John C. Lipman, MD, FSIR
Founder & Medical Director
Atlanta Fibroid Center
Heavy menstrual periods are a significant health issue that is underreported and under-appreciated by healthcare professionals and the women they serve. The reasons for this are multifactorial.
- Doctors and other healthcare professionals that encounter these women may not be listening or appreciate the significance of the problem. Doctors often don’t treat heavy periods if the patient is not anemic based on blood test results. In my opinion, this is not the right approach. If a woman’s quality of life is being affected by her heavy periods, it warrants treatment….period (pardon the pun)!
A study from Europe published in 20151, reported on over 1000 women with heavy menstrual bleeding. Almost half never consulted a physician and less than half of those that did were given any appropriate treatment.
If you feel that you are not being listened to, or that your doctor does not provide you with options to treat the heavy flow, you need to find a doctor that will. This underscores the point that no matter what health condition or concern that you have, you need to be your own health advocate.
- The woman herself may not appreciate that her flow is abnormally heavy. Just because you have bled heavy for a long time does not make it normal for you. Women may ask their mother or other close relative who also happens to bleed heavy and this gets passed on as “we’re just heavy bleeders.”
- What’s normal? There is no exact “normal” number. Some say 30-40 milliliters or mls (2-3 tablespoons), some report close to 60 mls (4 tablespoons). More than this is heavy and >80ml is generally agreed to be too heavy. Measuring the flow each month is cumbersome; particularly if you don’t use a menstrual cup. The cup has markings to measure amount (1cc=1ml) but tissue, mucus, clots can interfere with this measurement. Alternatively, if you change pads more frequently than every 3-4 hours, or need/change more than one pad at a time, or pass clots larger than a quarter, your period is too heavy. If have accidents in your own blood, episodes of blood gushing or flooding out of your body/down your legs, sit/sleep on protective plastic to prevent accidents, or wear an adult diaper, your period is obviously too heavy.
Why do women bleed heavily?
The conditions that cause a woman to bleed heavily are categorized in to two main groups (PALM-COEIN Classification). The “PALM” group are the most common and are due to structural causes in the uterus. They include:
P: Uterine Polyps
L: Leiomyoma (Fibroids) The most common of all of the causes
M: Malignancy (Uterine cancer)
The “COEIN” group are due to nonstructural conditions that affect the uterine lining and include:
C: Coagulation disorders (clotting problem)
O: Ovulation disorder (ex. PCOS, thyroid disorder)
E: Endometrial (uterine lining abnormality)
I: Iatrogenic (Gyn procedure-related)
N: Not yet classified (anything left over)
The most common of all of these causes are uterine fibroids. Fibroids are benign tumors that develop and grow in the uterus. They are the most common pelvic tumor in women; affect 1 in every 3 adult women, and up to 80% of African-American women. African-American women get fibroids earlier in adulthood, the fibroids are bigger and more numerous, and therefore, they are much more likely to get hysterectomy than other racial groups. If one looks at hysterectomy by race, white women get hysterectomy for uterine cancer which is totally appropriate, while black women get hysterectomy for benign fibroids. Why? Why are physicians amputating black women for a benign medical condition?
This is particularly troubling when there is a nonsurgical, outpatient procedure with over 25 years of medical data in peer-reviewed medical journals testifying to its safety and efficacy. That procedure is called Uterine Fibroid Embolization (UFE) or Uterine Artery Embolization (UAE). Despite this long track record of safety and efficacy, numerous studies have shown that most women suffering with fibroids never hear of this outstanding treatment option.
A study is the Journal of Women’s Health (JWH) from 20131 demonstrated close to half of the African-American women waited over 4 years to undergo treatment. This is because they were essentially given only two options: “watchful waiting” (i.e. live with it) or surgery (typically hysterectomy) and the significant majority did not want surgery and they were not told about UFE.
There are over 1 million women in the United States currently like the women in the JWH study. They are the “silent sufferers”. They suffer with miserably heavy periods caused by uterine fibroids. They were only offered surgery as a treatment option and they do not want to undergo a hysterectomy and lose their uterus. They are unaware of UFE, and therefore, continue to suffer unnecessarily. These women are young, typically in their thirties and forties, but some are even in their twenties. Hysterectomy is the 2nd most common surgery performed in the United States. That’s rather surprising as 50% of the population are men (who don’t have a uterus). The average age of hysterectomy is 39 years, and there are way too many women losing their uterus every day that could keep it if they knew about UFE.
Uterine Fibroid Embolization (UFE) is a nonsurgical, outpatient procedure performed by Interventional Radiologists (not Gynecologists), and therefore, a second opinion is often needed to know about UFE. The procedure takes less than one hour to perform and the patient is discharged on the day of the procedure with just a bandaid (at the top of the right leg or left wrist). The recovery at home is typically 5 days.
Hysterectomy does eliminate a woman’s fibroids and the miserable symptoms that go along with them. Gynecologists are often quick to tell women that if they’re done having children, they don’t need their uterus anymore. However, sometimes the “cure” is worse than the disease. Women that undergo hysterectomy for fibroids often suffer as a result of losing their uterus, and therefore, substitute one set of problems for another. They can suffer psychologically like a man being castrated, they often suffer sexually (exs. loss of libido, loss of orgasm), they will often leak urine which can be due to weakening of the pelvic floor muscles or an abnormal communication created during surgery between the vagina and the bladder (i.e. vesicovaginal fistula). There is a lot of bone loss post-hysterectomy and there is also evidence of increased risk of heart attack, high blood pressure, and stroke after a hysterectomy. Losing one’s uterus for benign fibroids is totally unnecessary when there is an outstanding nonsurgical option Uterine Fibroid Embolization (UFE).
UFE is obviously threatening to the >$10 billion hysterectomy industry which appears to be trying to maintain their dominance over a woman’s uterus. A bill was advanced recently in the Rhode Island legislature for insurance coverage of all surgical forms of fibroid therapy but failed to include Uterine Fibroid Embolization.2 This is a self serving act which is a disservice to women; particularly African-American women who are the most likely affected by this action. Some of the treatment options included in this bill are considered experimental by many insurance providers across the country, versus UFE which has been performed for over 25 years and verified safe and effective by the American College of Obstetricians & Gynecologists since 2008. Women are entitled to know all of their treatment options; not just the surgical ones. UFE is one of the biggest medical breakthroughs for women; particularly women of color that disproportionately suffer with fibroids.
What about research? What about educating doctors and the public on fibroids and UFE? Is there hope on the horizon? Yes, I believe so. Vice-President Kamala Harris (while she was in the Senate) and her counterpart Representative Yvette Clarke have re-introduced the Stephanie Tubbs Jones Uterine Fibroid Research and Education Act of 2021. The bill looks to address the need for improved patient and provider education surrounding the heightened risk for fibroids faced by women of color. It is a good first step to try to eliminate the most common cause behind the Period Pandemic.
This bill would:
- Establish new research funding through NIH, totaling $150 million over five years;
- Expand a CMS database on chronic conditions to include information on services provided to individuals with fibroids;
- Create a public education program through the CDC; and
- Direct HRSA to develop and disseminate fibroids information to health care providers.
One can only hope that the information disseminated is not just what the Gynecologists can provide through surgery as is being proposed in Rhode Island. Every woman suffering with fibroids needs to know about UFE, and any woman facing hysterectomy for fibroids should be offered UFE first.
- Fraser I et al Prevalence of heavy menstrual bleeding and experiences of affected women in a European patient survey. Int J Obstet Gynaecol 2015 Mar; 128 (3): 196-200.
- Stewart EA et al The Burden of Uterine Fibroids for African-American Women: Results of a National Survey. J Womens Health 2013 Oct 22 (10): 807-16.
- Rhode Island 2021 H5898: Provides health care coverage for laparoscopic removal of uterine fibroids, including intraoperative ultrasound guidance and monitoring and radiofrequency ablation, commencing January 1, 2022 (but does not cover Uterine Fibroid Embolization UFE).
- Congress.gov HR 2007 To provide for research and education with respect to uterine fibroids, and for other purposes.