What does the uterus do?
The uterus is where a baby develops during pregnancy. About once a month an egg in one of the ovaries grows and breaks free from the ovary. It moves into the Fallopian tube and travels down the tube towards the uterus. At the same time, hormones make the endometrium thicker so that if the egg is fertilised by a sperm it can lodge in the uterus. Often, the egg is not fertilised and it dies. The hormones change and the endometrium also dies and is shed. There is some bleeding from the raw endometrium for a few days. This is a typical period. The cycle then starts again for the next month. If the egg is fertilised it starts making extra hormones. These make the uterus and endometrium grow to take the developing baby.
After the age of about 45 years the ovaries stop making some of the female hormones. Eggs are not released each month. The endometrium is no longer shed. The periods stop. This is called the change or the menopause. The changes in hormones often cause hot flushes and dizzy spells. Sometimes the periods become very heavy during this time.
What has gone wrong?
There are several possible causes of your heavy bleeding.
Fibroids - These are swellings in the walls of the uterus. They are a very common reason for heavy or painful periods. They are benign tumours made of muscle and fibres. They make the surface area of the endometrium larger. This, in turn, makes the periods heavier and more painful.
Endometriosis - This is a condition where other tissues behave as if they were endometrium. The tissue is usually within the pelvis, especially around the ovaries. With each period there is bleeding into the endometriosis tissue. This internal bleeding leads to pain and a local reaction. The local reaction may be a collection of old blood, called a chocolate cyst, or adhesions of the ovaries to the back of the uterus. Removing the uterus and the ovaries may be the only cure.
Adenomyosis - Here, some endometrium is present in the muscle walls of the uterus. With each period, bleeding into the muscle gives a lot of pain. A reaction by the normal endometrium to the trapped blood makes the periods heavy.
Dysfunctional uterine bleeding - This is where we cannot find a clear cause for the problem. In some way the shedding mechanism of the endometrium is not working properly.
Malignancy (cancer of the endometrium) - This is something that needs to be ruled out, especially if there is bleeding after the menopause. The sample removed during the D&C will be sent to the laboratory for examination under the microscope.
The main aim of the operation is to take scrapings of the endometrium to send for examination under the microscope to find the cause of your bleeding. Sometimes we can also treat the cause. For instance, if the cause of the bleeding is an overgrowth of the lining, called a polyp, we can remove it at the same time as the D&C; this is called a polypectomy.
We should be able find out whether the endometrium is responsible for your bleeding. If the endometrium is not the cause, we can use other tests to find out what the problem is. You should then be able to start the correct treatment.
Are there any alternatives?
X-rays and scans, such as ultrasound, CT and MRI scans, can be of some help in finding the cause for the bleeding. None of these tests produce samples of tissue. A D&C is the simplest way of doing this but nowadays it is usually combined with a hysteroscopy which is diagnostically more accurate.
What if you do nothing?
If you do nothing, the cause of your problem will remain in doubt. You may miss out on important treatment. Any period problem is likely to continue until you reach the menopause.
Author: Dr David Hutchon M.R.C.O.G, F.R.C.O.G. Consultant Gynaecologist.
© Dumas Ltd 2006