heavy periods

Conquering the Uterus – Trends in Hysterectomy

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Every 10 minutes, 12 American women lose their reproductive organs, every day of every year. Hysterectomy is second only to cesarean in common surgeries. Approximately 660 women die each year in the United States from complications related to hysterectomy. Thousands more suffer long term side effects associated with oophorectomy – removal of the ovaries. The most common reasons for hysterectomy include:  uterine fibroids or rather the menorrhagia, heavy bleeding associated with the fibroids and endometriosis, an incredibly painful condition where uterine tissue grows outside the uterus. Both conditions are hormonally modulated, plague millions of women and take years to develop.

One would think that with such extended period of disease progression, 5-10 years, researchers and clinicians would have ample opportunity to develop innovative treatment protocols, long before the surgical removal of the uterus was necessitated. One would be wrong. Despite the cost of long term care leading to, and as a result of the hysterectomy; despite the outcry from the hundreds of patient associations, some with high profile members; despite the billions of dollars spent annually on performing what should be last resort surgeries, there has been no innovation in diagnostic tools for these conditions and no new therapeutics for women’s reproductive health developed in over 50 years, unless you call the re-purposing of old meds innovation.

Instead, innovation in women’s healthcare, much like American healthcare in general only magnified exponentially, comes at the end of the disease progression – when no other choice but surgery exists. Let’s build a cool robotic tool to remove even more uteri. Sure it will cost significantly more and have a higher complication rate, but the technology is so impressive that does not matter. Forget about developing early diagnostics and less invasive, more effective therapeutics, just take it all out and look cool doing so. Who would not want to perform surgery remotely with a million dollar piece of medical technology? Women don’t need their uteri anyway – a win win for all involved.

Robotic Assisted Hysterectomy

The robotic, joystick controlled, remote surgical tool is an impressive piece of engineering. With a price tag of over a million dollars per, it provides the cutting edge stature that all top-notch hospitals strive for. An added bonus, it makes gynecology, the long derided medical profession, the cool kid on the block. But does it work?

Well, not really. Sure it removes a woman’s uterus more quickly and with less scarring; a single ½ inch belly button scare versus two or three ½ inch abdominal scars, but it costs more and doesn’t reduce complications – may even increase them a bit. Compared to the minimally invasive laparoscopic hysterectomy, the robotic assisted hysterectomy costs $2000 more per procedure. As of 2010, about a quarter of all hysterectomies were performed robotically. That’s about $300 million dollars per year more to perform a robotic hysterectomy with no added gain health.  When combined with the costs multiple hospital stays, ineffective therapeutics and possible other surgeries that often led up to the hysterectomy, it is clear why women’s healthcare is so expensive.

Perhaps we could use our health dollars a little more wisely. Maybe we should spend some of those many billions of dollars or even a fraction of the $300 million spent annually on robot surgery, on prevention, early diagnostics or more effective therapeutics.

Update

Since this article was originally published in 2013, additional reports of complication rates for robotic surgery have been published. In a study of 298 patients undergoing robotic hysterectomy published in 2015, the complication rate was 18%. In 2017, a study of complication rates of a single surgeon using the robot, was 5.5% suggesting that some surgeons are better with this tool than others. In comparison, a study looking at 4505 hysterectomies performed by the same team between 1990 and 2006 (3190 were performed by laparoscopy, 906 by the vaginal route and 409 by laparotomy) saw the complication rates below 1%, significantly lower than that of the robotic surgeries, but again demonstrating that the skill of the surgical team is paramount.

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Photo by Sander Sammy on Unsplash.

This article was published originally on March 18, 2013.

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Heavy Menstrual Bleeding

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Heavy menstrual bleeding is a significant cause of poor health in women, and yet it is rarely discussed openly because of the widespread societal taboo against frank discussion about normal functions of women’s bodies. About 30 percent of women will experience heavy menstrual bleeding at some point in their reproductive lifetime. It can have a substantial effect on a woman’s quality of life including placing limitations on physical activities, social activities, and ability to work during menstruation. Anemia is often a result of heavy menstrual bleeding, and anemia can cause serious fatigue, weakness, dizziness, cognitive problems, depression, anxiety, and more. Although all of these issues have as significant an effect on a women’s quality of life as many other debilitating illnesses, most women probably feel quite isolated in dealing with the problem, because they may feel uncomfortable disclosing it to friends and family members.

What Does Heavy Menstrual Bleeding Mean?

Because of the lack of discussion and education around this topic, many women do not know what may constitute heavy menstrual bleeding versus normal menstrual bleeding. I know that for me, as an adolescent, I assumed it was normal to have to double up on tampons and pads, to need a bathroom every hour or two during my period, to get up several times at night to change tampons and pads, and to always have a change of clothes with me. It wasn’t until I had been seriously anemic for many years that I started to question what I had been told up to that point even by doctors, which was that my heavy periods were normal. We need better menstrual education for teens, so that problems like heavy menstrual bleeding and other women’s health issues can be diagnosed earlier.

The medical definition of heavy menstrual bleeding, also known as menorrhagia, is bleeding that is abnormally heavy (more than 80 mL of blood per period), abnormally prolonged (more than 7 days of bleeding), or both. However, even knowing the medical definition of heavy menstrual bleeding does not necessarily help women identify whether or not their bleeding is normal, because translating that number into what they are experiencing with their menstrual cycle is quite difficult.

Most women probably assume that most or all of the menstrual fluid is blood, but actually on average, only about 36 percent of the fluid is blood. And this percentage varies widely among women, from 1.6 percent to 81 percent. The guideline typically used is that bleeding that soaks through a large pad or tampon in under two hours, going on for several hours, or with large clots, is too heavy. But even among brands of pads and tampons the absorbency can vary from less than 1 mL to almost 100 mL. Because of the difficulty in quantifying bleeding, in many cases doctors will use a woman’s subjective description of her heavy menstrual bleeding as an indication that there is a problem that needs treatment. In some cases this will result in unnecessary treatment for a problem that does not really exist.

Causes of Heavy Menstrual Bleeding

When considering the possible causes of heavy menstrual bleeding, it is important to remember that heavy menstrual bleeding can result from gynecological causes, as well as hematological causes (bleeding disorders). Usually when a woman presents to her doctor with heavy menstrual bleeding, she will be referred to a gynecologist, resulting in an investigation of gynecological causes. However, even when the gynecological investigation does not provide answers as to the cause of the bleeding, hematological causes are not typically investigated. In approximately 50 percent of cases of heavy menstrual bleeding, no cause is found.

Gynecological causes of heavy menstrual bleeding include hormone imbalances, dysfunction of the ovaries, uterine fibroids or polyps, adenomyosis, pelvic inflammatory disease, and in rare cases, cancer. Hematological causes include inherited bleeding disorders such as von Willebrand disease, platelet function disorders, hemophilia A and B, or other clotting factor deficiencies. Bleeding disorders have traditionally been highly under recognized in women, and still are, and some, such as von Willebrand disease, can be hard to diagnose. After gynecological issues are ruled out as a possible cause of heavy menstrual bleeding, it may be important to investigate hematological causes, especially if there are any other bleeding symptoms such as nosebleeds, or abnormal bleeding with dental work or surgeries.

Treatment of Heavy Menstrual Bleeding

Although there are treatments for heavy menstrual bleeding, unfortunately in many cases they are not effective enough. Sixty percent of  women referred to a gynecologist for heavy menstrual bleeding will have a hysterectomy within the five years following the referral. Many of these hysterectomies may not be necessary—in some cases gynecological causes are not being treated effectively enough, or bleeding disorders are not being identified.

If a cause can be identified for the bleeding, treating the root cause, in most cases, is preferable. However, there are also treatment options that can address heavy bleeding regardless of the root cause, and the effectiveness and potential side effects of these options varies. There are non-specific treatments such as hormonal contraceptives and non-steroidal anti-inflammatory medications that are often used for a variety of women’s health conditions, and for some women, these can reduce heavy menstrual bleeding as well. There are also two treatments specifically used for heavy menstrual bleeding that can be fairly effective, but each comes with its own risks. Lysteda (tranexamic acid) is an oral medication used as needed during menstruation, and endometrial ablation is a surgical treatment option.

Lysteda/Tranexamic Acid

This medication has been used to prevent and treat blood loss in a variety of situations, such as in trauma cases, surgeries with heavy blood loss, and patients with bleeding disorders. In 2009, it was approved as an oral medication to treat heavy menstrual bleeding.  This medication works by slowing the breakdown of blood clots, helping to prevent heavy bleeding, and is used when needed during menstrual periods. It can be used for heavy menstrual bleeding from a variety of different causes, both gynecological, and hematological.

A review of multiple studies of the effectiveness of Lysteda concluded that it can reduce menstrual blood loss by up to 50 percent, and that use of Lysteda results in improved quality of life for patients. No significant side effects were seen observed in these studies. However, since Lysteda affects the blood clotting pathway, there is the potential for increased risk of thromboembolism (obstruction of a blood vessel by a blood clot), although studies to date have not shown any increased risk. This medication should not be used in women with active thromboembolism, or in those with history of or at risk of thromboembolism.

Endometrial Ablation Surgery

Another treatment that is used specifically for heavy menstrual bleeding is endometrial ablation. This is a procedure that surgically destroys the lining of the uterus. The surgery is minimally invasive, requiring no incisions—it is done through the vagina and cervix. In some cases, it can even be done in a doctor’s office, depending upon the method used and the patient characteristics. This treatment is usually used once other less invasive options have failed. However, pregnancy after endometrial ablation can have serious complication, so endometrial ablation is only recommended for women who do not plan to become pregnant.

Endometrial ablation is considered a fairly effective treatment for heavy menstrual bleeding. Depending on the method used, 28 to 71 percent of women will have no menstrual bleeding at all after ablation. Patient satisfaction for all methods is 89 percent or higher. However, about one in six women will require further surgery after endometrial ablation. Hysterectomy is the most common surgery after endometrial ablation, and some women will have a repeat endometrial ablation. Further surgery after ablation is considered a “treatment failure” and can result from continued bleeding, pain, or both. Younger age at the time of the procedure is associated with a higher risk of treatment failure.

Although the procedure itself has been shown to be safe and have a relatively low risk of complications, it is also well recognized that pelvic pain can develop or worsen after endometrial ablation. Longer term complications specifically related to ablation include painful obstructed menstruation, hemometra (retention of blood in the uterus), and post-ablation tubal sterilization syndrome, which is a painful condition that can develop in patients who have had both tubal sterilization and endometrial ablation.  About 21 percent of patients have pelvic pain following endometrial ablation. Risk factors for treatment failure with endometrial ablation, in addition to younger age, include painful periods prior to the surgery, endometriosis, adenomyosis, prior tubal ligation, and in some studies, obesity. Endometrial ablation has been used in a wider and wider group of women since its introduction; however, now that risk factors for treatment failure are better understood, women and their doctors can make a better informed decision about whether this procedure would be right for them.

Like many other women’s health issues, heavy menstrual bleeding is a problem that affects many women in significant ways, but is rarely discussed. Many women just put up with it for years or even a lifetime without seeking help. Removing the stigma from discussions about menstrual problems will help many women have a better quality of life and may lead to better treatment options than those currently available.

This post was published originally on Hormones Matter on November 23, 2015.

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When Should Teens Go to the Gynecologist?

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When should girls start going to the gynecologist? The general consensus from the medical community and public health education is that a girl need not see a gynecologist until she becomes sexually active..I disagree.

Reproductive Care Should Begin with the First Period

Consider this; the average age of menarche in the United States is a little above 12 years of age. The average age a woman loses her virginity in the United States is 17. Based on what is taught in health class, that leaves 5 years of no reproductive care for the average American female. Although the average teenager may not need annual visits to the gynecologist, reproductive care should not be ignored. This means pediatricians must be better informed about gynecological care.

Just because a young girl is not sexually active does not mean her reproductive system does not exist. Amenorrhea, dysmenorrhea, endometriosis, polycystic ovarian syndrome and menorrhagia are all terms (or concepts) that young girls of reproductive age should be familiar with; and yet a majority of girls of reproductive age would not be able to identify any of these terms.

Abnormal Periods are a Sign of Trouble

Young girls should be taught that abnormal periods, painful periods (dysmenorrhea), an absence of periods (amenorrhea), or extremely heavy periods (menorrhagia) are not normal and should be evaluated by a doctor. In many cases, finding the causes of abnormalities in menstruation early on, could prevent further complications down the road.

Most women who have uterine or menstrual abnormalities do not get a diagnosis or proper treatment until they discover they cannot conceive. That is because by the time these women go to the gynecologist for the first time they have been lead to believe that abnormal is their normal.

My Story

When I was twelve I was getting my period every other week and I was told that was normal and that every girls’ period takes some time to regulate – which is true.  However, it wasn’t true for me. I had endometriosis and uterine didelphys (two uteri) which required surgery, but because I was young, it was two and a half years before my painful periods were taken seriously. This is an all-too-common experience. Many women report suffering for decades.

In the case where a young girl’s menstrual problems are impacting her daily life – isn’t it better to be safe, rather than sorry? Read my full health story here.

The Need for Pediatric Gynecologists

Pediatricians and family doctors alike need to sit down with their female patients and have a detailed discussion about menstruation. No one should assume that health education in secondary schools is adequate to teach a young girl to stand up for her own reproductive care. The stigma of being too young (or not yet sexually active) to go see the gynecologist should be disregarded. Regardless of age, if any other part of the body wasn’t working one would go to the doctor to get it looked at; the same should go for the reproductive system.

How old were you at your first gynecologist appointment? When did your menstrual problems begin?

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Underinsured, Underdiagnosed and Anonymous: Endometriosis

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Endometriosis

I am continuing to write this anonymously because I continue to fear the social repercussions and potential backlash of publicly revealing my real name in association with my endometriosis and other health issues. I am uninsured and told by many, uninsurable.

We left off from Part 1 of my story with a tentative diagnosis of endometriosis, a ruptured ovarian cyst, and ever-increasing doses of oral contraceptives. At that point in my life, I was scared, in pain and worried that I and the doctors should be doing more.

But, as it turned out, there was not much more that I could do. The doctors said that even if it wasn’t endometriosis, the pill would probably still be the least invasive and least risky treatment option available to me. They told me this without any intention of scheduling further abdominal inspections, pelvic imaging, endometrial biopsies, or blood draws for biochemical markers, despite my pleas for each. Then again, they had confirmed my endo’ diagnosis without a laparoscope, or CA-125 antigen test, as it was. So, what else should I really have expected from them now? Life on oral contraceptives continued because, apparently, my only other choice was living without a uterus (and risking paralysis due to prior cervical vertebrae injury) at only twenty-five years of age.

I had never had long, frequent, heavy, or uncomfortable periods, much less menstrual cramps, as a young teenager. But, as a woman on COCPs in her mid-twenties, I was experiencing altogether nonexistent cycles, regular breast discharge, ceaseless bloating, and unrelenting gastrointestinal pain and pressure (on top of chronic neck and back pain from the past car accident). One silver lining to my proverbial cloud was that I had finally regained most of the neck control and movement previously lost in the collision. Another consolation to this difficult situation was that I had also saved up enough money, working through physical therapy, to return to school. And, maybe best of all, I had found (without trying) a steady, supportive, and understanding boyfriend, who was not only my match in every way, but who always stayed by my side, through the ups and downs alike. Little did we know the coming financial and health woes to befall us, yet again, over the next few years.

Fast forward about three more years into the future—I had transferred to the university as a junior during the Fall term. My boyfriend and I had been together, going on strong, for four years. And, I had been working part-time at a job that I loved for nearly two years. The future again seemed bright. Healthcare access, however, remained bleak.

The COBRA benefits from my old employer had long expired, not that I could have afforded them at $600 per month anyways. I didn’t qualify for health insurance at my new workplace because I wasn’t full-time there, owing to a loaded class schedule on-campus. And, the only medical coverage that I had been able to afford since leaving the other company was a short-lived, hybrid POS-HMO plan, which I ended up having to cancel early as nobody in my area would accept it (there went another few hundred dollars, I couldn’t afford to lose, down the drain). We had been working around the system, paying out-of-pocket for generic prescriptions, and general lab procedures, at local understaffed health clinics, since no one else seemed willing to work with us. This got us by (it had to) until an unexpected slip-and-fall accident that December rendered a hidden colon tumor palpable in my lower body (something we wouldn’t learn for another four months or so).

The ER wouldn’t treat me, and only served in referring me to a GI/Endoscopy specialist, who in turn refused to see me because I didn’t have insurance. A major medical carrier subsequently denied me coverage as uninsurable due to pre-existing conditions (namely my C2 fracture from nine years earlier, and my endometriosis diagnosis from four years prior), essentially blacklisting me among all other healthcare providers. I couldn’t even qualify for government assistance of any kind. I had come close to dying in just a few short months without knowing what was wrong with me, and we were running out of time and options fast. That’s when my boyfriend popped the question, to get me on his insurance, and to save my life…

To Be Continued.

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