If hormonal treatments do not work for you, there are several surgical approaches that can help control heavy bleeding. A D&C removes the endometrial tissue that is causing the heavy bleeding, but leaves the underlying layer of cells, which generates a new endometrium every month after your menstrual period. Other procedures — endometrial ablation, cryoablation, and hot-water balloon ablation — aim for a more permanent result: they remove the glandular endometrium and scar the underlying layer so that no new endometrium is produced. Another new treatment for women whose heavy bleeding is caused by fibroids is to deprive the fibroids of their blood supply by injecting particles, something like tiny styrofoam balls, into the arteries that lead to the fibroids. The procedure is done in a hospital setting with the assistance of a radiologist. The surgical procedure of last resort for uncontrollably heavy periods is a hysterectomy.
D&C (Dilation and Curettage)
During this procedure the cervix, the narrow opening to the main body of the uterus, is dilated. Then the lining of the uterus is scraped out with a sharp-edged tool called a curette. The old slang among physicians for a Dilation and Curettage was a “dusting and cleaning.” While not quite accurate, the term describes the procedure’s purpose, which is to clean out the glandular lining and get back to the underlying muscular layer of the uterus.
One common reason for performing a Dilation and Curettage is diagnostic. Why is there such heavy bleeding? Is the cause a hormone imbalance? Are polyps or fibroids the underlying cause? Or could the bleeding be an early indication of endometrial cancer? Whenever I do a Dilation and Curettage, I send tissue samples to a pathologist for careful examination and a definitive diagnosis. The procedure can also be used to perform an early-term abortion (though today suction aspiration is more common) or to clean placental tissue from the uterus after a miscarriage.
If you have a Dilation and Curettage, you will not be disabled for weeks and weeks; in fact, you will probably feel quite all right the next day. Most women have some cramping the day of the procedure, similar to the cramping of a heavy menstrual period. A mild painkiller such as Tylenol or Advil will probably take care of it. Spotting or staining for up to two weeks after the procedure is not uncommon, nor is it indicative of anything dangerous. You can usually return to your normal activities, including work, in a day or two. Much of the speed of recuperation depends on what type of anesthesia you were given.
Frequently a D&C can be done with local anesthesia in a doctor’s office or surgicenter.
The most commonly used technique is a paracervical block, in which Novocain or an equivalent is injected right into the cervix. A Dilation and Curettage with a paracervical block does cause some discomfort. The block anesthetizes the cervix, but it does not act on the inside of the uterus. A biopsy usually involves taking samples from different parts of the uterus to ensure getting representative bits of tissue, and women respond differently. I have had reactions ranging from “This is no big deal; why did you tell me it was going to be uncomfortable?” to “This is the worst thing that has ever happened to me.” A middle-of-the-road group responds with “This is not fun, but who wants to go through general anesthesia?”
I tell patients who are about to have any procedure under local anesthesia that if it gets too distressing they can ask me to stop and have it done later under general anesthesia — and sometimes I have abandoned a procedure because the patient is too miserable. If the procedure is being performed in an operating room facility, you can start with a paracervical block and proceed to general anesthesia if necessary.
Fifteen or twenty years ago, a Dilation and Curettage with general anesthesia was a major production. You were admitted to the hospital the night before and stayed a day or two afterward. Nowadays, even with general anesthesia, the vast majority of D&Cs are performed in surgicenters or other outpatient settings. You go in at about seven-thirty in the morning, the procedure is done an hour later, and you go home before lunch.
It makes sense that a Dilation and Curettage will help someone with polyps or fibroids, which can cause heavy bleeding, but sometimes women who have nothing visibly wrong may also improve after a Dilation and Curettage for reasons that are not understood. Usually these women do well for a year or two; then their periods may get heavy again.
Like a Dilation and Curettage, endometrial ablation removes the glandular lining of the uterus, but it uses the intense heat of a laser beam or an electrocautery instead of a curette. The doctor looks inside the uterus with a hysteroscope (a narrow, lighted viewing tool) and under its guidance focuses the laser beam to “fry” the endometrium. As in a Dilation and Curettage, the goal is to remove the entire endometrium and get back to the underlying muscular layer. Even if some bits of glandular tissue remain, the heavy bleeding is usually relieved. Like any surgical procedure, endometrial ablation should be performed by a skilled practitioner who has done it many times.
While endometrial ablation has its place in the range of available procedures, it is not without risks and potential drawbacks. If the uterus is large, the laser must be used extensively. Through the hysteroscope the physician can see an area about the size of a nickel, so must move the scope and the laser extensively to see and remove all the endometrial tissue. Ablation can also be difficult if the uterus has a lot of nooks and crannies (for example, a fibroid or two pressing inward through the outside of the uterine wall).
Some physicians insist that a woman go on hormonal medication like Lupron or danazol for a month or two before the ablation. The medication “flattens out” the uterine lining and makes the procedure easier. The same physicians may also recommend continuing the hormone therapy for a month or two after the ablation, to let the endometrium scar and keep it from growing back.
Melissa has three children and doesn’t want any more. She is seriously overweight and has high blood pressure. Because of her obesity, she tends to bleed heavily with her periods. She has tried progesterone but it hasn’t helped her.
Melissa might consider endometrial ablation. Since she plans to have no more children, she could have a hysterectomy. However, she is not a good surgical risk because of her weight and because other therapies have not helped her. She should choose this procedure with the same seriousness with which she would approach a Dilation and Curettage.
One new technique uses a “roller ball,” a little electric ball that rolls around the lining of the uterus and scars the endometrium with electric current — instead of a laser, which scars it with intense heat. It is perhaps safer than laser ablation because there is less risk of burning the bowel, which is close to the uterus in the abdominal cavity.
Another new method, which has been approved by the Food and Drug Administration (FDA), uses a hot-water balloon, a little sack at the end of a long slender tube. The sack is placed in the uterus and filled with very hot water. It remains there for slightly less than ten minutes, while the heat destroys the endometrium.
Cryoablation, recently approved by the FDA, uses cold instead of heat to destroy the endometrium. The physician inserts a probe into the lining of the uterus and freezes the area with refrigerant gas. I helped out during preliminary research for FDA approval of this procedure by checking temperature gauges attached to the surface of the uterus to make sure that nearby organs did not become damaged by the cold.
All methods that destroy the endometrium should be used only if you are certain that you have completed your family. They scar the uterus, which hinders fertility.
If you are sure you do not want more children and all other therapies have failed, hysterectomy is your final recourse. It is a major surgical procedure; you should anticipate two or three hours in the operating room and six weeks of recuperation time.
After Michelle’s second child was born when she was 30, she had her tubes tied. Unfortunately, she bleeds heavily every month. Birth control pills control her heavy periods but give her migraine headaches, sometimes as many as five a week. She decided to stop the pills, but started bleeding again and felt bad enough to miss work. We did a D&C with the aid of a hysteroscope, and the procedure confirmed that she does not have cancer or fibroids.
Michelle did not want to live her life choosing between migraines and heavy bleeding. After weighing her options carefully, she came in one day and said, “I can’t take this any more. I’m just going to have a hysterectomy and be done with it.” She had the procedure, during which her uterus but not her ovaries were removed; she has been happy with the results and has not missed a day of work since she returned after her postoperative recuperative period.
Will insurance pay for a hysterectomy to stop heavy bleeding?
If your heavy bleeding is caused by endometrial cancer, of course your HMO (health maintenance organization) should pay. If it is caused by large (grapefruit-size) fibroids, usually health maintenance organizations are willing to cover the costs. If your fibroids are smaller, the company may ask whether you have tried progesterone therapy or birth-control-pill therapy; if you say you have, the company will probably ask why you did not tolerate the pills. If you meet several criteria, you may be able to convince your insurer to pay. You will have to submit a blood count; if it shows that you are anemic your company may cover you because the hysterectomy is for treatment of a recognized disease. You also must submit clotting studies to be sure you do not have some clotting problem that could be life threatening after surgery. In short, you may be able to get your HMO to pay, but you will probably have to jump through hoops to do so. Just be sure to obtain preauthorization before you undertake the surgery, to avoid any nasty financial surprises afterward. Your doctor’s office staff will help you, but you will probably have to do some of the work yourself.