HYSTERECTOMY: ‘WATCHFUL WAITING’

For some women, coping with difficult menstrual bleeding or painful periods without drugs or surgery is an option worthy of serious consideration. The rationale for a ‘watchful waiting’ approach hinges on the well-established finding that oestrogen plays a major role in the growth of fibroids and endometriosis. When oestrogen output by the ovaries decreases after menopause, these conditions tend to become much less worrying. Many women are therefore prepared to give the watchful waiting approach a try if their period problems are bearable and they are nearing menopause.

Julia experienced intermittent, heavy and painful bleeding due to fibroids for two-and-a- half years before her menopause and considered having either a myomectomy or a hysterectomy during this difficult time. Looking back some years later Julia was pleased that neither procedure was ultimately necessary.

There are many reasons for difficult-to-manage bleeding patterns apart from fibroids. Lauren had lengthy menstrual bleeds in her late forties that were different from anything she had experienced previously. During them, spotting was typical on the first few days, then there were several days of heavy bleeding which resembled the heaviest bleed of former periods, followed by a handful of days when the bleeding tapered off. Managing the blood loss was tiresome because it went on for so long and Lauren was also concerned about the possibility that something was seriously amiss. Medical investigations including a hysteroscopy did not reveal any suspicious lumps or growths and showed that she was not anaemic. Doctors said changes in her sex hormone levels, consistent with an Impending menopause, were to blame for her symptoms. In order to sort out whether Lauren’s blood loss was excessive, it was suggested she record what her bleeding was like. ‘Keep a diary of how many days it lasts, how many and what sort of sanitary pad or tampon you use, whether pain occurs and when,’ her doctor said. ‘Then we’ll discuss the findings.’

Lauren’s diary confirmed that her blood loss was heavy and prolonged and a number of possible medical therapies were discussed as well as the option of watching and waiting. After talking with friends who had negotiated similarly difficult bleeding, Lauren decided to try a non-medical approach for a few more months. In particular, she started experimenting with dietary changes, including some herbal products, and the use of highly absorbent ‘overnight’ sanitary pads when the bleeding was heaviest. Her boss, who had herself been through similar difficulties some years earlier, was supportive and understanding. Lauren bled profusely at night on several occasions and found it reassuring to have a mattress protector in place as well as a towel beside her bed in case of flooding. After several months her periods dwindled then stopped.

An increasingly common cause of bleeding in the post-menopausal age group is hormone therapy. Sometimes there is no apparent reason why such problems affect one woman and not another. Occasionally the explanation seems to be pre-existing fibroids or the use of an oestrogen implant as part of post-menopausal hormone therapy. It has been noted that implants cause severe uncontrollable bleeding in some women, presumably because they deliver larger amounts of oestrogen than other hormone therapy formulations, for some of the time at least.

Another possible cause of bleeding is cancer of the endometrium in post-menopausal women who have used oestrogen therapy (in pill, patch or implant form) without added progestogen for several years. Even after oestrogen is no longer taken, the risk of cancer of the endometrium persists. It is important to seek medical advice promptly if this possibility applies to you.

The decision about whether to watch and wait or to try medical treatments or surgery depends on many factors including the amount of bleeding and its effect on daily living, the ability to cope with such difficulties, general health, the rate of change in conditions like fibroids, and the probable time to menopause. Situations in which watchful waiting is generally considered to be inappropriate include rapid fibroid growth resulting in a significant and measurable increase in the size of the uterus during a six-month period, bowel or urinary obstruction, and symptoms which make life seem hardly worth living.

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