Dr. Chris DeStephano Discusses Abnormal Uterine Bleeding
Hi, I'm Chris DeStephano a gynecologic surgeon at Mayo Clinic in Jacksonville, Florida. Many of my patients come to me because they're experiencing abnormal uterine bleeding and I wanted to share with you some demonstrations of treatment options. First let's discuss what a normal versus abnormal period is based on guidelines from the American College of Obstetrics and Gynecology. Periods occurring every 21 to 35 days with flow that is not excessive based on a patient's perception are normal.
Periods occurring less than 21 or more than 35 days with flow that is excessive based on patient's perception are abnormal. Abnormal flow such as clots, how often a tampon or pad has changed or the length of the period it's completely dependent on the patient's view of her period. Changes in duration and amount of bleeding are common at different ages.
Causes of abnormal bleeding can include polyps, adenomyosis, fibroids, cancer, bleeding disorders intermittent ovulation, and the effect of medications. The causes are often dependent on the age of the patient. Once a woman has no bleeding for over one year, she is considered post-menopausal. Any bleeding after menopause is considered abnormal. This is a very common reason for a visit to the gynecologist, as 70% of all consultations to a gynecologist near menopause are for abnormal uterine bleeding. Treatment will depend on what is found during the appointment.
If a woman is near menopause, does not have cancer, and her symptoms are bearable, then watchful waiting is prescribed. This is especially true for fibroids, which rarely interfere with pregnancy, grow slowly or not at all, and tend to shrink after menopause. Many factors influence the course of treatment for uterine fibroids. The factors include size, location, and symptoms. If the fibroids are small and not causing bothersome symptoms, observation without treatment may be reasonable. If the fibroid is submucosal, which means it is contained inside the cavity of the uterus, then it can often be removed without an abdominal incision. If the fibroid is large and causing significant symptoms, then a uterine fibroid embolization, myomectomy, or hysterectomy may be indicated. The specific recommendation is individualized to the patient and her symptoms.
If treatment is recommended, options can include oral contraceptive pills, a hormone-releasing contraceptive implant placed in the inner arm, injections of hormones every three months, or a hormone-releasing intrauterine device, also called an IUD. These typically require three to six months in order to be effective at reducing the flow of periods. If your doctor finds a small polyp during a hysteroscopy, it can often be removed in the office. Treatment with the hormone-releasing IUD [Simulation of Intrauterine Device (IUD) Placement] involves inserting a t-shaped frame into the uterus. [Simulation of Intrauterine Device (IUD) Placement] [Simulation of Intrauterine Device (IUD) Placement] With a hormone-releasing IUD, [Simulation of Intrauterine Device (IUD) Placement] bleeding is expected to decrease by 80% in 3 months. [Simulation of Intrauterine Device (IUD) Placement] By 6 months, bleeding is expected to decrease by 90%. [Simulation of Intrauterine Device (IUD) Placement] [Simulation of Intrauterine Device (IUD) Placement] Although the overall bleeding decreases, [Simulation of Intrauterine Device (IUD) Placement] it often occurs at random times.
[Simulation of Intrauterine Device (IUD) Placement] Some treatments may require sedation, consultation with an interventional radiologist, or need to be performed in the operating room. MRI guided focus ultrasound surgery preserves your uterus and requires no incision by focusing sound waves into the fibroid to heat and destroy small areas of fibroid tissue. This is still an experimental technique performed at a select number of institutions, including Mayo Clinic Uterine artery or fibroid embolization, which involves blocking the blood vessels that supply the fibroid, with small particles may be effective in shrinking fibroids and relieving the symptoms they cause. A hysteroscopic, [Simulation of Laparoscopic Surgery] laparoscopic or robotic [Simulation of Laparoscopic Surgery] myomectomy [Simulation of Laparoscopic Surgery] involves leaving the uterus in place, [Simulation of Laparoscopic Surgery] but removing the individual fibroids [Simulation of Laparoscopic Surgery] and then repairing the uterus. [Simulation of Laparoscopic Surgery] If there is no evidence of fibroids or cancer, treatments may include a hysteroscopic polypectomy, which cuts up small overgrowths of benign tissue, called polyps, with electricity or a small rotary blade. An endometrial ablation, which uses heat, microwave energy, hot water, or electric current, destroys the inner lining of the uterus, either ending menstruation or reducing menstrual flow.
These treatments can take up to six months to have maximum effect. Each woman is different. The effectiveness is also very dependent on age.
An endometrial ablation is more effective each year closer to 50, however, in exchange for fewer recovery days, the less invasive options for abnormal uterine bleeding often require patience. Finally, if there is evidence of cancer or these less invasive options are unsuccessful, your doctor may recommend a hysterectomy, which is the complete removal of the uterus. Due to the possibility of redevelopment of bleeding by leaving the cervix, typically a total hysterectomy, which involves removal of the uterus and cervix, is recommended. If a woman is pre menopausal or recently became menopausal, the ovaries are typically preserved and the fallopian tubes are removed. One or both ovaries can be removed at the time of a hysterectomy, which is called an oophorectomy. There are many approaches to hysterectomy.
The least invasive option is a vaginal hysterectomy, which involves no abdominal incisions. The uterus is able to be removed from the vagina. Depending on the reason for the hysterectomy, [Simulation of Laparoscopic Surgery] your doctor may recommend a laparoscopic [Simulation of Laparoscopic Surgery] or robotic approach, [Simulation of Laparoscopic Surgery] which may be able to be performed [Simulation of Laparoscopic Surgery] from one incision in the belly button or [Simulation of Laparoscopic Surgery] multiple small incisions. [Simulation of Laparoscopic Surgery] If a hysterectomy cannot be performed using one of these minimally invasive approaches, then a larger incision will be made in the abdomen. We recommend discussing all of these options with your physician. To request an appointment visit mayoclinic.org.
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