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See Dr Morton’s manage periods and understand endometriosis
Periods can be heavy but not painful; heavy and painful; or just very painful but not unduly heavy. All shades of grey for both.
Previous articles published by Dr Morton’s – the medical helpline, have discussed fibroid embolisation for the non-surgical treatment of fibroids and the use of MRI and ultrasound diagnosis in gynaecology. Links below:
detecting fibroids with imaging
uterine fibroids and embolisation
fibroids – who is suitable for embolisation
magnetic resonance imaging
ultrasound in gynaecology
endometrial ablation: the 3-minute solution to heavy periods
In this article we discuss a very important and not uncommon cause of painful periods; a cause which has often been missed in the past or a false diagnosis of fibroids given. It is called adenomyosis. It is a rather long medical name for a condition in which cells from the lining of the womb (endometrium) where a baby would develop and which sloughs off every month giving a woman a period, migrate into the muscle of the womb and form nests of endometrial cells. This is a variety of endometriosis, which is the umbrella term for endometrium in other places than just in the uterus. These cells in the wrong place swell up and bleed in response to normal hormonal cycles, producing tiny blood filled cysts in between the muscle fibres of the uterus. It is like having a tense bruise in a muscle. This process results in women, particularly in their forties, developing an enlarged uterus, with very heavy periods usually with severe pain and not infrequently they become anaemic and are significantly debilitated.
Approximately 20% of women who present with heavy periods and pain during periods will have this condition. Very often radiographers carrying out an ultrasound scan mistake adenomyosis for fibroids and the author has encountered numerous such situations. The most accurate method for the diagnosis of adenomyosis is using magnetic resonance imaging (MRI) scans which, with current technology, can pick up even relatively mild degrees of the condition. In the past adenomyosis has been very difficult to treat except by hysterectomy which has been the mainstay of treatment. However, we are now able to treat this condition with uterine artery embolisation: the procedure which I have previously described in my article which tiny particles are injected into the uterine arteries which target the abnormal tissue and kill it. The procedure is exactly the same as for fibroid embolisation: those who wish to get a precise description of this minimally invasive procedure (it involves a tiny 0.5 cm incision in the groin) should visit my website where there is a video description of it. Whereas fibroid embolisation has a cure rate of around 95% the cure rate for adenomyosis is not as high. One embolisation would be expected to cure approximately 50% of women permanently, the rest will get an initially favourable result and then their periods will gradually deteriorate again. We are now treating that situation by second and rarely third embolisations.
Women are very pleased to avoid a hysterectomy and even those in whom symptoms recur, it has been shown in multiple studies that they are still glad they had embolisations for the respite it gave them. In some cases, a woman’s symptoms can be controlled until the menopause when the adenomyosis becomes inactive unless the woman takes hormone replacement therapy.
In approximately 30% of women, no cause can be found for their heavy, painful periods. This is called have dysfunctional uterine bleeding, meaning that their uterus is to all intents and purposes normal but simply working in an antisocial unacceptable way. Today there are very effective measures to deal with this problem without surgery. Hormone treatment such as the contraceptive pill, particularly taken back to back, or the progesterone only pill may do the trick. Another alternative is to have a Mirena IUS inserted. This hormone releasing coil releases a tiny amount of progesterone every day and this has the effect of making the endometrium inside the uterine cavity and within its muscle wall unresponsive to the ovary’s hormonal cycles. Usually periods stop altogether by 6 months.
For those women who are prepared to accept that they should not have further pregnancies, removal of the endometrium in its entirety, either by resection or thermal ablation works well. These treatments do not work effectively either in women with significant fibroids or with adenomyosis uteri. Fortunately we now have a minimally invasive treatment for both these conditions in the form of uterine artery embolisation (UFE, UAE).