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Rasheeda Bhagat

Dr P. M. Gopinath, President-elect of the Obstetric and Gynaecological Society of Southern India

IN AN obstetrician's clinic, in the government or private sector, roughly 10 per cent of the patients come seeking treatment for excessive or abnormal menstrual bleeding. For a good percentage of women over 40, who complain of abnormal bleeding during their monthly cycle, the treatment now being offered is hysterectomy, but its numbers can be brought down, says Dr P. M. Gopinath, the Chennai-based President-elect of the Obstetric and Gynaecological Society of Southern India.

By definition, heavy or abnormal bleeding during a menstrual cycle is when the woman continues to bleed beyond three days and loses blood much above 100 ml. The average blood loss during a menstrual cycle is 80-100 ml. "We really cannot define what is `heavy'; women who complain of heavy bleeding might be actually bleeding less, while others despite heavy bleeding might continue to do their routine work. When bleeding incapacitates a woman we call it abnormal bleeding."

This malady can occur in all age groups. For teenagers and women in the reproductive age group, the treatment is different. In young girls, heavy bleeding could be due to a bleeding disorder and this is treated with hormones or some other medication. In women in the reproductive age group, a D&C (dilatation and curating) is done to ascertain the cause of excessive bleeding.

These women are then put on oral contraceptive pills or prescribed some hormones to bring them back to the normal rhythm of monthly periods. But when this condition occurs close to menopause, around 40 or so, it is more difficult to control with medication, says the obstetrician.

Menstrual bleeding comes from the endometrium, the inner coating of the uterus, which sheds and regenerates every month under hormonal influence.

Heavy or abnormal bleeding is a result of abnormal maturation of the tract, and disturbances in the signal that comes from the brain (hypothalamus) to the ovaries, which then secrete oestrogen and progesterone, resulting in menstrual bleeding. "This signal is something like an electrical link or a computer connection; a small disturbance in any of the signals can lead to abnormal uterine bleeding. This is the commonest cause," says Dr Gopinath.

Another cause for heavy menstrual bleeding could be a fibroid growth in the uterus, which is often treated by hysterectomy. But if any of these causes are not indicated and the excessive bleeding is only an endocrine problem, other methods of treatment are available. One is medical treatment, under which the woman has to take drugs for five- seven days during the period.

"The drawback is that the woman might find this cumbersome, the drugs can have side-effects and they tend to work only for a few women. The other alternative is to do a D&C and check up what is happening inside. But this is not a cure. Besides these two, the commonest remedy being practised, at least in our country, is hysterectomy," he says.

So does he think an unnecessary number of hysterectomy operations are being performed today? "Definitely. The problem is that even an older woman, particularly a woman busy with her career, tends to put off going to a doctor. She thinks that if I go to a gynaecologist, she will do a hysterectomy and I will lose two months of my precious time. And she keeps postponing medical attention," says Dr Gopinath. He says that both women suffering from this disorder as well as most doctors are not aware of a simple alternative that is available for women in the 40-plus age group.

"I believe that, as a gynaecologist, we have to give a via media to such women, before thinking of a hysterectomy. So just like you mow the lawn, an obstetrician can put an electrical connection inside the uterus and lightly scrape out the endometrium, strip by strip, under vision and through an instrument."

This is called endometrial ablation and can be done with a hysteroscope. When the endometrium is scraped out, the woman will stop menstruating. But this can be done only in older women, and its advantage is that both the uterus and the ovaries are left intact, which means that there is no depletion of the hormones.

"But the disadvantage is that this procedure can be done only by one who is an expert at using a hysteroscope — an instrument to visualise the uterus. Very few obstetricians have this expertise. If you take the 600-odd members of the O&G Society, only a handful can perform a hysteroscopy," says Dr Gopinath.

The next generation treatment, he says, is thermal ablation. This can be done by inserting into the uterine cavity a copper T or a small rod, with a collapsible balloon at its end. Inside the cavity, the balloon is distended with about 30 ml of dextrose (ordinary glucose used as IV fluid.) This device is connected to a controller unit that heats the dextrose up to 87 degree centigrade.

"At this temperature, the entire endometrium is destroyed without any adverse effect outside the uterus. And then you just pull it out and send the patient home in two hours. The advantage of this procedure is that if you can insert a copper T, which our midwives can do, this can be done. But, of course, only a qualified obstetrician should do this," he says.

The woman can return to her normal household work the next day and office work after three days.

"This is the best alternative to women with problems such as diabetes, hypertension, heart disease or kidney problems; conditions that make surgery is a risky proposition. Also, once women know that this simple treatment is available, those with heavy bleeding will seek medical help in time and end their discomfiture soon."

Dr Gopinath has been trained by a Dutch expert and, in the last three years, has done over 400 such procedures with satisfactory results. "In the US they have completed a five year follow up, and a US patent has been obtained. It is not only simple and less traumatic but is cheaper too," says the doctor.

About the success rate, he says the procedure has to be timed soon after the period is over, so there will be only 3 mm residue of the endometrium left and it won't regenerate. As a result, the woman will either not get her period at all, or will get a scanty one .

The procedure costs around Rs 10,000 because the balloon is imported from the US. "But compared to a hysterectomy it is both cheaper and less traumatic and the woman can return to work in three days."

Of the 417 cases he has done, about 67 per cent of the women have not got their periods again, and only in a couple of cases, the heavy bleeding could not be checked and a hysterectomy had to be resorted to. In India, says Dr Gopinath, at present, only 10 obstetricians are doing this procedure. All over theworld, about two million such procedures have been done compared to only 8,000 in India.

"I have to stress that this is not an alternative to hysterectomy. It is only one more method by which a woman can be relieved of her symptoms. Considering that about 50 per cent of hysterectomies in India are today being done for excessive bleeding, this is a viable alternative that should be offered to women who qualify. Its biggest advantage is that it can be done at a place 80 km away from Chennai, where hysterectomy cannot be done because post-surgical complications cannot be handled there."

But it cannot be done in women who have an abnormal sized uterine cavity, because the balloon is designed for an average size cavity. Nor should it be done when a malignancy is suspected, he adds.

(Response can be sent to rasheeda@thehindu.co.in)

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