Treatment

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After a diagnosis by your health care professional, treatments for menstrual disorders may range from taking over-the-counter medication for relief of PMS to considering a hysterectomy to end abnormal uterine bleeding.

Abnormal Uterine Bleeding

Medication and surgery are used to treat AUB. Typically, less invasive therapies should be considered first. Treatment choices depend on your age, your desire to preserve fertility and the cause of the bleeding (dysfunctional or structural). Some treatments may reduce your menstrual bleeding to a light to normal flow.

Medication

Medication therapy is often successful and a good first option. The benefits last only as long as the medication is taken, so if you choose this route, you should know that medical treatment is a long-term commitment.

Low-dose birth control pills, progestins and nonsteroidal anti-inflammatory drugs (NSAIDs) may help control heavy or irregular bleeding caused by hormonal imbalances. If your periods have stopped, oral contraceptives (OCs) and contraceptive patches are highly effective in restoring regular bleeding. Both can also help reduce menstrual flow, improve and control menstrual patterns and relieve pelvic pain during menstruation.

They are considered for PMS treatment if your symptoms are mostly physical, but may not be effective if your primary symptom is mood changes. However, a newer brand of oral contraceptive containing a form of progesterone called drospirenone and marketed under the brand name YAZ may reduce some mood-related symptoms such as anxiety, irritability, tearfulness and tension.

Birth control pills may not be an appropriate treatment choice if you smoke, have a history of pulmonary embolism (blood clots in your lungs) or have bothersome side effects from this medication. The risk of these side effects is even higher if you use the birth control patch, because it contains higher levels of estrogen.

Progestins, either oral or injectable, are also used to manage heavy bleeding, particularly that resulting from a lack of ovulation. Although they don't work as well as estrogen, they are effective for long-term management.

The levonorgestrel IUD (Mirena) may also help decrease heavy bleeding for some women by slowly releasing progestin into the uterus for up to five years. Studies find that it may reduce menstrual blood loss by 40 to 50 percent and decrease pain associated with periods.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are available over the counter and can help reduce menstrual bleeding. These medications include ibuprofen (Advil, Motrin), naproxen (Aleve) and mefenamic acid (Ponstel). Common side effects include stomach upset, headaches, dizziness and drowsiness.

Surgery

Except for hysterectomy, surgical options for heavy bleeding preserve the uterus, destroying just the uterine lining. However, most of these procedures result in the loss of fertility, ending your ability to have children.

There are other important considerations for each of these treatment options. Risks common to all surgical options include infection, hemorrhage and other complications.

• Endometrial ablation. These procedures are recommended only for women who have completed their families, because they destroy the uterine lining and, therefore, fertility. However, following treatment, you must use contraception. Although endometrial ablation destroys the uterine lining, there is a small chance that pregnancy could occur, which could be dangerous to both mother and fetus. Overall, endometrial ablation procedures have a success rate of between 80 and 90 percent, and about 14 to 55 percent of women stop having menstrual periods after undergoing endometrial ablation.

The main types of ablation are:

• Hysteroscopic endometrial ablation or endometrial resection (EMR). During hysteroscopic endometrial ablation, the uterine lining is viewed through a small telescope and cauterized with an electrosurgical tip called a "rollerball". EMR is another hysteroscopic technique, in which the uterine lining and a quarter-inch of its underlying muscle are removed. The procedures are considered outpatient surgeries and normally take about 20 to 30 minutes, depending on the skill of the surgeon. They are performed under epidural or general anesthesia and should take one to two days to recover, in most cases.

  Hysteroscopic procedures (rollerball and EMR) are acquired skills that not every physician possesses. Ask yours about past experience in this procedure before agreeing to it. Both procedures also require filling your uterus with fluid so its contours can be visualized on a monitor and so it remains open during the procedure. While viewing your uterus, the physician moves the rollerball (which resembles the type of tool you might use to smooth wallpaper) or wire-loop electrode, which delivers an electrical current, from top to bottom of the uterus until the entire surface of the uterus has been cauterized or removed.

  Risks associated with this procedure include uterine perforation and fluid overload. Because the fluid pumped into your uterus is kept under pressure during the procedure, there is a very slight risk that fluid may escape into the uterine blood vessels, upsetting the concentration of electrolytes, such as sodium, in your blood stream. This imbalance may be life threatening. However, the risk of fluid overload is very rare in the hands of an experienced physician and with the new fluid monitoring equipment available.

• Hot water ablation. This method of ablation uses a hot saline solution to destroy specific tissue inside the uterus. A computer monitors the uterus to make sure no fluid leaks through uterine walls or tubes. It is performed under local anesthesia. The surgeon inserts a hysteroscope and tubing through the vagina into the uterus. The heater canister, which is located outside the body, heats saline fluid (salt water) to a temperature of 176 to 194 degrees F. With the aid of the pump and valves, the heated fluid is circulated through the uterus for 10 minutes, followed by a cool-down phase, where fluid at a temperature of 34 degrees F is circulated for one minute. The exposure to the heated fluid destroys the endometrium.

• Uterine cryoblation therapy. This therapy system uses freezing to destroy the lining of the uterus. It involves a slender probe attached to a cooling unit. After receiving local anesthesia, the probe is inserted through the cervix into the uterus. The tip of the probe is brought to a very low temperature (-130 degrees F) to freeze and eliminate the uterine lining.

• Bipolar radiofrequency ablation. This system works by ablating, or destroying, the lining of the uterus using electrical energy. The procedure is performed with a handheld catheter that delivers radio frequency energy to the uterine lining for about 90 seconds, significantly less time than for other endometrial ablation treatments.

• Uterine balloon therapy. During this procedure, a soft, flexible balloon attached to a thin probe is inserted into your vagina through the cervix and placed in your uterus. The balloon is inflated with sterile hot fluid and expands to fit the contours of your uterus. Then the fluid is heated to 189 degrees F for eight minutes. This treatment lasts for about 30 minutes and thermally destroys your uterine lining. Afterward, the fluid is withdrawn, the balloon deflates and the device is removed from your uterus through your cervix and vagina. This is an out-patient procedure, usually performed under general anesthesia.

  With this procedure, no visualization is necessary, the instrument is smaller and no special surgical skill is required. The major drawbacks of uterine balloon therapy are that it cannot be used if you have uterine polyps, fibroids or abnormally shaped uteri (those that are larger than normal, have an abnormal shape or contain fibroids or polyps), and it appears to be less effective than hysteroscopic techniques in experienced hands.

  About 13 percent of women treated with thermal balloon stop having periods.

• Microwave ablation. Performed under local anesthesia, this procedure uses microwave technology to destroy the uterine lining. A long, slender tube is inserted into the uterus to deliver the microwaves. The treatment lasts one to four minutes.

• Hysterectomy. This is one of the most common surgical procedures performed to end heavy bleeding. It is the only treatment that completely guarantees bleeding will stop. But it is also a radical surgery that removes your uterus.

  Several factors make elective hysterectomy a serious consideration: It is major surgery and includes all the risks associated with any surgical procedure. A lengthy recovery period, often four to six weeks, may be necessary for some women. Fatigue associated with the procedure can last much longer.

  Several types of hysterectomy are available. More information is available at www.HealthyWomen.org.

Menstrual cramps

If you are experiencing severe menstrual cramps (called dysmenorrhea) regularly, your health care professional might suggest you try over-the-counter and prescription medications and exercise, among other strategies.

Medications such as nonsteroidal anti-inflammatories (NSAIDs), like ibuprofen and naproxen, can be purchased without a prescription. Treatment works best if started hours before the onset of cramping. If you wait until you have pain, it doesn't work as well. This will also help reduce heavy bleeding.

Other ways to relieve symptoms include putting heat on your abdominal area and mild exercise.

PMS and PMDD

To help manage PMS symptoms, try exercise and dietary changes suggested here and ask your health care professional for other options. If you suffer from PMDD, however, don't try to treat on your own; make sure you talk to your health care professional.

Dietary options for PMS include:

• cutting back on alcohol, caffeine, nicotine, salt and refined sugar, which can make PMS and PMDD symptoms worse.
• increasing the calcium in your diet from sources such as low-fat dairy products, soy products, dark greens such as turnip greens and calcium fortified orange juice. Increased calcium may help relieve some menstrual cycle symptoms.
• increasing the amount of complex carbohydrates in your diet; these include fruits, vegetables, grains and beans.
• increasing the amount of water you drink to help flush out fluids from your body and make you feel more comfortable.

Exercise is another good way to relieve menstrual cycle symptoms. You will get the greatest benefits from exercise if you do it for at least 30 minutes, five days a week. But even taking a 20- to 30-minute walk three times a week can:

• increase brain chemicals that give you more energy and improve mood.
• decrease stress and anxiety.
• improve deep sleep at night.

Other medical therapies your health care professional might suggest include:

• Antidepressants such as paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa) and fluoxetine (Prozac). These are prescribed because they are effective in regulating the brain compound serotonin, which is related to PMS
• Anti-anxiety medication such as alprazolam (Xanax)
• GnRH agonists (Lupron), sometimes in combination with estrogen or estrogen-progestin hormone therapy, for short-term treatment (less than six months). This treatment has numerous side effects, however, including hot flashes and vaginal dryness.
• Diuretic medications, such as spironolactone (Aldactone) to help with water weight gain and bloating.
• Oral contraceptives (specifically a new brand of oral contraceptive called YAZ) that contain a progesterone called drospirenone may help reduce some mood-related PMS symptoms, such as irritability, anxiety, tearfulness and tension.

There's evidence that some nutritional supplements such as vitamin E, magnesium and vitamin B-6 may help ease symptoms of PMS. Discuss these and other strategies with your health care professional before taking any dietary supplement.