Academic OB/GYN

The following is a cross post of a blog post we wrote for the MIRI network (http://www.miriwomen.com), a network of expert gynecologic surgeons.

Nicholas Fogelson, MD, Richard Rosenfield, MD

Pearl Women’s Center, Portland, OR

1. Why am I bleeding so much?

Heavy menstrual bleeding (menorrhagia) is one of the top reasons that women seek gynecologic care with us. When we consider bleeding, we have to think of two different systems that are involved – the endocrine (or hormone ) system, and the structural system, which in this case is the uterus itself.

The uterus is a muscular sac that in its normal function serves as a place to carry a pregnancy and to deliver the baby. As far as we know, that’s its only function. In order to serve that function it works in concert with the endocrine system to prepare a place for an embryo to implant and grow every month. If a pregnancy occurs, there is no bleeding that month and a pregnancy ensues. If there is no pregnancy, the bed of endometrium (uterine lining) is shed in what we know as a menstrual cycle. If a woman has normal hormonal function, and the uterus is normal in shape and contour, then in most cases she will have a relatively light and short menstrual cycle.   At least that’s the way it is supposed to work! In women who are having exceedingly heavy menstrual, some part of this system is having a problem.

A woman with a normally functioning endocrine system will ovulate once a month, leading to the typical once a month menstrual cycle. Some women will have problems that lead them to have irregular ovulation, including polycystic ovarian syndrome, thyroid disorders, extremes of weight (both obesity and extreme thinness). Any one of these problems can lead to heavy or irregular menstrual cycles, because the uterus fails to receive the hormonal signals it needs to have a short and light menstrual period.   When patients have these problems, there are often medical treatments that can improve their hormonal system that will in turn improve their menstrual cycles. These treatment can include birth control pills, progesterone based drugs, and in some cases insulin related drugs. Hormonal intrauterine devices can also be quite effective in controlling this type of issue.

In some cases, the hormonal system is functioning correctly, but the uterus itself can be structurally abnormal leading to heavy menstrual cycles. Fibroids are a common cause of bleeding. These are muscle tumors that are within the walls of or within the cavity of the uterus. Fibroids can cause very heavy long menstrual cycles, irregular bleeding, and in some cases can contribute to infertility or miscarriage. Another structural cause of bleeding is a condition called adenomyosis, which is common in patients who have had many children. In this condition the lining of the uterus has grown into the muscle wall of the uterus, effectively causing the women to menstruate directly in the muscle of the uterus.   Women with this condition tend to have painful, heavy menstrual cycles, and often have uterine tenderness that may cause pain with intercourse.   Additionally, there are some rare conditions of the uterus that are congenital (present at birth) that can cause problematic bleeding patterns.

Structural issues of the uterus can also be treated with the previously mentioned medical treatment options,  though this may be less effective depending on the severity of the structural issue.   Fibroids of the uterus can be removed surgically, which can be done either through an open incision or laparoscopically. A number of procedures exist to remove or burn the lining of the uterus, which in many cases can significantly decrease bleeding. This option works best in women who have uterus that are normal to mostly normal from a structural point of view. The entire uterus can also be removed (hysterectomy), which entirely eliminates bleeding.   This procedure can also be open, laparoscopically, or vaginally.

Hysterectomy is a procedure that is thought of differently by women from different backgrounds. Some women want to preserve their uterus, even after childbearing, while other women absolutely giddy to be rid of the source of their bleeding.   At Pearl Women’s Center we are excited to work with women with their bleeding issues and provide the treatment that best fits their needs. Both of our surgeons have extensive experience with minimally invasive techniques and can provide myomectomy and hysterectomy procedures through very small incisions and minimal downtime in the vast majority of their cases.   In the last 10 years we have completed over 1000 laparoscopic hysterectomy procedures and have been a driving force on a national level in showing that these procedures can be safely performed in the outpatient surgery center setting. Our rate of conversion from laparoscopy to open procedures (having to open up) is less than 1%, compared to a national average of 10-20% depending on surgeon experience and setting.

Dr. Fogelson is a gynecologic surgeon and endometriosis specialist who practices at Northwest Endometriosis and Pelvic Surgery in Portland, OR.  Call 503-715-1377 for clinical consultation.  http://www.nwendometriosis.com