As if unpredictable periods weren't enough, some women find that their periods become very heavy during perimenopause. This may be rather benign, and just a bit more bleeding than you have been always had; or it can mean significant blood loss, or be a sign of something serious. You may want to start counting the pads or tampons you use in a day and keep a note of it on your calendar, in case you need that information to discuss heavy bleeding with your health care provider.
As you've learned, unusual bleeding can have a number of causes, but two relatively common benign causes are fibroids and polyps. Uterine fibroids are benign growths of muscle tissue that develop within the wall of the uterus, on the uterine lining, or on the outside of the uterus. Also called leiomyomas, fibroids are extremely common and by age fifty as many as 80 percent of women have them. Fibroids within the uterine lining can cause abnormal bleeding because of the way they distort the lining and prevent it from shedding normally. Fibroids vary tremendously in size, from undetectable to the size of a grapefruit, or larger. Their size alone can cause problems, such as pelvic pressure, bloating, urinary frequency, or pain during intercourse. If you have unusually heavy or midcycle bleeding, your doctor probably will check for the presence of fibroids.
If your symptoms are found to be from fibroids, rather than from hormone fluctuations or other causes, your health care provider will probably recommend treating you. Treatment options for fibroids also vary, depending on the size of the tumors; whether you want to retain your fertility (not usually an issue during perimenopause, but it might be); and what resources are available in your area. Among the accepted treatments for uterine fibroids are the following:
“Wait and Watch.” Because these are benign growths, some health providers prefer to wait and monitor fibroids. This is acceptable if symptoms are not seriously affecting your life and health. Since fibroids usually shrink after menopause, this may be a good choice for women in perimenopause who are not having serious symptoms.
Embolization. Fibroid tumors are dependent on the blood supply that develops around them, and in this procedure a specially trained radiologist injects a plastic or gelatin substance into the blood vessel through a small incision in the leg. A tube is inserted into the uterine artery, where particles are deposited on both sides of the artery, stopping the blood supply to the fibroid. It is relatively safe and can be done on an outpatient basis. Embolization is not usually recommended for women who want to remain fertile, since a pregnancy requires excellent blood supply to the uterus.
Medications. There are several medication approaches to treating fibroids. You may be advised to take iron to treat anemia if you have been bleeding heavily. Or your doctor may prescribe non-steroidal anti-inflammatory medications (NSAIDs, such as ibuprofen, naproxen, etc.) for pain and inflammation and to decrease prostaglandin activity — this can decrease total menstrual blood loss by up to 50 percent. Oral contraceptives are used to decrease the bleeding, but they do not reduce the size of the fibroids. Because fibroids respond to a reduction of female hormones, sometimes androgens (“male” hormones) or a class of medications called gonadotropin-releasing hormone agonists may be used to reduce the action of estrogen and progesterone, thereby shrinking the tumors.
Myomectomy. This is the surgical removal of the tumor itself, and is one choice for women who want to keep their uterus and are having significant symptoms of pain or bleeding. This treatment may be done by abdominal surgery or by laparoscope, and carries all the usual risks of those types of surgery.
Myolysis. This treatment means using an electric current or liquid nitrogen to destroy the fibroid tissue. Done through a laparoscope, it seems to present fewer risks than abdominal surgery, but its safety and effectiveness are still being studied. It is not recommended for very large fibroids or for women who want to eventually become pregnant, since scarring and adhesions often follow the procedure.
There is often cramping with fibroid embolization, and the pain may become severe as the fibroid tissue “dies” after the blood supply is cut off. This process of tissue death also increases the chance of infection. Although serious infection is rare, it can lead to hysterectomy. Be sure to explore the risks of this procedure before you decide to pursue it.
Focused Ultrasound Surgery (FUS). FUS is the use of ultrasound to destroy fibroid tissue, and is done using a special magnetic resonance imaging (MRI) machine to locate and target the tumor. It is not yet well studied, but has promise as a less invasive form of surgery and is already being used for other procedures.
Hysterectomy. Surgical removal of the uterus is the only certain way to eliminate fibroids and the symptoms they cause. It is major surgery, however, and has its own set of risks and benefits, which must be considered before accepting it as the treatment of choice.
If you are diagnosed with fibroids and they are causing problems, discuss the options with your health care provider. He or she can help you weigh the seriousness of your symptoms with the risks and benefits of treatments.
Uterine fibroids can cause bleeding serious enough to make you anemic. If you find during your period that you are changing a maxi-pad or super tampon more than eight times in eight hours, or if you have clots that last over eight hours, make an appointment with your health care provider to be evaluated for these benign but troublesome tumors.
Uterine polyps are smaller benign growths on the lining of the uterus. Science and medicine have yet to explain why polyps develop in some women, and not in others. Polyps bleed, just like fibroids, but because they are typically small, they're unlikely to cause the amount of blood loss associated with fibroids. When a health care provider diagnoses polyps (usually through an ultrasound test or a biopsy sample), he or she can remove them through a simple outpatient procedure in which the doctor snips the polyps from the uterine lining. This procedure usually involves a hysteroscopy — a sophisticated dilation and curettage (D and C) procedure where a small (one-eighth-inch) camera lens and instrument port are inserted into the cervix to locate the polyps and remove all of them at that time. Although pain is usually minimal, you may receive mild sedation or anesthesia during the procedure, and some pain medication afterward.