About endometriosis

The exact cause of endometriosis is still unknown. The most popular theory is that during menstruation, the menstrual tissue passes backwards through the fallopian tubes and into the pelvis where it attaches and grows.

Endometriosis does seem to run in families, so you will be more likely to have it if your mother or another woman in your family has had it.

What are the symptoms?

Many women have endometriosis with no symptoms or problems but this is not always the case.

Common symptoms of endometriosis include:

• period pain
• pain with sex
• pelvic pain at other times of the menstrual cycle
• back pain
• low energy
• pain passing a bowel motion.

All of these symptoms have other possible causes.

Some women who have difficulty becoming pregnant are found to have endometriosis, even when they don't have other symptoms.

How is endometriosis diagnosed?

A discussion about your symptoms and a physical examination should provide your doctor with enough information to determine if you might have endometriosis.

If your doctor thinks you may have endometriosis they will most likely recommend you have an ultrasound. This will usually be able to show if you have lumps (nodules) of suspected endometrium growing near or into your bowel and bladder. A definitive diagnosis can only be made if you have a laparoscopy (keyhole surgery). A tiny incision is made in your abdomen and a small sample of tissue taken. Tests done on the tissue will confirm if it is endometrium or not.  Based on the severity of your symptoms, your doctor will plan the best treatment for you. 

There are currently no non-invasive tests for endometriosis available in Australia.

Endometriosis and fertility

There are many reasons why a couple may be infertile. Endometriosis is sometimes found in women who are having trouble getting pregnant. In a minority of these women, scar tissue caused by the endometriosis will have caused a blockage of the fallopian tubes.

However, in most women it is not clear why the endometriosis affects their fertility. Theories include that the endometriosis:

• results in eggs that are less likely to fertilise
• produces natural toxins to sperm.

Treating with MRI

Uterine fibroids are one of the causes for heavy periods. An MRI scanner is used to heat and shrink the fibroids and thus treat your heavy menstrual bleeding.

This is a relatively new treatment for uterine fibroids. It is also referred to as MRgFUS and uses an MRI scanner to deliver a focussed, high-intensity ultrasound beam to heat the fibroid and shrink it.  It is only suitable for some women and while it is non-invasive it can be hard for some patients to remain still for the whole procedure.

Risks and benefits

Benefits	Disadvantages
Fast recovery time, women are able to go home the same day Less complications than with surgery	Not suitable for fibroids larger than 10cm or too close to surrounding tissue Not suitable for women who are unwell and require immediate treatment as complete effect of MRgFUS will take twelve months. Long-term effectiveness and safety is not yet known. Not readily available at most hospitals

Treating with surgery

If you have tried medication treatments for your heavy periods with no improvement, surgery may be your next option.

You may consider surgery if you:

• tried medication but it didn’t help
• could not try medication because of other health issues
• have fibroids
• have other conditions which cause bleeding and pain (e.g. endometriosis).

Surgery aims to stop bleeding and pain completely by removing or reducing the cause (fibroids, polyps or the lining of the uterus) or by removing the uterus completely.

There are three main operations used to treat heavy menstrual bleeding.

Endometrial ablation removes or destroys the lining of your uterus using heat or microwaves. A long, narrow instrument called a hysteroscope is put inside your uterus (through your vagina) to allow the doctor to see and to perform the ablation. This can be done under local or general anaesthetic.

Myomectomy removes fibroids from your uterus. Sometimes this involves one long cut across your belly (abdominal myomectomy) or several small cuts across your belly (laparoscopic or ‘keyhole’ myomectomy). Sometimes it is done using a hysteroscope and so there are no cuts at all (hysteroscopic myomectomy). This is done under general anaesthetic

Hysterectomy removes your entire uterus and sometimes your cervix, ovaries and fallopian tubes. This can be done with one cut (abdominal hysterectomy), several small cuts (laparoscopic or‘keyhole’ hysterectomy) or without any cuts (vaginal hysterectomy).

You and your doctor or surgeon will discuss the best course of action for you. Write down any questions or concerns about your possible treatment and discuss them and your options with your doctor.

Treatment options

	Benefits	Disadvantages
Endometrial ablation	Safest surgical treatment Usually only in hospital for one day Significantly reduces heavy bleeding (around 85 percent of women have improvement and around 35 percent have no further bleeding) Can also be used to remove some fibroids and polyps	For some women heavy bleeding returns May not reduce period pain There are major complications in about 1 in 1000 procedures. These can include infection, damage to the bowel or a hole in the uterus It may be difficult to investigate any future problems in the uterus
Myomectomy	Reduces heavy bleeding The best surgical option for women who want to be able to have (more) children May improve other symptoms caused by fibroids such as feelings of pressure	There is a small risk that an emergency hysterectomy will be need to be done There is also a risk of excessive bleeding requiring a blood transfusion Fibroids can regrow
Hysterectomy	The only guaranteed way to stop menstrual bleeding completely May reduce period pain Most women are very satisfied with it Reduces the risk of uterine and ovarian cancer (even when your ovaries are not removed)	Is a major surgical procedure with potential complications Recovery takes 2-6 weeks depending on the type of hysterectomy You will no longer be able to have children May lead to early menopause (even if your ovaries are not removed) May increase the risk that your bladder or bowel move down into your vagina

Treatment with medication

Medication is usually the first treatment option that doctors recommend for heavy periods.

Treatment with medication:

• can be very effective
• often has fewer and less serious side effects than other treatments
• does not affect your ability to have children or cause early menopause
• is suitable for many women.

There are six types of medication used to treat heavy menstrual bleeding.

Tranexamic acid helps your blood to clot, which will reduce the bleeding. It comes as a tablet that you take during your period.

Non-steroidal anti-inflammatory drugs (NSAIDs) reduce the amount of prostaglandin in the lining of your uterus, as prostaglandin seems to contribute to heavy bleeding and pain. It also comes as a tablet that you take during your period.

Hormone-releasing intrauterine device (IUD) is a small, usually plastic device that sits inside your uterus and releases a small amount of progestogen (a drug that acts like the natural hormone progesterone). With each menstrual cycle the lining of your uterus becomes thick and spongy in preparation for pregnancy. When you don’t get pregnant, the lining sheds and you bleed it out. Protestogen works by reducing the thickness of the lining of your uterus.

The contraceptive pill releases substances that act like the natural hormones oestrogen and progesterone. These stabilise the lining of the uterus so that it doesn’t get so thick.  The Pill can be taken continuously so that you don’t bleed at all, or you can have a period each month. It comes as either a tablet you take daily or as a small, flexible ring that is put inside your vagina and slowly releases the medication. The ring is usually removed after three weeks to allow you to bleed and a new one is put in at the end of your period.

The progestogen-only pill (POP or mini-pill) also works by stabilising the lining of the uterus. If you take protestogen throughout your menstrual cycle, the lining of the uterus is never able to build and thicken and so there is very little to shed when it comes time for your period. 

Danazol is a tablet that stops the normal ovulation cycle and reduces your body’s oestrogen levels. It causes some women to stop menstruating completely.

Your treatment options summarised

	Benefits	Disadvantages
Tranexamic acid	Reduces bleeding by about 40 percent	Requires long-term use
NSAIDS	Reduces bleeding by about 30 percent Relieves period pain	May cause stomach upsets, nausea and diarrhoea Requires long-term use
IUD	Reduces bleeding by about 95 percent after at least three months use May reduce period pain Is also a contraceptive You don’t need to remember to take tablets You can have it removed It only has to be changed every five years	Often causes irregular bleeding or spotting in the first couple of months May cause acne, mood changes  and breast soreness May fall out but this is rare Although rare, it may push through your uterus and need to be removed in an operation May not be an option if you have fibroids 20 percent of women (one in five) ask for it to be taken out because of the side effects
Oral contraceptive pill	Reduces bleeding by about 40 percent May reduce period pain Helps keep periods regular Is also a contraceptive Can be used to skip your period entirely Reduces your risk of ovarian and endometrial cancer by about 50 percent	May cause nausea, breast soreness, headaches and changes to sex drive or libido May cause irregular spotting Not suitable for all woman (for example, those who are over 30 years old and smoke, or get blood clots in their veins (called thromboembolism) Requires long-term use
POP or mini-pill	Reduces bleeding by about 85 percent Works quickly and can be used as a short-term treatment or for periods that are particularly heavy	May cause bloating, mood swings and breast soreness May cause irregular bleeding Often requires long-term use
Danazol	Reduces bleeding by about 65 percent	May cause weight gain and acne

Investigation & treatment

If you are worried about your periods visit your GP. You are likely to be referred a gynaecologist.

The gynaecologist will generally do the following:

• ask you questions about the history of your health
• do a blood test
• examine your vagina and cervix, using special tongs (called a speculum). At the same time, they may take a tiny sample of your cervix for testing (called a Pap test)
• take an ultrasound of your pelvis. This usually involves putting a small wand (called atransducer) inside your vagina to take a picture of your cervix, uterus, endometrium and ovaries. If you haven’t had sex before, it is more likely that an external ultrasound will be done. Gel is put on the outside of your belly and a small handheld transducer is moved over the skin.

Further investigations may include a hysteroscopy and/or a curette.

A hysteroscopy uses a long thin telescope or camera (called a hysteroscope) that allows the doctor to see inside the uterus. The hysteroscope can show polyps, fibroids and endometrial thickening. A sample of the endometrium can also be taken for testing. A curette involves removing the top layer of your endometrium for testing and can be done at the same time as a hysteroscopy.

A hysteroscopy can be done under local or general anaesthetic. A curette is usually done under general anaesthetic.

Treatment 

There are a number of treatment options for heavy periods, including medication, surgery and radiology. Your doctor will recommend the best option for you based on your medical history and the reasons for your heavy periods.

Your treatment options will depend on:

• your age, health and medical history
• whether you want to have any (more) children
• how successful other treatments have been for you.

There are three main types of treatment.

• Medication to reduce or control the bleeding and pain. This usually involves taking tablets but sometimes an IUD is placed inside your uterus, which slowly releases the medication into your body.
• Surgery aims to stop the heavy bleeding by removing potential causes like the lining of your uterus (called an endometrial ablation), fibroids in your uterus (called a myomectomy) or your whole uterus (called a hysterectomy).
• Radiology and ultrasound treatments aim to reduce or stop heavy bleeding and pain by reducing and destroying fibroids.

What causes heavy periods

Diagnosing what causes heavy periods can sometimes be difficult. However, some physical condition affecting the uterus, such as fibroids and polyps, may cause heavy menstrual bleeding.

The more common reasons for heavy periods are:

• fibroids
• polyps
• endometrial hyperplasia
• endometrial cancer
• adenomyosis.

Fibroids

Fibroids are abnormal growths that form in the muscle of the uterus. They are very common and can occur in up to 80 per cent of women. They are often referred to as ‘tumours’, but the vast majority are not cancerous.

Fibroids are more likely to cause symptoms if they are large, if there are many of them or if they push on your other internal organs. Some women with fibroids have very heavy menstrual bleeding, pelvic pressure or pain that interferes with their life, and some women have problems with fertility and pregnancy. However, fibroid symptoms tend to get better after menopause.

Fibroids can bulge from the inside or outside of the uterus. They can range in size from microscopic to the size of a grapefruit or even larger. The majority of fibroids are small and do not cause any symptoms at all.

Polyps

Uterine polyps are usually non-cancerous (benign) growths of the lining of the uterus (the endometrium). They can also occur at the cervix. Polyps may cause heavy menstrual bleeding, bleeding between periods or bleeding after sexual intercourse. Occasionally, polyps can develop abnormalities, particularly in older women, so it is generally advised to remove them before they become dangerous.

Cancer, malignancy and hyperplasia

Some women may develop an abnormally thick lining of the inside surface of their uterus. This condition is called endometrial hyperplasia and it may cause heavy menstrual bleeding, irregular bleeding or a bloodstained vaginal discharge. In some cases, endometrial hyperplasia may progress to endometrial cancer, a condition that is more common after menopause but can occur in younger women.

Women are at an increased risk of developing endometrial hyperplasia or endometrial cancerif they:

• are over the age of 45 years
• are over 90 kg in weight
• have never had children
• have a family history of endometrial, ovarian or bowel cancer
• have polycystic ovarian syndrome
• carry a gene that increases their cancer risk (such as HNPCC).

Adenomyosis

Adenomyosis is a common cause of painful and heavy periods, and can have the same symptoms as endometriosis and fibroids. It occurs when the endometrial glands grow into the muscle of the uterus. As a result, the uterus grows larger, and it can be tender when you are examined. However, it is not easily diagnosed because ultrasound, hysteroscopy, keyhole surgery and magnetic resonance imaging (the common approaches used) will not pick it up all of the time. Women tend to be in their 30s when they are diagnosed.

Other uncommon causes for heavy periods include:

• an underactive thyroid
• the use of anticoagulant drugs
• some liver and kidney conditions
• blood clotting disorders, for example Von Willebrand’s disorder
• using hormone contraception such as the Pill or a prostestogen IUD.

Sometimes a reason for heavy periods is never found. In fact, for nearly half of all women with heavy periods all investigations will show that there is no obvious cause for their bleeding. This is referred to as Dysfunctional Uterine Bleeding and can happen at any age. It is more common in women in their late thirties, which may mean that it is related to hormonal changes as women get older.

What is a heavy period?

Heavy menstrual bleeding is defined as excessive menstrual blood loss that interferes with a woman's physical, social or emotional quality of life.

A period is heavy if you are:

• passing lumps of blood (or clots) that are larger than a 50 cent coin
• bleeding so much that you have to change your pad/ tampon every hour 
• having to get up most nights to change your pad/tampon
• having to put a towel in your bed or use large maternity pads when you sleep
• bleeding through clothing
• bleeding that lasts more than eight days.

Heavy periods can lower your iron levels and red blood cells so you may:

• feel tired more easily 
• feel weak or dizzy
• be short of breath and have chest pains.

Heavy periods can generally be managed using hormone therapies or surgery. Your doctor or gynaecologist can talk to you about options that suit you. 

If you are worried about heavy menstrual bleeding

• See your doctor, nurse or gynaecologist (specialist in women’s health).
• Talk to them about the changes to your period.
• Tell them about any medications or contraceptives you are using.

They will most likely:

• ask you questions about the history of your health
• examine you
• do a blood test.