Some of the most common are:
- Heavy periods that are not controlled on hormones or an inability to take hormones to control the period.
- Large fibroids that press on the bladder or the bowel, or are so large they can be felt on the abdomen.
- Endometriosis (usually if this is requiring a hysterectomy it is due to both pain and bleeding).
- Uterine artery embolization where microscopic plastic beads are inserted into the uterine arteries to block the majority of blood flow to the uterus. This causes the uterus to slowly shrink in size. The uterus may decrease to half of its normal size within 2-3 years. Initially there is a lot of inflammation of the uterus as it loses its blood supply. The pain associated with this will usually require ibuprofen and narcotics. Most women stay in the hospital for overnight, and it is usually about 2 weeks before you are feeling well enough to resume normal activities.
- Myomectomy, a surgical removal of the fibroids. There are two types, one is done from the inside of the uterus (hysteroscopic myomectomy) and the other is on the outside or wall of the uterus (done either laparoscopically or through an abdominal incision). If the fibroid inside the uterus can be removed this is an excellent way to control the bleeding. This is not always an option, based on the size of the fibroid and how far into the uterine cavity it reaches. Removal of the fibroids in the uterine wall will make the uterus smaller, but will not always affect the bleeding. This is because the bleeding may be due to other factors than the fibroids. The main purpose of removing these fibroids is to make the uterus smaller, and save the uterus for having babies. The uterus is a muscle and does not play any part in a woman’s sex drive, or hormones, but is a place for babies to grow. The recovery of a myomectomy is about 6 weeks due to the inflammation of the uterus after the fibroids have been removed and it has been sewn back up. There are often 3-4 incisions on a uterus when we remove fibroids, and they are very deep and take a long time to heal.
- Endometrial (uterine lining) ablation, done through the vagina and cervix, with no incisions. This is a “hysteroscopic” procedure where the uterine lining is “ablated” (essentially cauterized), treated with hot water or frozen to destroy the cells of the lining so they will not recurrently grow and slough, which is the cause of menstrual periods. This is an outpatient procedure. Recovery is much faster, most women return to normal activities in 2-4 days. This will make the period lighter or stop it all together. The major problem with this is if there is deeper uterine lining it will not destroy this and there can be bleeding and pain that will develop after a few years. Also, this will not make the uterus any smaller.
- If the only problem is heavy periods or the pain related to these, then a progesterone IUD or implant is often a great treatment. This can be placed in the office. For women over age 40 there is often no to minimal periods. Sometimes there is a 3 month period where there are slightly increased symptoms such as breast tenderness, acne, mild nausea, and headaches. This is not a good choice in patients with migraines.