| Symptoms and Treatment Considerations for Pelvic Health Conditions
Learn more here about heavy menstrual bleeding, fibroids, stress urinary incontinence and pelvic organ prolapse, including symptoms and treatment considerations.
Menorrhagia is defined as soaking a pad and/or tampon every hour or less during each menstrual cycle. The heavy bleeding can also lead to iron-deficient anemia, the most common health-related threat of menorrhagia. While most cases of anemia are easily treated with oral iron supplements, sometimes the bleeding is so severe a woman's entire volume of blood drops, leading to shortness of breath, severe fatigue and heart palpitations that require hospitalization.
Lifestyle options
There are several options you may want to try yourself to reduce heavy menstrual bleeding. These include:
- Ice packs. Put an ice pack on your abdomen for 20 minutes at a time, several times a day when bleeding is especially heavy.
- Vitamins. Try vitamin C supplements to strengthen blood vessels and vitamin E supplements to reduce the growth of new blood vessels in the uterine lining.
- Iron. Some research suggests low iron levels can increase menstrual bleeding, and that supplementing with the mineral can reduce menstrual bleeding.
Always check with your health care professional before taking any medication, even herbs and nutritional supplements.
Medical options
If you have heavy menstrual bleeding, your health care professional will probably begin treatment with medical therapies such as:
- Nonsteroidal anti-inflammatories. These drugs, which include naproxen (Aleve), ibuprofen (Motrin), and the prescription NSAIDs diclofenac (Cataflam) or mefenamic acid (Ponstel), work by reducing levels of prostaglandins, hormone-like chemicals that interfere with blood clotting. Studies find they can reduce blood flow an average of 25 to 35 percent.
- Oral contraceptives. Oral contraceptives can reduce menstrual bleeding up to 60 percent by preventing ovulation and thinning the endometrium. One study compared them to the NSAIDs mefenamic acid, naproxen and danazol and found all four worked just as well at reducing bleeding.
- Progestin. Progestin is the most-prescribed medication for menorrhagia, with studies finding that it can reduce bleeding up to 15 percent. Progestins work by reducing the effects of estrogen in your body, slowing growth of the uterine lining. But side effects, including weight gain, headaches, swelling and depression, lead many women to quit using this option.
- Gonadotropin-releasing hormone agonists (GnRH agonists). These drugs are used only on a short-term basis because of their high cost and severe side effects. Basically, they temporarily send a woman into menopause, complete with hot flashes. However, they are very effective in reducing menstrual blood flow. But because they interfere with the activity of estrogen in your body, long-term use could lead to osteoporosis.
- Danazol. Danazol is a form of the male hormone testosterone that blocks the action of estrogen in your body. It causes your period to stop in about four to six weeks, but can have side effects, including acne and reduced breast size.
- Intrauterine device (IUD). Mirena is an IUD that releases a progestin called levonorgestrel. A large review of studies comparing surgical to non-surgical treatments for menorrhagia found it worked just as well as endometrial resection or ablation in improving quality of life and controlling bleeding over the long term. The main side effect can be some light bleeding between periods, particularly in the first three months.
Surgical options
- Hysterectomy. Seventy-five to 80 percent of women with heavy menstrual bleeding do not need a hysterectomy, yet many women still opt for this surgical procedure. While very effective in ending uterine bleeding (without a uterus, your periods stop), it is a major surgical procedure that requires hospitalization and weeks of recuperation. Additionally, it can have several complications. One study of 634 women who underwent hysterectomy for noncancerous conditions found complication rates of 18 percent in those having an abdominal hysterectomy, 8 percent in those having a vaginal hysterectomy, 8.2 percent in those undergoing a laparoscopically assisted vaginal hysterectomy and 5.8 percent in those undergoing a laparoscopic hysterectomy. Meanwhile, another study of 10,110 hysterectomies found rates of complications ranging from 17.2 to 23.3 percent, depending on the type performed, with infections the most common. Hysterectomy should be a last resort for women whose only medical problem is heavy bleeding. Other, less invasive options are:
- Endometrial ablation. In this minimally invasive procedure, the lining of the uterus is destroyed via freezing, electricity, microwaves, radiofrequency (radio waves) or hot water. Ablation is performed on an outpatient basis or in a doctor's office with mild anesthetic and has a very quick recovery. It enables a woman to keep her uterus and, in many instances, may halt her periods altogether. If you choose this treatment option, you should be sure to continue using contraception, as necessary; pregnancy following ablation is not recommended.
Certain surgical procedures, including myomectomy and uterine artery embolization, are used if fibroids are the cause behind the bleeding.
Questions to Ask Your Health Care Professional about Menorrhagia
- Is the amount of menstrual bleeding I'm experiencing abnormal?
- What tests do you need to conduct to diagnose my menorrhagia, and why are you doing them?
- Is this heavy bleeding affecting my iron levels? What can I do about that?
- Why are you recommending this particular treatment option for my heavy bleeding? If that doesn't work, what do you recommend next?
- What are the disadvantages and risks associated with each recommended treatment?
- Even if you find a problem like fibroids causing my abnormal uterine bleeding, is it possible to avoid a hysterectomy?
- How many endometrial ablations of this type have you performed in the past year? What is your success rate? What kind of complications have you encountered?
Fibroids are noncancerous uterine tumors that occur in most women by the time they reach menopause. Fibroids don't always cause symptoms; however, an estimated 20 to 25 percent of women with fibroids will experience symptoms.
- Heavy menstrual bleeding (so heavy, it may lead to anemia). This is the most common symptom.
- A mass in the pelvis that may make you appear pregnant
- Pressure in the pelvic area caused by the enlarged uterus
- Frequent urination
- Urinary incontinence
- Difficulty emptying bladder
- Constipation
- Rectal pressure
- Pelvic pain
- Infertility (with fibroids that bulge into the uterine cavity)
Treating fibroids is optional. In almost all cases, fibroids only need to be treated if they cause symptoms that are so bothersome that they interfere with your quality of life. Treatments include:
Medical options
- GnRH medications. GnRH antagonists like leuprolide (Lupron) work by preventing estrogen from affecting cells. Studies find these drugs can reduce heavy bleeding associated with fibroids and shrink fibroids as much as 50 percent. However, because these drugs block the effects of estrogen on all cells, they can only be used for a short time, typically in women already close to menopause. Once you stop using them, the fibroids grow again. These drugs are most often used to shrink fibroids before a surgical treatment, not to treat the fibroid itself.
Surgical options
In addition to hysterectomy, the most commonly performed surgical procedure for fibroids, other options include:
- Uterine artery embolization (UAE), also called uterine fibroid embolization (UFE). This procedure blocks the blood supply to the arteries that feed the fibroids. Without an adequate blood supply, the fibroids shrink. Studies find that UAE shrinks fibroids about 40 percent and improves troublesome symptoms like heavy bleeding and pelvic pressure in 90 percent of women undergoing the procedure. While more research is necessary, women who get pregnant after UAE tend to do well and deliver healthy babies, but they may have an increased risk of uterine rupture and often elect to have cesarean sections.
- Myolysis. In this procedure, the tumor is destroyed using laser, radiofrequency energy or freezing. It is usually performed using a laparoscope through a small incision in your abdomen, although sometimes via a hysteroscopy (through the vagina). Myolysis usually can't be performed on a woman who has a very large uterus, and you shouldn't try to get pregnant after the procedure because the uterus could rupture.
- Magnetic resonance imaging-guided focused ultrasound (MRgFUS). A noninvasive method uses an MRI to precisely target ultrasound energy, which is sent through the abdomen and focused on the fibroid. The sound waves increase the temperature of the fibroid tissue to destroy the tissue and shrink the fibroid. This procedure is not an option if you plan to get pregnant in the future.
- Endometrial ablation. This minimally invasive treatment is performed on an outpatient basis or in a doctor's office with local anesthetic. Although not indicated for the treatment of fibroids, it uses electrical energy, radiofrequency, microwaves, hot water or cold to destroy the lining of the uterus. However, studies find about 20 percent of women choose to have a hysterectomy within five years of an ablation, more as time goes on, because the fibroids and symptoms return. An endometrial ablation procedure does not treat the fibroids but reduces or eliminates heavy periods by destroying the endometrial lining. This procedure is not indicated for women who suffer from "bulk" symptoms, such as urinary frequency, constipation or pelvic pain.
- Myomectomy. This procedure surgically removes just the fibroids, leaving the uterus, and is the second most common treatment for fibroids after hysterectomy. It's a good option for women who still want to be able to have children, although studies find about 27 percent of fibroids recur by 10 years after treatment. Complications include infection, blood loss requiring a transfusion and postoperative adhesions (which may require additional surgery). This procedure can be performed with general anesthesia or a localized anesthesia and can take weeks for recovery. Although studies find that new fibroids may appear within five years, few women require additional surgery.
Question to Ask Your Health Care Professional about Fibroids
- Are fibroids causing my symptoms?
- Could another condition be causing these symptoms?
- How large are they?
- Are the fibroids pressing on or blocking any important organs, like the ureters or fallopian tubes?
- Is treatment necessary?
- What treatment option do you recommend?
- What about nonsurgical treatments?
- Will the symptoms I'm experiencing go away eventually or get worse?
Stress urinary incontinence (SUI) is diagnosed if you involuntarily release urine when you sneeze, cough, laugh or exert yourself.
- Involuntary leaking of urine when you sneeze, laugh cough or exert yourself
Treatment first involves identifying any underlying causes for the incontinence, such as a urinary tract infection or certain medications. Don't confuse incontinence with frequent urination, which also can have underlying causes, such as diabetes or taking in too much fluid. Treatments for incontinence include:
- Kegel exercises. Numerous studies find that consistently practicing these exercises strengthens the pelvic floor and reduces SUI. To do Kegels, pull in or squeeze your pelvic muscles as if you were trying to stop the flow of urine or keep from passing gas. Count to 10 as you hold the contraction, relax, then repeat. Aim for at least three sets of 10 contractions a day. Combining these exercises with pelvic floor therapy with a trained therapist, biofeedback, vaginal cones and/or electrical stimulation may be more effective than simply doing them on your own.
- Weight loss. Losing weight relieves pressure on the bladder and pelvic floor, reducing the incidences of stress incontinence.
- Dietary changes. This includes reducing or cutting out bladder irritants such as alcohol, caffeine, carbonated beverages, spicy food and citrus and limiting the overall amount of fluids you drink.
Medical options
- Imipramine. Low doses of this tricyclic antidepressant can help treat stress incontinence, although the drug is not approved for this use.
- Pseudoephedrine. This medication, found in over-the-counter drugs like Sudafed, can also help with stress urinary incontinence. Again, it is not approved for this use, but your doctor can prescribe it "off label."
- Duloxetine (Cymbalta). Another antidepressant, this drug is approved in Europe but not in the United States for treating stress incontinence. It treats stress incontinence by stimulating the muscles at the opening of the bladder. However, your doctor can prescribe it off label. One study that combined duloxetine with pelvic floor therapy found the two worked much better together than either alone, with incontinence episodes dropping 76 percent with the combined therapy.
- Estrogen therapy. Applied vaginally in a cream, vaginal pill or ring, low-dose estrogen therapy helps improve the normal functioning of muscles involved in urination, which can help with stress incontinence.
Continence devices
Special devices are available to help manage stress incontinence. They include external devices that "catch" and contain the urine; devices you insert into the vagina to support the bladder neck; and devices that are attached to the opening of the urethra or are inserted into the urethra. All require a doctor's prescription and training in how to use them.
Surgical options
There are several commonly used surgeries for stress incontinence. The one that works best for you depends on your condition. The most common are:
- Colposuspension. These procedures can be performed laparoscopically (through a small opening in the abdomen), vaginally or through a traditional open procedure. The goal is to reposition the bladder neck or bladder if weakened support muscles under the bladder have caused the SUI. The surgery often involves raising the bladder or bladder neck and securing it with stitches to muscle, ligaments or bone. The surgery requires general anesthesia and a hospital stay of several days.
- Mid-urethral procedures. These procedures involve using a piece of pelvic connective tissue or a synthetic material to create a sling that supports the bladder and/or urethra to prevent leaks. While older procedures required a hospital stay and surgery under anesthesia, newer devices enable the procedure to be performed on an outpatient basis under local anesthesia with a short recovery and minimal scarring. The largest randomized clinical trial ever to compare one such procedure—using a sling to support the bladder—with the most commonly performed colposuspension procedure, called the Burch, found the sling procedure was more effective at improving SUI than the Burch procedure.
- Injectable bulking agents. With this treatment, natural substances such as collagen are injected into tissues around the urethra to "fatten" them up to better support the urethra and help the muscle that keeps the urethra closed stay closed. The collagen material can be implanted by a health care professional under local anesthesia in less than 30 minutes. The injections have to be repeated over time, however, because your body eventually eliminates the collagen material.
Question to Ask Your Health Care Professional about Stress Urinary Incontinence
- What type of incontinence do I have?
- Is an illness or disease I have causing my incontinence and will the leakage stop with treatment?
- What tests should I have to determine the cause of my incontinence?
- Could my prescription or over-the-counter medications be contributing to my incontinence?
- Can my diet affect my bladder control?
- Will losing weight help?
- Can pelvic exercises help? How do I do them?
- Are there any medications available? What are their benefits and side effects? Will they interact with any other prescriptions or over-the-counter medicines I'm taking?
- Is menopause affecting my ability to control my urine? Will estrogen or hormone therapy help?
- Can surgery solve my urine leakage problem?
- What surgical procedure might help me, and what is its success rate?
- What are the potential risks of the procedure, and what are possible complications after surgery?
Pelvic organ prolapse (POP) occurs when the organs in your pelvis—uterus, vagina, bladder, urethra, rectum or bowel—descend into or even out of the vaginal canal.
- Feeling of pelvic fullness or pressure
- Feeling as if a tampon were falling out
- Incontinence
- Discomfort with intercourse
- Pain or bleeding from the vagina (not menstrually related)
- Lower back pain
- Constipation
Treatment for POP depends on the type of prolapse you have.
Nonsurgical options
- Kegel exercises. These exercises strengthen your pelvic floor, which can help you retain your organs in the pelvic region. Pull in or squeeze your pelvic muscles as if you were trying to stop the flow of urine or keep from passing gas. Count to 10 as you hold the contraction, relax, then repeat. Aim for at least three sets of 10 contractions a day.
- Pessaries. Silicon rings can be painlessly placed in the vagina to support the pelvic organs. While a pessary isn't a cure, it can help reduce your symptoms and delay or even prevent surgery.
Surgical options
Although hysterectomy is still commonly performed in women with symptomatic POP, there are numerous other surgical procedures available. Which one your doctor recommends depends on your condition and the specific type of prolapse. Surgeries can be performed through an abdominal incision, laparoscopically (through a small incision in your belly) or vaginally.
The goal of surgery is to reposition the prolapsed organs and secure them to the surrounding tissues and ligaments. Sometimes synthetic mesh is used to hold the organs in place, while surgery is designed to strengthen the pelvic floor itself.
Question to Ask Your Health Care Professional about POP
- What type of POP do I have? Do I have more than one type?
- What treatment do you recommend to treat my prolapse?
- What is the success rate of the treatment you recommend? What are the benefits and potential risks?
- Can you treat my prolapse, or do I need a referral to a physician who regularly treats patients with my condition?
- How many patients with prolapse do you see a month?
- How many procedures do you perform on a monthly basis to treat prolapse?
- What are my treatment options if I still want to have children?
- Will treatment affect my sexual function?
- How soon after treatment can I return to my daily activities?
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