Case histories

Mary

Mary G is a 43-year-old secretary who was sterilised eight years ago at the birth of her third child. All her births had been by caesarean section. Before that she had used the ‘pill’ for contraception before and between pregnancies. Since stopping the ‘pill’, her periods had become increasingly heavy and at first she could cope, but lately she’d been finding that for the first three days she had to use double or even triple protection. On one occasion her period started unexpectedly early at work and she had a very embarrassing accident which prompted a visit to her GP.

The doctor gave Mary a pelvic examination and found her uterus to be slightly bulky. Suspecting the presence of a fibroid, she organised an ultrasound scan. A blood test showed that Mary was mildly anaemic so iron tablets were prescribed. The ultrasound scan showed a fibroid pressing into the lining of the uterus. Her ovaries were healthy. After discussion, her doctor prescribed tranexamic acid tablets to reduce the amount of bleeding. She was to take two of these three or four times daily, starting once the bleeding became heavy.

Mary found these quite helpful, provided that she took them four times daily for five days each month, but, if she delayed or forgot the tablets, her bleeding was again very heavy. She also found that her cycle was becoming shorter, giving her less of an interval in between her periods. This trend towards a shorter cycle had started even before she commenced the tranexamic and her GP confirmed that it was not a side effect of the medication. She offered Mary some hormone tablets to take during the second half of the cycle in order to delay the onset of bleeding, but Mary declined these as she felt that she was already taking enough tablets.

Her sister had had a hysterectomy and she wondered if this would be an option for her too. She was referred to a gynaecologist at the local hospital who examined her and took a biopsy from the uterine lining. They discussed the various options. The gynaecologist offered to fit a Mirena coil (IUS) but warned her that there was a risk that it might be expelled because of the fibroid. They also discussed endometrial ablation and she was very keen to be considered for microwave ablation (MEA). However this was dependent on the result of an ultrasound scan that would measure the thickness of the uterine wall over the caesarean section scar.

Unfortunately the scan result indicated that MEA was not suitable. She was called back to the clinic for further discussions. Mary was by this time determined that hysterectomy would be the best option for her and was keen that this should be done vaginally as this was the operation that her sister had had. However the gynaecologist advided her that this would not be possible as she had never given birth normally. He also warned her about the risk of possible damage to her bladder following the three caesarean sections. However on the day the operation was uncomplicated and Mary’s ovaries were preserved.

Twelve months later Mary has had no regrets about the operation, although she did feel that it took a little longer for her to recover than she had expected and she was off work for the full three months. This was because she was anaemic after the operation and had developed a pelvic infection, although this was successfully treated with antibiotics.

Helen

Helen McC was 39 when she first went to her GP complaining of heavy periods. She had also been aware of some abdominal swelling but had thought that she was putting on weight because pressure of work had meant she’d stopped going to her exercise classes. After an examination, her doctor told her that she had a greatly enlarged uterus, most probably caused by fibroids. He warned her that she might need a hysterectomy, arranged an ultrasound scan to confirm the diagnosis and requested an appointment with a local gynaecologist.

Helen was somewhat dismayed at this news. She had one son, now a teenager, and had assumed she might have another child. However, she had never established a long-term relationship after the break-up of her marriage and was currently building up her career. The possible loss of her uterus was something she had not considered and she was concerned about taking time off work. She went to read up on the subject of fibroids on the Internet. By the time she saw the hospital consultant gynaecologist she was fairly well informed. The diagnosis of uterine fibroids had been confirmed but both her ovaries were healthy. They discussed four main options; doing nothing and using medical treatment to reduce the bleeding, hysterectomy, myomectomy and uterine artery embolisation. She had wondered about the possibility of keyhole surgery but her consultant explained that her uterus was too large to be removed using keyhole surgery, even if she first had a course of drug injections to shrink the fibroids.

After further consideration Helen decided to request embolisation. She had a consultation with the radiologist who arranged for her to have an MRI scan. This confirmed that she would be suitable for the procedure. She was aware that there was a small risk of infection which might result in a hysterectomy and that there was no guarantee that her symptoms would be cured. She was also aware that this procedure would not guarantee future fertiltiy but she was keen to avoid major surgery if possible. She was admitted to hospital on the morning of the procedure and was allowed home the next day. She was on a morphine drip for the first 12 hours and required regular pain killers for the first few days but recovered very well and was able to get back to work after two and a half weeks. She experienced quite a heavy vaginal discharge for the first few weeks and passed what she thought was pieces of one of the fibroids but after this there was a definite improvement in her periods. A repeat scan 12 months later showed that the fibroids were a great deal smaller and she continued to notice an improvement in her periods.

She is very much hoping that she might continue to avoid a hysterectomy although she still has some years before she reaches the menopause.

Tricia

Tricia H had always experienced heavy painful periods, even before the births of her two children and she had taken the “pill” on and off over the years. She wanted to go back on it when, at the age of 41, her bleeding became more troublesome but her doctor was unwilling to prescribe it as she is a smoker.

The doctor examined her, took a smear which was due and prescribed mefenamic acid (Ponstan), explaining that it would ease the pain and help to reduce the amount of bleeding. Tricia found that it made little difference to the bleeding and went back to her GP several months later to see if there was anything else she could try. He reassured her that her heavy periods had not caused her to be anaemic and prescribed tranexamic acid (Cyklokapron) together with the mefenamic acid. This time her heavy bleeding seemed to improve but she found that the combination of tablets seemed to upset her stomach. The next time she visited the surgery she was referred to the gynaecological clinic at the local hospital for further advice.

Examination by the gynaecologist revealed no obvious abnormality. She was given information about the progestogen-containing IUS and also about endometrial ablation. She was informed that the IUS could be fitted right away as there was no possibility that she could be pregnant (she had been sterilised). She was anxious to avoid surgery of any kind and opted to go ahead with the IUS. The procedure to fit the IUS also involved the gynaecologist taking a biopsy beforehand and she found both procedures uncomfortable but the clinic nurse was with her the whole time and was able to reassure her. She felt well enough to go to work in the afternoon. The gynaecologist had warned her that she would experience irregular bleeding and this was initially quite bothersome but there was remarkably little pain with the bleeding. She found that it took several months before the bleeding really settled and 18 months on she still gets a few days of bleeding each month but it is light and painless. She is very please with the result and plans to continue with the IUS for the full 5 years. She has been informed that her GP will be able to change it for her when the time comes.

Questions & answers

My periods are very heavy and painful and I am trying to get pregnant. Is there any treatment that might help?

You should be able to use non hormonal drugs. Mefenamic acid will relieve both heavy bleeding and pain. Tranexamic acid is more effective at reducing blood loss and can be used together with a pain killer if necessary. Both of these need to be prescribed by a doctor. It is advisable for you to discuss your symptoms with your doctor (GP) in case you need an examination or any tests to see if there is an underlying cause for your period problems which might affect your fertility.

I have been taking the “pill” on and off for a number of years. I am 38 and my partner & I feel that our family is complete. We were wondering about sterilisation but I am reluctant to come off the pill because every time I stop it my periods become very heavy and painful. What do you suggest?

If you are healthy and a non smoker you can continue taking the combined pill until you reach the menopause. If you smoke or have any other risk factors for blood vessel disease (eg high blood pressure), you could change to a pill which does not contain any oestrogen (progestogen only pill) but these pills may not control your periods so well. A sensible alternative would be the Mirena IUS (intrauterine system). It lasts for 5 years and is as effective as sterilisation. Unlike sterilisation, will also relieve your period problems.

Is there a risk that the IUS will cause a pelvic infection?

The older contraceptive “coil” got a bad name because some types did increase the risk of infection. This is unusual with the newer coils, most of which contain copper. The risk is even less with the IUS because the progestogen hormone thickens the mucus plug in the cervix, increasing the barrier against infection. If you have a past history of infection or think that you may have been exposed to a sexually transmitted infection, you should be tested for this before insertion of an IUS.

Can my GP insert the IUS?

Most surgeries will include at least one GP who can insert an IUS. Alternatively this is available at all family planning clinics. However, depending on the pattern and nature of your bleeding, your GP may prefer you to be seen by a gynaecologist in case any additional investigations are required.

Do I need to use contraception after endometrial ablation?

Yes. Destruction of the uterine lining is likely to reduce fertility but if a pregnancy does occur there is a high risk of complications including miscarriage, infection and premature birth.

I’m confused about endometrial ablation. The method available at my local hospital isn’t mentioned in your booklet

This is because new methods are being developed and there are also some older ones which aren’t widely available. Although the methods are different, the results seem to be similar. Prior to the treatment you should be given an information leaflet which will explain what you should expect.

Can I become pregnant after fibroid embolisation?

Yes – but this cannot be guaranteed. After embolisation there is a very small risk of an early menopause and also of complications that might lead to a hysterectomy. The effect of embolisation on fertility is not known. Pregnancies which have occurred in women following embolisation have generally been successful but numbers are still small.

I have endometriosis. Is it true that I will eventually need a hysterectomy?

Not inevitably. Some women find that their symptoms are permanently relieved after minor surgery or a course of medical treatment. Endometriosis may be cured after a pregnancy. If symptoms return, further courses of medical treatment or further surgery may be successful. In some cases the symptoms improve on their own over time. If not, hysterectomy with removal of both ovaries may give the best chance of a cure but some women prefer to continue on long term medical treatment until they reach the menopause.

My periods are heavy and painful and I’ve been sterilised. Can I choose just to have a hysterectomy rather than try other treatments which may not work?

Unless there is any underlying problem such as large fibroids, it is always worth trying something simpler first. Few gynaecologists would agree to do a hysterectomy straight away because the risks of hysterectomy are greater than with the other alternatives and the recovery time is very much longer. Simple non hormonal drugs are often beneficial. If not, both the IUS and endometrial ablation are effective for the majority of women and are much quicker to organise.

I am still getting heavy and prolonged bleeding although I am nearly 54. Is this abnormal?

The average age of the menopause is 52 so it is not unusual for women to still have periods well on into their 50’s. Menstrual problems are commonly experienced in the years leading up to the menopause and are usually related to hormonal changes but more serious problems, including cancer, may also occur. If you are concerned about the pattern or heaviness of your bleeding you should discuss this with your GP as you may need some investigations (see page xx). If the problem is hormonal, cyclical progestogens or the IUS (pages xx – xx) are likely to be effective.

Will having a hysterectomy affect my sex life?

The majority of women who have had a hysterectomy resume a normal sex life afterwards. However results of studies comparing women who have had a hysterectomy with those who have had endometrial ablation have suggested that loss of the uterus may reduce sexual arousal . This may occur even if the cervix and the ovaries have been left behind but is more likely if the ovaries are removed. Sexual problems are more likely if you have experienced problems beforehand. If you have had your ovaries removed, you may experience dryness of the vagina and pain on intercourse. This is relieved by hormone replacement therapy (HRT) or by vaginal creams or pessaries containing oestrogen. There are also non-hormonal remedies available to help with vaginal lubrication. Your GP will be able to advise about suitable treatment.

Can I choose to have a vaginal rather than an abdominal hysterectomy?

Not all women are suitable for vaginal hysterectomy and you will need to discuss this with the gynaecologist who is carrying out the operation. If you have large fibroids or endometriosis, it is much less likely that you would be offered a vaginal hysterectomy. Women who have had normal childbirth are more suitable for a vaginal hysterectomy than those who have had no children or only caesarean section births. This is because childbirth results in some stretching of the upper vagina and of the ligaments that support the uterus, making a vaginal hysterectomy easier and safer. If you request removal of your ovaries, this may not be possible with a vaginal hysterectomy. However, some gynaecologists may recommend a laparoscopically assisted vaginal hysterectomy in which the ovaries are removed with the aid of the laparoscope and the remainder of the operation is done via the vagina.