Hormonal medications

The oral contraceptive pill

The ‘pill’ or combined oral contraceptive pill (COCP) is an extremely effective treatment for the relief of both heavy and painful periods, because the combination of the hormones oestrogen and progesterone not only stops ovulation (egg release), but also causes thinning of the uterine lining and reduces muscle wall cramps. It reduces menstrual bleeding by around 40%. It may also reduce symptoms of PMS.

Unfortunately, many women mistrust the ‘pill’, partly because of bad publicity from the lay press which has tended to sensationalise reports of the risks while overlooking its many benefits. What is often not appreciated is that the ‘pill’ has other benefits besides those of contraception and relief of menstrual problems. Long-term users of the COCP have a significantly reduced risk of both uterine and ovarian cancer and are less likely to develop uterine fibroids or endometriosis.

Hormonally related side effects are common and include bloating, breast tenderness, headaches and mood swings. These can often be relieved by changing to a different brand. Serious side effects, although well publicised, are extremely rare. A minority of women are at greater risk of developing venous thrombosis (blood clots) if they take the ‘pill’.

The COCP may also increase the risk of heart disesase or stroke if prescribed for women over the age of 35 who smoke or have high blood pressure. These complications occur as a side effect of the hormone oestrogen. Pills containing oestrogen are not suitable for women who are significantly overweight, have high blood pressure or a history of thrombosis. Although the ‘pill’ is most often prescribed for younger women, it can be used safely in women of all ages who are non-smokers and have no risk factors for heart or blood vessel disease.

Synthetic progesterone

For women who need to avoid oestrogen, progesterone derivatives, known as progestogens may be helpful and are suitable for women of all ages. In order to reduce heavy periods, these need to be taken in a similar way to the COCP; for 21 days each month, starting on the 5th day of bleeding. The most effective of the progestogens for control of abnormal bleeding is norethisterone.

Taken three times daily in this way it can reduced blood loss by up to 80%. Norethisterone is particularly useful in controlling problem bleeding in the lead up to the menopause. The perimenopausal ovary may fail to produce enough progesterone, enabling the uterine lining to thicken up too much under the influence of oestrogen. The period may be delayed and then be unusually heavy and prolonged. In these circumstances, the bleeding can be controlled by taking a 21 day course of norethisterone to balance out the effect of the oestrogen.

Once the initial course of norethisterone is stopped the bleeding will restart as the uterine lining is shed. If this is again abnormally heavy or prolonged, a further 21 day course of the norethisterone can be prescribed and repeated as necessary. If the bleeding does not settle down promptly investigations must be done to exclude a more serious cause. Some women experience side effects with progestogens such as bloating, nausea and weight gain, but serious side effects are very rare.

Synthetic progesterone is also available as a three-monthly injection (depo-provera). This is normally prescribed as a contraceptive, but it can be helpful for the treatment of heavy or painful periods by stopping the bleeding altogether.

 The intrauterine system (IUS)

This simple device has revolutionised gynaecological practice by its simplicity and ease of administration. It is a T shaped device which fits neatly into the cavity of the uterus. The stem of the T contains the hormone progestogen (synthetic progesterone). There is one such system currently available, known as Mirena, but other similar systems are likely to be available in the future. It was originally developed as a contraceptive. However, unlike older intrauterine contraceptive devices (coils), Mirena was found to reduce menstrual bleeding dramatically – by over 80 per cent. It is thus more effective than the “pill” or tranexamic acid. Treatment trials have shown that it is as effective as the surgical option of endometrial ablation and can offer a real alternative to hysterectomy.

Although originally devised as a contraceptive the Mirena intrauterine device can help to reduce heavy menstrual bleeding

How does it work?

It releases the progestogen into the cavity of the uterus where it gradually causes thinning of the lining (endometrium). The uterine lining does not thicken up in response to the normal hormone changes of the menstrual cycle, thus considerably reducing blood loss. This thinning out process can take up to three or even six months and during this time it is common to experience irregular bleeding although this is not usually heavy. However by the end of the first year of use, the majority of women experience no bleeding at all or very light bleeding or spotting. Another advantage of the intrauterine system is that it relieves period cramps.

How is it inserted and removed?

Inserting the device into the uterus is simple, involving the use of a speculum. The cervix is viewed and then usually held with a grasping instrument to steady it while the IUS is inserted. Prior to insertion a biopsy of the lining may be taken or an instrument called a “sound” used to measure the length of the uterine cavity.

The whole process takes a few minutes and usually causes only mild to moderate discomfort. Some women do not feel anything at all! Insertion does not usually require an anaesthetic although a local anaesthetic is sometimes used. Once in place, it can remain in the uterine cavity for up to five years. The device is easy to remove and the effects are reversed as soon as it is removed, so it may suit you if you want to have more children in the future.

The device can be inserted, removed and replaced by your GP or a family planning doctor, or at the hospital. However, some GPs prefer to refer you to hospital for insertion of the device and to enable a more detailed discussion of the various treatment options. Occasionally a general anaesthetic is required for its insertion. This is more likely if you have never given birth.

What are the side effects?

The dosage of the progestogen in the IUS is sufficient to act on the uterine lining but only very small amounts are absorbed into the bloodstream so that hormonal effects elsewhere in the body are very minimal. The IUS does not stop ovulation or normal hormone production so should not affect your mood and the way that you feel generally.

Some women do complain of mild side effects including acne, headaches or breast discomfort but this is not common and usually settles down after a few weeks. There is no evidence that the IUS causes weight gain. The main disadvantage, as mentioned above, is the high liklihood of irregular “breakthrough” bleeding during the early weeks after insertion. This can sometimes persist for several months. If this is a problem, you are usually advised to persevere for a bit longer as this almost always settles down eventually. Some women are concerned about the possibility of infection; a risk with some of the earlier contraceptive “coils”. This is very rare with the IUS. The progestogen causes thickening of cervical mucus which acts as a barrier to infection.

The only risk might be at the time of insertion if you have previously been exposed to a sexually transmitted infection. If this is the case you should be offered a screening test (urine and or swab test) before insertion.

How successful is it?

Mirena is the most successful of all the medical treatments for heavy periods; causing a 70-90% reduction in menstrual blood loss. It also relieves menstual cramps. Some women find that it reduces PMS although this is difficult to understand as it does not alter hormone production by the ovaries. It is as effective as the surgical procedure of endometrial ablation and has been shown to reduce the liklihood of a hysterectomy being performed.

Is the IUS right for me?

It is suitable for most women with heavy periods and particularly for those who are concerned about the risks of surgery or loss of fertility. It is particularly suitable for women also needing contraception and is a sensible alternative to sterilisation for women whose periods tend to be heavy. It can be used at all ages, regardless of whether or not you have had children and although its insertion may be more difficult if you have not had children, a local or general anaesthetic can be used if necessary.

It can also be used for the treatment of some abnormalities of the uterine lining such as excessive thickening (hyperplasia) and for treatment of women thought to be at risk of developing uterine lining cancer. For women nearing the menopause, it can be used in conjunction with oestrogen HRT.

It may also be suitable for women with small fibroids although if the fibroids are large there is a chance that the device may be expelled. It is also sometimes recommended for the treatment of the symptoms of endometriosis.

Medical treatments for endometriosis

Endometriosis can cause severe pain during or before the onset of periods and during sexual intercourse (see page xx). The symptoms arise because small patches of uterine lining tissue (endometrium) have become attached to the pelvic lining and/or the ovaries, and is stimulated to grow and shed each month by the hormones released by the ovaries.

Some women find adequate relief of symptoms of endometriosis using non-hormonal treatments such as simple pain-killers such as paracetamol or NSAIDs such as ibuprofen.

Alternative therapies (for example, homoeopathy, herbal preparations) have an important role for some women although their benefits are not scientifically proven.

As the symptoms of endometriosis are triggered by the hormones released by the ovaries, treatments are often prescribed to suppress this hormone production. Similarly, endometriosis is relieved by the natural menopause. Hormonal treatments work by causing temporary cessation of the periods. This allows the patches of endometriosis to shrink away.

There are several different forms of hormonal treatment which are described below. All may cause side effects but these differ from woman to woman. They are all effective in relieving pain in the short term but endometriosis can recur in up to 50% of women in the longer term once treatment is stopped. Thus medical treatment may need to be repeated intermittently or continued long term.

While hormonal treatments preserve future fertility, all of them prevent ovulation (egg release) and are thus not suitable for use if you are trying to conceive a baby. Some women with endometriosis require surgery or in-vitro fertilisation (IVF) treatment to help them to conceive.

Hormone treatments containing oestrogen and/or progesterone

Used continuously, high doses of synthetic progesterone (progestogens) gradually shrink and inactivate deposits of endometriosis. They also suppress menstrual bleeding because of a similar thinning effect on the uterine lining. Medroxyprogesterone acetate is the progestogen most often used for treatment of endometriosis. Progestogens have been used for many years in this way and their advantage over newer treatments (see below) is that they can be used for longer. However, side effects may occur, particularly irregular bleeding (spotting), bloating and fluid retention. This is because of the high doses of the hormones.

An alternative is the combined oral contraceptive pill which works best for endometriosis if you take it continuously, without a monthly break. Another alternative which has recently become available is low dose desogrestel (Cerazette), a new type of contraceptive pill which is taken continuously and contains no oestrogen. It differs from the very low dose progestogen-only pills (or minipills) in that it contains sufficient progestogen to stop ovulation but the levels of progestogen are less than in the high dose preparations mentioned above so that side effects are very much less. It has not yet been fully tested for the treatment of endometriosis but is already being recommended by gynaecologists and seems to be helpful for many women.

The Intrauterine System (IUS)

Because the IUS (Mirena) is very effective at shrinking normal uterine lining tissue and in relieving period pain, it is often used by gynaecologists to relieve the symptoms of endometriosis. However it has not yet been fully tested for use in this condition. The potential advantages are that hormonal side effects are much less than they would be with tablets or injections. The potential disadvantage is that unlike the other hormonal treatments used for endometriosis, the IUS (Mirena) does not stop ovulation and may thus be less effective for some women if the endometriosis is primarily present in the ovaries.

GnRH analogues

Gonadotrophin-releasing hormone (GnRH) analogues are taken by nasal spray (sniff) or by monthly or three monthly injections. They are synthetic versions of a natural hormone known as the gonadotrophin-releasing hormone. They work by blocking the signal which goes from the the pituitary gland to the ovaries, thereby stopping the hormone production from the ovaries. This stops you having periods and deprives the areas of endometriosis of hormonal stimulation.

They are extremely effective in relieving the symptoms of endometriosis but their main disadvantage is that this creates a temporary artificial menopause and you may experience side effects such as hot flushes, night sweats and vaginal dryness.

The other problem is that the the lack of oestrogen caused by GnRH analogues may lead to loss of calcium from bones, leading to an increased future risk of osteoporosis. However, it is possible to take very low doses of oestrogen and progesterone in order to protect the bones and relieve the other side effects if you need to remain on the treatment for a long time. This is known as “add-back” hormone replacement therapy.

Male hormone derivatives

Male hormone derivatives work by suppressing hormone release from the pituitary gland and the ovaries. Unlike the GnRH analogues, they do not cause bone loss or menopausal symptoms, but side effects of weight gain, fluid retention and greasy skin are very common.

The best known of these drugs is danazol which you take in tablet form on a daily basis. A newer alternative is gestrinone which is more convenient in that you take it twice a week rather than every day.

Side effects may include weight gain, fluid retention and greasy skin. There is also a small risk of growth of unwanted body hair and voice changes although fortunately these effects are rare. As a result, although they are very effective at relieving symptoms, they are usually used only in the short term.

Medical treatments for uterine fibroids

Fibroids are extremely common and do not always cause symptoms but, if they distort the cavity of the uterus, they may be a cause of heavy menstrual bleeding. Like endometriosis, uterine fibroids are dependent for their growth on ovarian hormones and so tend to shrink naturally after the menopause.

Treatments that lower hormone levels, such as GnRH analogues, make fibroids shrink in size, but they are less useful for this condition than they are for endometriosis because fibroids almost always re-grow immediately the drug treatment is stopped. They may however be useful if you are very near to the menopause.

Other hormones such as synthetic progesterones, danazol, the oral contraceptive pill or the IUS (Mirena) may be used to relieve blood loss resulting from fibroids, but do not cause shrinkage and are thus not helpful if the fibroids are large and causing pressure problems. There is a greater risk of expulsion of an IUS if there are fibroids distorting the cavity of the uterus. If you have smallish fibroids which are causing heavy periods, non-hormonal treatment with tranexamic acid may be very helpful and may cause fewer side effects than hormonal therapies. Bleeding resulting from fibroids may mean you develop anaemia, in which case a short course of a GnRH analogue, together with iron may be prescribed to treat it, but you may ultimately need to have the fibroids treated by embolisation or removed surgically by myomectomy or hysterectomy.

KEY POINTS

• Tranexamic acid (Cyklokapron) is a non-hormonal treatment that reduces bleeding

   

• The oral contraceptive pill relieves heavy bleeding and pain, and helps to protect against ovarian and uterine (endometrial) cancer

   

• The Intrauterine System (IUS) is very effective in reducing heavy periods, but irregular bleeding is a problem initially

   

• Medical treatments are usually effective in the treatment of bleeding problems that occur in the lead-up to the menopause

   

• Medical treatments relieve the symptoms of fibroids and endometriosis but are not a long-term cure