When menorrhagia or abnormal bleeding stems from anatomical problems like fibroids and polyps, the recourse, two decades ago, used to be an invasive surgical procedure called myomectomy or removal of the noncancerous growths.
But myomectomy did not always stop the bleeding. And there are other causes behind abnormal bleeding, like hormonal imbalances.
For a majority of patients, the outlook was pretty unpleasant. High-dose hormones caused a host of side effects like rapid weight gain. A procedure called dilation and curettage, or D&C, which scraped away the lining of the uterus, typically failed to stop the bleeding for more than a few months.
The last resort was a hysterectomy — major surgery to remove the uterus and sometimes other reproductive organs as well.
But things have since changed a lot. "Women no longer need to choose between suffering and major surgery," said Dr. Glenn Schattman, a reproductive surgeon and associate professor of obstetrics and gynecology at the New York Presbyterian Hospital/Weill Medical College of Cornell. "Today, the key is avoiding major surgery, and thankfully, the overwhelming majority of patients can now be treated with minimally invasive procedures or medication."
The changes began in 1987, when the Food and Drug Administration approved a laser that could destroy the lining of the uterus by heating it. The laser outpatient procedure that became known as endometrial ablation was a retreat from the finality of a hysterectomy which, back then also required up to two months of recovery time, Carolyn Sayre writes in New York Times.
A few years later, physicians began to refine the procedure, developing more sophisticated techniques like endometrial resection, which removes the uterine lining entirely.
Dr. Morris Wortman, director of the Center for Menstrual Disorders & Reproductive Choice in Rochester notes that endometrial ablation stops bleeding in nearly half of women and significantly reduces bleeding in another 40 percent.
But like most procedures, endometrial ablation and resection also have downsides. About 15 percent of patients still need a hysterectomy, and while the uterus remains intact after the endometrial procedures, a woman's chance of conception is destroyed.
Medical therapies now help eliminate some of the fertility concerns. In the early '90s, low-dose birth control pills began to be prescribed for women with heavy bleeding who did not have structural problems. Perhaps the biggest breakthrough came in 2001, when the F.D.A. approved Mirena, an intrauterine birth control device that lightens bleeding in more than 80 percent of women.
Today, most physicians consider the fertility-preserving Mirena IUD to be the first-line treatment for heavy bleeding in women with normal anatomy.
"It works beautifully," said Dr. Linda Bradley, director of hysteroscopic services for the department of obstetrics and gynecology at the Cleveland Clinic's Center for Menstrual Disorders and Fibroids. "Women who take it either don't get their period or bleed very lightly."
In a small percentage of women, the device causes side effects like spotting or abdominal pain and may need to be removed.
And for women with anatomical problems like fibroids and polyps, minimally invasive procedures like laparoscopic myomectomy have reduced recovery time significantly. And uterine fibroid embolization, a nonsurgical technique that shrinks or kills the growths by cutting off their blood supply, has helped certain patients with structural problems avoid surgery altogether.
Now that alternative treatments to hysterectomy have been developed, physicians say their biggest challenge is raising awareness and acceptance among women, many of whom still fear that major surgery is their only option.
"I can't believe how many women are essentially bedridden during their periods for a year or two before they see a doctor," Dr. Schattman said. "They are still scared that heavy bleeding means they will need a hysterectomy."
In US nearly one in five women in the 35-49 age group suffer from the problem.
According to the Centers for Disease Control and Prevention, 20 million women have had a hysterectomy. "That number should be lower," Dr. Wortman said. "And it would be if more women understood all of their options."