Dr Roper has experience in a wide range of gynaecological conditions.
These include menstrual disorders, infertility workup, abnormal pap smears and contraception. He has experience in the non-surgical management of pelvic floor prolapse.
He recognises the need for subspecialists in gynaecology and has a network of subspecialists he may refer patients to for major laparoscopic surgery, cancer surgery, IVF and urogynaecology.
Heavy Menstrual Bleeding (“Menorrhagia”)
Menorrhagia is defined as heavy menstrual bleeding that is unacceptable to a woman. The usual volume of menstrual blood that is lost with each menstrual period is 30‐40mL. If a woman is losing more than 80mL per menstrual cycle it is likely that she will develop iron deficiency and anaemia. Common causes of heavy menstrual periods include:
- uterine fibroids
- advanced age, lack of ovulation
- pelvic infection
- disturbances of blood coagulation
Sometimes no specific cause is discovered and this is called ‘dysfunctional uterine bleeding’. This ‘diagnosis of exclusion’ actually accounts for most cases of heavy menstrual bleeding.
Management of heavy menstrual bleeding starts with a consultation with a GP or gynaecologist. A physical examination will be performed and may include taking microbiological swabs and a Pap smear. You may be referred for blood tests to establish your iron status, haemoglobin, thyroid. A pelvic ultrasound may be ordered to look for fibroids and adenomyosis.
Fibroids are very common benign tumours of the uterine wall. They occur in more than 20% of women over the age of 35. They may sometimes be discovered during the course of pelvic ultrasounds for other indications such as pregnancy or pain. There are three main types of fibroids:
- Submucosal fibroids – these are fibroids close to the inside of the uterus and can distort the cavity of the uterus. These can be responsible for heavy periods. Some can be removed by a technique called endometrial resection which is performed under general anaesthesia.
- Intramural fibroids – these develop within the wall of the uterus and can also cause heavy periods. These are usually only detected on ultrasound examination.
- Subserosal fibroids - these distort the outer contour of the uterus and may press on adjacent organs such as the bladder or be easily palpable within the abdomen if very large. These fibroids tend not to cause heavy periods and their removal has no impact on menstrual bleeding.
This condition is where the usual undulation of the lining of the womb (the endometrium) is exaggerated. These undulations of endometrium create a situation where there is a greater surface area from which to bleed and may also give rise to a sensation of congestion within the pelvis. Adenomyosis usually involves the back wall of the uterus and can lead to an overall increase in the size of the uterus. It is typically found in women in their 40’s.
This is usually diagnosed by the performance of microbiological swabs particularly looking for chlamydia.
These are an uncommon cause of heavy menstrual bleeding, but may occur in women taking anticoagulant drugs such as Warfarin for the treatment or prevention of thrombosis.
Endometriosis is a condition where some of the cells of lining of the womb (the endometrium) have made their way into the pelvic cavity by a process called retrograde menstruation. These cells then implant into the lining of the abdominal cavity and respond to hormones in a similar way to the endometrium of the uterus. These pockets of abnormally situated endometrial cells, referred to as endometriosis, bleed internally at a similar time as a period occurs.
Endometriosis sometimes has no symptoms associated with it and is discovered incidentally during the course of other surgical procedures. However, the presence of these deposits of endometriosis within the pelvis can result in increase in menstrual pain and flow, painful intercourse and pain on passing bowel motions when a woman has her menstrual period. Endometriosis can also be associated with reduced fertility. Physical examination may reveal tender areas within the pelvis and a reduction in the degree of mobility of the pelvic organs. Ultrasound examination may also show deposits of blood within either ovary. Ultimately the diagnosis is made by laparoscopy under general anaesthesia in hospital.
TREATMENT FOR HEAVY MENTRUAL BLEEDING
Treatment is tailored to the individual patient depending on their age, anatomy and desires for future fertility. Treatment options include:
Simple treatment with oral iron tablets may be sufficient to overcome symptoms of tiredness and lethargy due to heavy periods. They can restore a woman’s haemoglobin and iron stores.
Mirena Intrauterine Device
This device has revolutionised both contraception and management of heavy periods and provides an ideal solution for many women, eliminating heavy menstrual bleeding.
See Contraception page for detailed information about this device.
Oral Contraceptive Pill
As well as reducing menstrual blood loss this has the added benefit of contraception and of menstrual regularity. Its disadvantage is that it sometimes stimulates fibroid growth. Use can be problematic around the time of menopause as it can disguise the onset of menopause and it is also not recommended to continue the contraceptive pill in the presence of other medical conditions that can become more common at this age such as high blood pressure.
This medication affects the balance of clotting and anti‐clotting factors within the uterus. It has taken in a high dose for the first four days of menstruation only and it is not taken at other times of the month. It reduces menstrual bleeding by approximately 50%. Cyklokapron causes nausea and diarrhoea in some women as well as a rare side effect of disturbance of colour vision.
This is a technique whereby the lining of the womb (endometrium) is destroyed by thermal energy, electrical energy or microwave energy. One technique is the Cavaterm balloon. Under general anaesthesia the balloon is inserted into the uterine cavity. Fluid that is heated to 78 degrees Celsius is circulated within the balloon for eight minutes. It is not a procedure that should be used in women whose families are not complete. After this procedure, 90% of women are satisfied with their level of menstrual bleeding (40% of women experience no bleeding at all). Up to 33% of women will experience some increase in menstrual cramping several years later and occasionally hysterectomy is the only effective treatment option.
Hysterectomy is the removal of the uterus. The ovaries are left in place if they are not abnormal. Hysterectomy eliminates all menstrual bleeding and is only suitable for those people who no longer wish to have children. Hysterectomy is major surgery which involves hospitalisation for 2‐3 days and time off work for between 3‐6 weeks, and exclusion from very heavy work and certain sporting activities for up to three months. The operation can be performed by a variety of different routes ‐through an abdominal incision, laparoscopically in selected cases and vaginally in selected cases. Risks include damage to adjacent organs such as the bladder, ureters and bowels. There are also risks of blood loss requiring transfusion, infection, development of deep vein thrombosis (blood clots in the legs) and pulmonary embolus (blood clots in the lungs) which can sometimes be fatal. The development and use of the Mirena has dramatically reduced the need for this major operation.