New Approaches to Treating Heavy Menstrual Bleeding

For most women, monthly menses only presents a short-lived, minor inconvenience, but for other women, who experience extremely heavy or prolonged menstrual bleeding, their periods can significantly diminish the quality of their lives for many days out of the month.  After an initial assessment to identify the cause of the bleeding, several different treatment options can be employed to reduce or eliminate menstrual blood flow.  For women who desire to maintain their ability to have children, medical treatments are typically the best choice.  These include a combination of non-steroidal anti-inflammatory medications, hormonal contraceptives like oral contraceptive pills or progesterone secreting intrauterine device, or a non-hormonal medication that improves the body’s ability to stop bleeding by increasing one of the necessary proteins to clot blood.  However, when women who suffer from heavy periods have finished childbearing, many are looking for a definitive option that will solve the problem with their terrible periods for good.  If the medical treatment options have failed, are not well-tolerated because of side effects, or if a patient is simply tired of just managing her periods, a surgical treatment for heavy menstrual bleeding might be the right choice.

Previously, the surgical options for management of heavy menstrual bleeding were either a dilatation and curettage or a hysterectomy; the former is a minor procedure but not a permanent solution and the latter is major surgery.  Much like Goldilocks, there were procedures that were either too little or possibly too much for many patients, and we needed an alternative in the middle that was just right.  The answer to that dilemma was the endometrial ablation, a minimally invasive outpatient surgical procedure that provided targeted destruction of the tissue that lines the womb cavity.  This is the tissue that grows in response to the hormonal stimulation of the ovaries and the same tissue that is shed during a menses.  By eliminating the ability of this endometrial tissue to proliferate, one could reduce or eliminate menstrual bleeding without the removal of the uterus itself.  Since the 1980s, several techniques for this minimally invasive approach for surgical management of heavy menstrual bleeding have been developed.  The early iterations of these techniques involved the use of laser energy to vaporize the womb cavity lining or resecting instruments that would shave the lining off the entire womb cavity in small strips.  Over time, the minimally invasive procedures to treat the endometrial cavity evolved to become simpler, safer, and requiring less time and technical skills to achieve good results.

The newest generation of devices for endometrial ablation first became available in the late 1990s and employed a variety of modalities to destroy the endometrial tissue in the womb cavity.  These ranged from freezing to burning with heated free water or heated water in a balloon to devices that use microwaves or radiofrequency energy to desiccate the tissue in the endometrial cavity.  These endometrial ablation procedures, while minimally invasive, do typically require the use of anesthesia because of uterine cramping during the procedure.  Afterward, patients would typically experience some level of cramping as well as a discharge for the first few weeks after the procedure.  Patient satisfaction rates with these types of endometrial ablations were high, but the percentage of patients who quit bleeding altogether varied significantly.  Some had rates of no bleeding as low as 15% and others as high as 50%.  Despite the inability to guarantee the absence of any uterine bleeding whatsoever, most patients who had endometrial ablations were happy, at least initially, to accept a reduction and normalization of their menstrual bleeding.

Minerva is the first new endometrial ablation device on the market in the last 15 years and was designed to address some of the drawbacks of previous endometrial ablation systems. Specifically, Minerva reduces patient discomfort during and after the procedure, provides additional safety features, and improves the percentage of patients who experience a complete cessation of their menstrual bleeding.  The Minerva system uses three methods to burn the lining of the endometrial cavity and in so doing can use less energy to achieve a more complete treatment of the surface of the entire cavity.  After initial measurements of the uterine cavity, a silicone lined membrane is introduced into the endometrial cavity.  This membrane is filled with argon gas which is heated until it becomes plasma.  The heat from the plasma heats the silicone membrane that is in contact with the surface of the womb cavity.  This heat desiccates the endometrium.  Heat from the silicone membrane also heats the small amount of fluid that is typically present in the womb cavity to allow superficial burning of any part of the endometrium that is not in direct contact with the silicone membrane.  Finally, a portion radiofrequency energy used to heat the argon gas also heats the endometrium but with less energy than other radiofrequency ablations.  The use of less energy results in less pain and cramping during the procedure, which means that it can be performed with a patient fully awake in the office under a local anesthetic block of the cervix.  Most patients experience only mild to moderate cramping or pressure.   The procedure itself takes four minutes to complete.  In a study to assess the effectiveness of the Minerva endometrial ablation device, 92% of women who underwent the Minerva endometrial ablation a significant reduction in their bleeding and 66% had no bleeding at all after the procedure.  Overall, 98% of those women were satisfied with their procedure.   Rates of post-procedure bleeding, cramping, discharge, bloating, and nausea were all low.

For us at Frisco Women's Health, women who are the best candidates for an endometrial ablation procedure are those who have not gone through menopause yet, have bothersome heavy menstrual bleeding, do not desire to have more children, have a method of permanent contraception, and have completed an evaluation to determine the cause of their bleeding and to assess the size and shape of the womb cavity.  Patients who have postmenopausal bleeding, have precancerous changes to the womb cavity lining, or have uterine fibroids that protrude into the endometrial cavity are not good candidates.

If you are experiencing heavy bleeding every month and have had enough of overnight pads, super tampons, and rearranging your life around your period, endometrial ablation may be the answer you have been searching for. The Minerva endometrial ablation system provides many women with an alternative to chronic medications or hysterectomy to treat their bothersome menstrual bleeding.  Watch their stories here.

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