Abnormal Uterine Bleeding – Interview With Dr. William Parker
|Dr. William Parker
University of California, Los AngelesExpert in minimally invasive gynecological surgery Dr. William Parker talks with NWHRC Executive Director Elizabeth Battaglino Cahill, RN about medical options for treating abnormal uterine bleeding using minimally invasive techniques.
Dr. Parker, lots of women say that they have heavy periods. When is uterine bleeding considered to be a clinical problem?
We consider it a clinical problem, first of all if a woman herself feels like things are changing that may be a problem but the definition is a period every 21 to 35 days, usually lasting somewhere between 5 to 7 days, changing a pad or tampon no more than every 3 or 4 hours. That would be clinically considered. But if you’ve had very light periods your whole life and then all of a sudden there’s a dramatic change, even if it doesn’t necessarily meet these criteria, probably that should be discussed with the doctor.
What are the causes of abnormal uterine bleeding?
Well most people think about fibroids first but actually it’s further down the line. Often it’s hormonal, minor hormonal fluctuations that are pretty common. Thyroid disease can do it, either in overactive or underactive thyroid can do it. Very common and not very well understood, even among doctors, there is a blood clotting disorder called von Willebrand disease, which can cause very heavy periods. It’s usually present from the first period on and I’ve had patients tell me I’ve had incredibly heavy periods from—and they expect that that’s normal but in fact we found a number of women that have had blood clotting disorders. And that’s important to know because if you need surgery down the line it would be important to know that. Fibroids is definitely on the list. That’s a fairly common problem. And then irregular bleeding, ovarian cysts can do it, some other less common things.
How often is heavy bleeding a symptom of fibroids?
Well we know that of all the women that have hysterectomies, about 35% of them are for fibroids and the majority of that is for bleeding disorders. So I’m not sure that that number is known but that’s probably close.
And how do women know that it’s time to talk to their doctor about their heavy bleeding?
I think women should talk if there is a dramatic change. One of the things about bleeding is that it sometimes can sneak up on you. You bleed a little bit more this month than you did last month. And a little bit more next month. And before you know it a year and a half has gone by and you’ve forgotten what normal was for you a year ago or two years ago. I had one patient actually carried into my office by her husband because she couldn’t stand up. And she had had just progressive heavy bleeding over a period of time. So, you don’t want to wait that long. You want to discuss it early on when there’s a change. If you’re changing a menstrual pad every 2 hours or 1 hour, that’s not normal. It should be discussed.
And can abnormal uterine bleeding happen at any age?
Yes. In young women, it’s often hormonal. In the reproductive age of women, it can be any of the causes we discussed, thyroid disease, fibroids, ovarian cysts, etc. And then after the menopause it’s particularly concerning because there’s a possibility that it’s associated with cancer or pre-cancer. I don’t want to scare people about the cancer because that’s actually rare but that’s one of the things that needs to be ruled out. So it’s important to see the doctor about that.
The report found that over one-third of all baby boomers are affected by abnormal bleeding. Do you think that one-third of 40 and 50 year olds are talking to their doctor about this?
No, I don’t think they talk, they talk to their best friend and their best friend tells them what to do. And often they’ll do what their friend tells them to do. They usually come to the doctor when it’s already bad and it’s been bad for a while. And it probably makes sense because there are a lot of things we can do to treat this now short of hysterectomy. And I think it’s worth talking to the doctor earlier in the course before you get anemic, before the treatment options are limited.
What do you think is necessary to happen for more women to discuss abnormal uterine bleeding with their doctors?
Well hopefully this program and your information on your website. There have been a lot of articles in the lay press, magazine articles to try to encourage women to talk to their doctor and if they don’t like the answers get a second opinion.
What are the treatment options for abnormal uteerine bleeding?
So one of them would be medical therapy. And actually medications like Aleve and Motrin can often be used if they’re used prior to the onset of bleeding, they will sometimes dramatically cut down heavy bleeding. So 2 or 3 tablets every 8 hours starting maybe a day before the menstrual period really will make a difference for a lot of women. Other medical therapy, hormonal therapy, birth control pills work really well. And now most women know that you can take the pill, you can actually even skip periods. Take the pill for three months in a row, have a period. Take the pill for six months in a row and have a period. And that works very well. Another form of hormonal treatment is the Mirena IUD. So progesterone containing IUD. Tiny amounts of progesterone but working locally in the tissue. Very effect. In fact, in Europe it’s probably first line there because it’s been shown to be so effective for bleeding. Six months of irregular bleeding but then most women have even no bleeding or very very light bleeding. That’s probably underutilized in this country but utilized in Europe. And then endometrial ablation for women that have completed childbearing and have periods often can be either office procedure or certainly outpatient. No incisions, no recovery time. Patients don’t believe me when I tell them this but no pain afterwards. After the procedures done they go home and take Aleve, Tylenol, Motrin for a day and that’s it and go back to work in a day. Very effective, somewhere in the 90% range for abnormal bleeding. And then there’s more surgical therapies. Certain a hysterectomy can be done. Myomectomy, removing fibroids when they’re present. Very effective for bleeding. Hysterectomy I like to think of as a last resort because it’s a bigger operation and longer recovery time, time in the hospital. But you do get the hundred percent guarantee no more bleeding.
Which surgical treatments can be performed on an outpatient basis?
The endometrial ablation can now be performed in the office with certain methodologies. There are probably 5 or 6 different ways to do it and 2 or 3 of them can be done in the office as an outpatient. Local medication and injection near the cervix, maybe some oral Valium, very effective.
And are there times when hysterectomy is the right option and when might that be?
I think hysterectomy should be a last resort. You’ve tried some of the simpler less invasive methods and you say you know what I’ve had it, I’m sick of it, I’ve got to get back to work, I don’t want to mess with this anymore. Now most women with the simpler methods are going to have success. So now you’re talking about a very very small portion of that population that’s going to eventually say I’m sick of it. But I see that even in my practice. I try to be very conservative. But every once in a while a patient walks in and says I’ve had enough.
Lots of women have seen the same gynecologist for many years but their doctor might not offer all of the latest treatments.
How does a woman know if she should seek a second opinion?
Well I think women nowadays have a lot of avenues to educate themselves. The Internet, it has good and bad but there’s a lot more good now than there used to be. Really good sites like your site. Straight, unbiased information. If somebody goes to a site and it sounds like they’re selling one thing probably should go to another site. But that information is available. There are books available now. And I think you have to educate yourself, going into talk to your doctor with a list of questions. If they don’t offer you ablation, let’s say or Mirena, you should ask why. And hopefully they’ll be honest enough to say because I don’t know how to do it and if they don’t know how to do it then you need to get a second opinion.
What kinds of comments from doctors are clues to women that they need a second opinion? Such as, you’re just a few years from menopause, it will get better. You need a hysterectomy, no other options offered. You get a better outcome with an open abdominal hysterectomy.
Well, again, I think you have to go in knowing the information, knowing what is available and I think it’s totally legitimate to ask as many questions as you need to ask. Do you do this procedure. I’m think about ablation. Do you do it? How many have you done? How many have you done in women like me? Have you had any complications? And that’s totally legitimate and women need to ask their doctors those questions. And if they’re not happy with the answers, time to go find another doctor.
You have published research that found women should not routinely have their ovaries removed during hysterectomy. Please tell us about that research and what women should know.
So in 2005 we published an article that was a computer model for many studies that have been done over 30 years looking at the outcomes after taking out ovaries. And what we found is when you take out your ovaries there’s obviously a lower risk of ovarian cancer, which is a really frightening disease for women but it’s really rare. For instance, 14,000 women die in this country every year of ovarian cancer, 450,000 women die of heart disease. And what we found is if you take out ovaries you’ve actually increased the risk of heart disease. So it doesn’t take much change on this arm to overpower the loss of life on this one. Now we’re talking about death and that’s horrible no matter what but we found that if you leave ovaries women have less risk of heart disease, less risk of dying of hip fracture and incidence of hip fracture. There’s some data that suggests maybe less risk of stroke.
Thank you Dr. Parker.