Dysfunctional uterine bleeding is very common during the whole of women’s reproductive life. The condition is more frequent in the perimenopause: 25% of women aged 41-49 complain of too heavy bleeding and up to 17% of women aged 41-55 years are actually affected of which 50% are over 45 years.

WHY IRREGULAR OR EXCESSIVE BLEEDING?

Regular periods are the result of a precise hormone balance causing regular ovulation.  During the years preceeding the menopause, changes in hormone levels interfere with ovulation.  If ovulation does not occur, the ovary will continue making estrogen, causing the endometrium to keep thickening.  This often leads to a late and heavy menstrual period followed by irregular bleeding and spotting.  This can also result in endometrial polyps, a greater thickening called “hyperplasia,” or in extreme long-standing cases, cancer of the endometrium.
It is not unusual to have irregular bleeding for up to 6 months before menstrual periods stop completely. Unless the bleeding is excessive, or a woman is at high risk for uterine cancer.  As a result, abnormal uterine bleeding is a common reason for consulting general practitioners and gynaecologists.  It is estimated that approximately 10-15% of all gynaecological patients receive treatment for repeated episodes of dysfunctional uterine bleeding.  The quality of life of women suffering from excessive bleeding is impaired in many respects.  Excessive bleeding or pain, or both, may impose severe constraints on their professional, social, and family activities.

TREATMENT OF EXCESSIVE BLEEDING

Hysterectomy
Until recently, medical treatment has been disappointing, and various surgical techniques in the form of endometrial ablation have been developed.  Excessive bleeding is a major reason for hysterectomy among fertile women. Approximately 30% of patients referred for gynecological treatment are for menorrhagia, often leading to surgical intervention if conservative treatment (e.g. contraceptive pills, progestogens, fibrinolytic inhibitors and prostaglandin inhibitors) fails. In the USA, 700,000 hysterectomies are performed each year of which 30% for excessive menstrual bleeding. In the UK 40% of the 100,000 hysterectomies are performed for that reason.

Intrauterine treatment : a  highly effective alternative to hysterectomy
LNG-releasing intrauterine systems (IUS) have been developed to provide a localised effect, suppressing the endometrium.  The localized effect of LNG is many times stronger than the effect which can be obtained by oral treatment.  Even when the uterus harbours fibroids, a LNG IUS is effective in the majority of patients.  Between 50 up to 70 or 80% of hysterectomies can be avoided.

 

Uterus containing fibroids. Uterine myoma (leiomyoma, fibroid) is a very common disease. Leiomyomas occur with an incidence of up to 77%.  They are often asymptomatic but some 25-50% of women will experience symptoms such as menorrhagia (heavy or excessive menstrual periods) and pelvic discomfort. Around 5% of the fibroids are intracavitary and submucosal and are most difficult to treat.  Hysterectomy is still the most commonly used procedure although medical treatments are preferable.  Uterine fibroids are responsible for 30% of hysterectomies.  Recently, new conservative treatment options have been developed such as the treatment with GnRH analogs and the levonorgestrel-releasing intrauterine system (LNG IUS) releasing small amounts of the hormone levonorgestrel per day for several years.  The system avoids surgery in many women.