Amy Terlisner, ND
Heavy menstrual bleeding can present as a significant health issue in premenopausal women. Average blood loss in normal menses is defined as 35-40 mL over 4-7 days. Menorrhagia is defined as a loss of over 80 mL per month. Blood loss that is normal in quantity should not produce an iron deficiency anemia with adequate diet and no other health issues, such as malabsorption. Yet, iron deficiency due to menorrhagia is a common issue that we practitioners face. I am sure we have all had small numbers of patients who do not respond well to our protocols and who continue to struggle with marked fatigue month after month as a result of their anemia.
Dysfunctional uterine bleeding and menorrhagia can occur commonly around menarche and perimenopause, and the majority of these cases are due to anovulatory cycles, with unopposed estrogen thickening the uterine lining to an excessive degree.1
Causes of Menorrhagia
Rare causes of dysfunctional and heavy uterine bleeding include von Willebrand’s disease, idiopathic thrombocytopenic purpura, disseminated intravascular coagulation, hemophilia, leukemia and hyperprolactinemia. Liver problems which decrease clotting factor production must be considered as well as morbid obesity, which creates a hyperestrogenic state. A common cause of menorrhagia includes thyroid imbalance. Finally, smokers tend to have heavier periods than nonsmokers.
Standard Allopathic Treatment
Allopathic treatments vary and depend on the level of anemia. If anemia is mild (Hct >33%, hemoglobin >11 g/dL) oral iron is recommended while waiting for normalization of menstrual bleeding. If anemia is moderate (Hct 27-33%, hemoglobin 9-11 g/dL), oral contraceptives are first line therapy and require a pill with at least 30-35 mg of ethinyl estradiol. If severe anemia is present (hematocrit <27%, hemoglobin < 9 g/dL), oral contraceptives are given 4 times a day until bleeding has arrested. Second line drug therapies include medroxyprogesterone, NSAIDS, goserelin and danazol.2
After failure of hormonal and drug therapies, allopathic physicians will often recommend surgical procedures including dilatation and curettage, hysterectomy, and uterine ablation.2 The focus of the rest of this article is to familiarize the naturopathic physician with the procedure of uterine / endometrial ablation.
Uterine Ablation
Uterine ablation is a surgical procedure aimed at damaging the basal layer of the endometrium in order to prevent monthly thickening and shedding of the functional layer; thus, the patient experiences a cessation of monthly bleeding. Uterine ablation techniques can be divided into 2 types: resectoscopic and nonresectoscopic. A resectoscope is a hysteroscope with a built-in wire loop that uses high frequency electrical current to cut or coagulate tissue. The resectoscope is inserted through the cervix and requires dilation. Essentially, the nonresectoscope technique is done blind.
Types of uterine ablation include laser, thermal, hydrothermal, electrical current, bipolar radiofrequency, microwave, and cryoablation.
Uterine ablation will dramatically decrease the volume of monthly menses or stop it altogether. Rarely, patients may need more than one procedure if they are looking to completely stop bleeding.
According to a Cochrane review which compared the newer ‘blind’ techniques (second generation) with the gold standard hysteroscopic ablative techniques (first generation), there was no evidence of overall differences in the improvement in heavy menstrual bleeding or patient satisfaction. Surgery was an average of 15 minutes shorter, local anesthesia was more likely to be used, and equipment failure was more likely with second-generation ablation. Women undergoing newer ablative procedures were less likely to have fluid overload, uterine perforation, cervical lacerations and hematometra than women undergoing the more traditional type of ablation and resection techniques. However, women were more likely to have nausea, vomiting, and uterine cramping with the newer techniques.3
In a 5-year follow-up of 107 patients receiving the Novasure procedure (which uses radiofrequency), no intraoperative or postoperative complications were observed. Local or general anesthesia was used, and procedure time averaged 94 seconds. Amenorrhea was reported by 75% of patients and successful reduction of bleeding was achieved in 98%, with hysterectomy and retreatment rates of 2.9% and 3.8%, respectively. The researcher concluded that the NovaSure system of uterine ablation is a safe and effective method for treatment of women with menorrhagia secondary to dysfunctional uterine bleeding.4
Minor side effects after uterine ablation include cramping for 24-48 hours after the procedure; thin, watery, and often bloody discharge which can last for weeks; frequent urination for up to 24 hours; and nausea. Some rare risks of the procedure include perforation of the uterus or bowel; burns to the vagina, bowel, or vulva; fluid leakage into the bloodstream; and sepsis.5
The major side effects are related to pregnancy after having the procedure, and a second form of birth control must always be used. There are case reports of death by uterine rupture, placenta increta, and miscarriage in women with unplanned pregnancy following the procedure.6 Women who choose to undergo this surgery must be counseled that there are life-threatening complications that may occur if they get pregnant post procedure.
Case Studies
I have recommended uterine ablation to a handful of patients who went on to have the procedure. I wish to discuss two cases. In each case, the patients were perimenopausal and in their late 40s. Both had already had children and did not wish to have any more. Each patient suffered from long-standing iron deficiency anemia (not corrected by numerous allopathic and naturopathic therapies), marked fatigue, and dysmenorrhea. Each patient had had a full workup to discover the etiology of their menorrhagia. In both cases, the bleeding was due to uterine fibroids, and each had spent months engaging in aggressive naturopathic treatment protocols to reduce the bleeding, address the anemia, as well as improve overall health.
The first patient was a 48-year-old smoker and had multiple fibroids under 5 cm that contributed to her menorrhagia. I spent considerable time educating her on the negative effects of smoking. She saw me one day and explained that she had set up an appointment to have a hysterectomy. At this time I mentioned uterine ablation and recommended a consult with a skilled ob/gyn surgeon. The patient had the procedure and continues to be happy with the results.
The second patient was a 46-year-old with a 9 cm uterine fibroid that she refused to have surgically removed. Each month she suffered severe dysmenorrhea which did not respond to hydrocodone/acetaminophen or NSAIDS. She also suffered from menorrhagia, urinary frequency and urgency, and bowel symptoms. This patient spent 3 months on a strict detoxification regime including dietary restrictions, botanical medicine, high-dose fiber, acupuncture, and colon hydrotherapy, all of which did nothing to shrink the mass. Again, I mentioned uterine ablation after she stated her desire to have a hysterectomy. Within 90 days of the procedure, the patient’s symptoms completely disappeared. Even more encouraging was the shrinking of the uterine fibroid, which I am confident will shrink further once the patient goes through menopause.
Uterine ablation should be considered in perimenopausal patients who desire to have a hysterectomy after failed naturopathic or allopathic protocols and whose quality of life has been severely affected by menorrhagia. This procedure allows patients to retain all their pelvic organs, which would surely lower the incidence of prolapse and other common side effects related to hysterectomies. I encourage each naturopathic physician to seek out an excellent surgical referral for the rare instance when this procedure may be appropriate.
Amy Elizabeth Terlisner, NMD attended Bastyr University. She has an extensive teaching background, which she believes is a critical element of naturopathic medicine. Dr. Terlisner’s specialties include women’s health, cardiovascular disease, gastroenterology, preventive and anti-aging medicine, and bio-identical hormone replacement therapy.
References:
1. Farrell E. Dysfunctional uterine bleeding. Aust Fam Physician. 2004;33(11):906-908.
2. Dysfuctional Uterine Bleeding. MD Consult Web site. http://www.mdconsult.com. Accessed December 22, 2009.
3. Lethaby A, Hickey M, Garry R, et al. Endometrial resection / ablation techniques for heavy menstrual bleeding. The Cochrane Collaboration Web site. http://www.cochrane.org/reviews/en/ab001501.html. Accessed December 22, 2009.
4. Gallinat A. An impedance-controlled system for endometrial ablation: five-year follow-up of 107 patients. J Reprod Med. 2007;52(6):467-472.
5. The American Congress of Obstetricians and Gynecologists Web site. http://www.acog.org/publications/patient_education/bp134.cfm. Accessed December 22, 2009.
6. Laberge PY. Serious and deadly complications from pregnancy after endometrial ablation: two case reports and review of the literature. J Gynecol Obstet Biol Reprod (Paris). 2008;37(6):609-613.
