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Gynaecological treatment options for menorrhagia


For some women, the medical treatments described in the section Medical treatment options will not work. Heavy, prolonged bleeding during the menstrual cycle will continue. For these women, gynaecological procedures, including surgery, may be considered. It is important that women have all the information before making their decisions.

These are some of the options:

Mirena

Mirena IUD (levonorgestrel-releasing intrauterine system)

The Mirena IUD is a small, flexible device that is inserted into the uterus through the vagina. It releases low amounts of hormone locally and in many cases this reduces the amount of blood lost during a menstrual period. It must be inserted by a gynaecologist or other specially trained health care provider and can last up to 5 years. It is important that the placement is checked a few months after insertion to be sure it is in the right place.

Advantages
  • Insertion can be done in a clinic and does not require an operation.
  • The Mirena is an effective method of birth control, however, women can still get pregnant after it is removed.
  • Patients don’t have to remember to take pills on regular basis.

Disadvantages
  • Some patients experience discomfort and cramping during insertion.
  • Menstrual periods can be irregular for the first 3 – 6 months after insertion.

Uterine ablation (endometrial ablation)

The purpose of this operation is to destroy the lining of the uterus. This is the endometrial tissue which bleeds so much during menstruation. The operation is done through the vagina so no surgical cutting is needed. The uterine lining is burned away. Hormone therapy is given in the two months before the operation to reduce endometrial growth. A woman cannot have children after this operation.

This is a new operation but success rates are promising.
-    50% of women have no more menstrual bleeding and
-    35% of women have much less menstrual bleeding.

Advantages
  • The operation involves no surgical cutting so there is much less chance of bleeding than with a hysterectomy.
  • The operation can be done in a doctor's clinic. Therefore, the woman does not have to stay in hospital.
  • The recovery time is much shorter than with a hysterectomy.
  • The success rates are promising.

Disadvantages
  • Unlike with medical treatment, the woman can no longer have children.
  • The operation may have to be repeated.
  • In about 10% of women, this operation does not reduce bleeding.


Hysterectomy (removal of the uterus)

The purpose of this operation is to remove the uterus so that menstrual bleeding stops once and for all. Sometimes, the ovaries and the fallopian tubes are removed as well.

This operation is often recommended to women with menorrhagia before even testing for von Willebrand disease or other bleeding disorders. This means that some women lose the ability to have children when their bleeding could be successfully treated.

Advantages
  • Hysterectomy stops menstrual bleeding once and for all.
  • It may be the only option for women who do not respond to medical treatment, and for whom uterine ablation is not effective.

Disadvantages
  • Unlike with medical treatment, the woman can no longer have children.
  • A hysterectomy is a major operation. In women with bleeding disorders, there is increased risk of bleeding both during and after the operation. This can be managed with factor concentrates.
  • The recovery time is much longer than with a uterine ablation.
  • The operation requires a stay in hospital.




Laparoscopy (to remove endometrial tissue outside the uterus)

The purpose of this operation is to remove endometrial tissue which has formed outside the uterus. This tissue bleeds during menstruation. The bleeding can cause pain in the pelvis and abdomen. Two small incisions are cut in the abdomen. Two tubes are inserted - one a tiny camera, the other a tube by which the endometrial tissue is cut out.

Advantages
  • This operation can reduce pain and bleeding in the woman who does not respond to hormone therapy or other medical treatment.

Disadvantages
  • While not a major operation, a woman with a bleeding disorder will need appropriate preparation with factor concentrates.


Oophorectomy (removal of the ovaries)

The purpose of this operation is to stop bleeding from the ovaries. This bleeding may happen even when:
-  a woman is having hormone therapy to reduce menorrhagia
-  a uterine ablation has been done or
-  a partial hysterectomy has been done.

Advantages
  • It can reduce bleeding and pain.

Disadvantages
  • An oophorectomy is a major operation.
  • Women can no longer have children.
  • Women need to take hormones until the age of menopause.

Dilation and Curettage (D&C)

NOT RECOMMENDED TREATMENT
The purpose of this operation is to scrape and clean the lining of the uterus. This may need to be done to diagnose another problem; however, for women with menorrhagia, it will not be effective in reducing bleeding. In fact, the opposite is probably true. The D&C will remove any existing platelet plugs and fibrin clots and make the bleeding worse.