausal heavy bleeding

Read the information about very heavy menstrual bleeding provided in this article, whch outlines how taking ibuprofen and iron supplements can help get you back to health. I'd also recommend that you start keeping the Daily Perimenopause Diary. If you are still having heavy bleeding despite taking ibuprofen several times a day during heavy flow days, and are still feeling weak and tired from anemia despite taking iron therapy to treat a low blood count, then you need your doctor's help. This article, written for health care providers, will guide you and them through the other possible medical therapies. Progesterone therapy is sensible and effective for heavy flow because progesterone normally thins the endometrium, allows for complete shedding with the period, and prevents endometrial cancer. In perimenopause, when estrogen is in overdrive and progesterone levels low, high and daily progesterone therapy for several months is sometimes required.

In summary

I, too, am a survivor of perimenopausal flooding. Because of my own difficult experiences, I began the investigations that have led to our new understanding of the hormone changes of perimenopause. I also realize how important it is to provide practical, science-based help for women such as you.

Although all women live through perimenopause, heavy menstrual flow is one of the common things (along with night sweats and increased trouble coping during the premenstrual days) that many mid-life women experience. Unfortunately, physicians are just starting to make the link between heavy flow and the higher estrogen and lower progesterone levels/disturbed ovulation of perimenopause. Perimenopause is like adolescence in this imbalance with estrogen excess/progesterone lack-both commonly have heavy flow. Happily, we are learning about the perimenopausal hormone changes, their relationships with problematic flow and how to help with progesterone and other therapies.

Hope this is helpful for you.

All the best,

Jerilynn


Life Phase: 
Perimenopause
Updated Date: 
Tuesday, November 19, 2013 - 13:15

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