Heavy Periods Age 45

Sandra Hash is a 45 year old long time patient mine who was in the office several months ago for a routine physical exam when she noted on her intake questionnaire that she was having trouble with heavy periods.

She is the divorced mother of two, and had gone off her birth control pills a couple years ago. Since then, she’s had increasingly heavy, lengthy periods and cramps. She is not sexually active and has not been active for two years. She denied any other symptoms. Her periods last 8 days, with the last two days just spotting.

All of her exam was normal, except for her uterus which was about 10 week size, firm and slightly irregular in contour. It was not tender.

We have an ultrasound scanner in the office, so I scanned her pelvis and discovered a few significant findings. First, her uterus was enlarged irregularly with several measurable fibroid tumors. Two were subserosal, two were intramural, and one larger one was on the posterior wall slightly distorting the endometrial cavity.

I also found that her endometrial stripe or lining was a little bit thicker than I was expecting, considering that she had just completed her period yesterday. It was about 15 mm. Her ovaries had a single 7 mm ovarian follicle, which is what I expected at this stage in her menstrual cycle.

Because of the thickened lining in this 45 year old woman with heavy periods, I performed another test, called a sonohysterogram. I threaded a thin catheter into the uterine cavity and then, while watching with ultrasound, I injected a small amount of sterile saline into the cavity. As the saline was distributing itself around the cavity, it became obvious that much of the thickened uterine lining was not really thickened endometrium, but an enlongated endometrial polyp, about 1 cm x 1 cm x 3 cm, that was attached to the fundus on the anterior uterine wall.

So this patient had two reasons for her heavy periods, uterine fibroids as well as an endometrial polyp.

Based on these findings, we scheduled her for minor surgery and performed a hysteroscopy and D&C to remove the polyp. Re-evaluating her several months later, her periods were much more manageable, although the cramping was still significant and her fibroids remained unchanged.

When we did the hysteroscopy, we did not attempt to resect the submucous fibroid because it was way too deep within the uterine wall and only slightly distorted the endometrial cavity. It would have been too dangerous to attempt resection.

After re-evaluating her response to the removal of the benign endometrial polyp, we had to decide between simple observation of her bleeding pattern, or living with the heavy flows provoked by the fibroids, versus hysterectomy, versus trying birth control pills. Each of these had their own set of risks and benefits, but each could be a reasonable choice for the patient. She opted to try birth control pills.

The birth control pills, by virtue of suppressing ovarian function, will result in an overall reduction in circulating estrogens, making it less likely that the fibroids will grow and possibly discouraging their growth. Further, by limiting the endometrial stimulation, her periods should be lighter and less crampy.

Three months later, she was very happy, with 3 day light periods and no cramps. She was given the option of shifting to continuous birth control pills to completely suppress menses, but she declined, and we were fine with that.

So our approach to this patient with menorrhagia was to first evaluate her with a pelvic exam, ultrasound, and sonohysterography. We then proceeded to hysteroscopy and D&C because we had an identifiable and resectable problem, the endometrial polyp that can cause or contribute to the heavy bleeding. Had there been no polyp, then I would have performed an office endometrial biopsy to evaluate the thickened uterine lining on a microscopic level. In her case, there was no need for that since the D&C would sample the lining.

We certainly could have performed a hysterectomy, and that would have been effective, but it is major surgery with the potential for major complications, and all of that for a problem that will naturally resolve at the time of menopause, on average at age 51. The patient was much more comfortable with simply taking birth control pills to control her symptoms, and as a non-smoker, this was a very acceptable choice.