[music plays] [no dialogue] >>Lori Banks: On this edition of Being Well, we welcome OB/GYN Mildred Nelson to the show.

We'll be talking about the diagnosis and treatment of heavy menstrual periods, particularly for women in their late 30s and early 40s.

Dr. Nelson will explain the root causes, and what options are now available that can provide relief.

It's an informative program coming up, so don't go away.

[music plays] Production of Being Well is made possible in part by: Sarah Bush Lincoln Health System, supporting healthy lifestyles.

Eating a heart healthy diet, staying active, managing stress, and regular check-ups are ways of reducing your health risks.

Proper health is important to all at Sarah Bush Lincoln Health System.

Information available at sarahbush.org.

Dr. Ruben Boyajian, located at 904 Medical Park Drive in Effingham, specializing in breast care, surgical oncology, as well as general and laparoscopic surgery.

More information online, or at 347-2255.

>>Singing Voices: Rediscover Paris.

>>Lori Banks: Our patient care and investments in medical technology show our ongoing commitment to the communities of East Central Illinois.

Paris Community Hospital Family Medical Center.

[no dialogue] Welcome back to Being Well.

I'm your host, Lori Banks.

And today's topic is for our female viewers out there.

And if you're probably 40, you may be experiencing some rather painful and uncomfortable periods.

And we've got Dr. Mildred Nelson here today on the show to kind of help us through what's going on, why it's happening, and what sort of treatments are available for women who suffer from these.

So, tell us a little bit about your practice, and what you do.

>>Dr.

Mildred Nelson: I'm in a general OB/GYN practice in Effingham, Illinois, which is Effingham Obstetrics and Gynecology, where we have four women and one guy, and several physician assistants who are also women, that practice the breadth of obstetrics and gynecology.

>>Lori Banks: From delivering babies to... >>Dr.

Mildred Nelson: Well, adolescents and their needs, to pregnancy, and through your 40s and all the fussy things that occur in your 40s with your female world, and menopause.

>>Lori Banks: Alright, so you cover the gamut.

When do you start seeing women come in and say, "Dr. Nelson, my periods are different.

I'm having more pain, and it's just not working for me."

>>Dr.

Mildred Nelson: Well, usually it's, I mean there's a subset of young people that have heavy periods, and they'’’ll tell you they've always had heavy periods.

You know, the adolescent that misses school because of her periods, and so forth and so on.

But by and large, the majority of people that present with significant heavy menstrual cycles, which is turned menorrhagia, occur in your late 30s, early 40s.

Potentially, you know, after having children.

Women might complain of cyclical cramps with their periods.

And what I mean by cyclical is that it starts just before your period starts, or just when your period starts, and continues until your period ends.

You might have back pain with your periods.

You might have nausea with your periods.

You might have changes in your bowel habits with your periods.

Some people get diarrhea, some people get constipation.

And you might have periods that are longer, or you might have periods that start out like spotting, spotting, spotting, bleeding, bleeding, bleeding, spotting, spotting, spotting.

>>Lori Banks: It just never goes away.

>>Dr.

Mildred Nelson: And then, you can have, correct, and then you have people who, the cyclicity changes.

So, you know, the young people today have an app.

You know, my 17-year-old will say, "My period's supposed to start next Wednesday."

I'm like, "Well, how do you know that?"

"My phone tells me so."

But the cyclicity will change, and that can be very disconcerting.

>>Lori Banks: Why does it seem to be, because I remember going to see my doctor when I turned 40, and she sat me down.

She's like, "Okay, you can expect this, this, and this."

And I thought, well, 40 doesn't sound all that great.

Why does it seem about for women in that 40-ish age range, that suddenly, things are not like they used to be?

>>Dr.

Mildred Nelson: Well, women can develop gynecologic, benign diseases, primarily endometriosis.

And endometriosis can be outside the uterus, that's what causes the back pain with your periods because it implants on the ligaments that go from your back of your uterus to your tailbone.

It can also occur in the muscle of the uterus.

And that's called adenomyosis.

Some people believe that there's a process called pelvic congestion syndrome, which is an engorgement of the blood supply or veins that supply the uterus that can be painful.

Women can develop, in their 40s, polyps in the uterus.

So, you know, we think about polyps as something like in the colon.

But you can have polyps in a lot of different places.

And polyps are glandular little finger-like projections in the uterine cavity that could cause bleeding.

Women in their 40s can develop fibroids in the uterus.

And not all fibroids cause heavy bleeding.

Actually, the majority do not.

But some of them, when they protrude into the uterine cavity, can cause very significant heavy bleeding.

So some, and then some people have hormonal imbalances.

You know, you can be peri-menopausal.

The normal fluctuation in your hormones that produces ovulation and menstruation cannot be synchronous.

Some people have metabolic disorders that cause irregular periods and heavy menstrual cycles that are hormonally based, as well.

So, there really is a huge sort of bag of tricks, so to speak.

>>Lori Casey: So, it's not one thing.

But are there other factors that can contribute to those issues, like maybe hereditary, if you had children or didn't have children, if you were on birth control or not?

>>Dr.

Mildred Nelson: So, having been on birth control pill doesn'’’t make you more prone to have heavy periods or less prone, but it can mask the symptom.

So, if you took birth control pills, you know, from the time you were 18 until you're 40, you didn't really know you had heavy periods, because birth control pills are one of the therapies for heavy menstrual cycles.

There are genetic disorders, gynecologic disorders that have a genetic association, such as endometriosis or polycystic ovarian syndrome.

So.

>>Lori Banks: What about, we see, we do a lot of these shows, and it seems like, you know, as Americans are heavier, it causes all sorts of problems.

Does a woman's weight have anything to do with heavy periods, painful periods?

>>Dr.

Mildred Nelson: I mean, obese women can be more prone to menstrual irregularity.

Missing periods, so that when you have that period that you didn't have for three months, you essentially have as much bleeding as you were having for three months.

But I don't know that obese people are more prone to heavy menstrual cycles.

>>Lori Banks: So, what is considered, if women are watching and they go, "Well, I don't know if my level of pain or the flow is normal," how can they judge whether what their experiencing is normal, and should they go see their doctor about it?

>>Dr.

Mildred Nelson: Well, if it's a change.

So, the question I would ask you as a patient is: do you have increasingly heavy periods?

So, this was your, the way you had cycles, you know, through your teens, early 20s and 30s, and it's different.

Number two, it bothers you.

Number three, you know, do you have to miss work for it.

Is it interfering in your activities of daily living.

Are you buying more tampons and pads than you ever bought before.

Are you anemic, meaning your blood count is low.

So, you know, it takes 120 days to make a red blood cell.

If you bleed so much in your period, you know, by the time you have your next cycle, you aren't-- >>Lori Banks; It hasn't regenerated.

>>Dr.

Mildred Pearson: It hasn't regenerated, then you go down, down, down, down, down.

Are you just totally drained when you have your period.

Do you get dizzy when you sit up when you have your period.

Another reflection of anemia.

Is your pulse increased, another reflection of acute blood loss.

As far as cramping goes, I mean, it's a subjective thing.

So, I would ask you: do you have back pain with your periods, do you have nausea with your periods, do you have abdominal pain, does your pain radiate down your thighs, how do you rank your pain on a scale of one to 10.

But at the end of the day, if you never had pain with your periods, and now you do, that's enough.

>>Lori Banks: So, are you seeing, do you think that women through evolution, or hormones, or whatever, are experiencing more heavy and painful periods now than maybe they did 30 years ago?

Or is it that now, there's just more options out there to deal with the problem?

>>Dr.

Mildred Nelson: Well, I think that there are definitely more options out there.

I think it wasn't one of those things that women talked about, right?

So, with the emergence of, you know, the feminist movement and more women in the workforce, and so forth and so on, it wasn't pictured as something that you had to suffer with, right?

And so, people are saying that's not acceptable, in terms of lifestyle, and I want to do something about it.

>>Lori Banks: So, if a woman gets to the point where she says, "You know, this is interfering with my life.

I'm uncomfortable, I'm having all these symptoms."

They make an appointment with their doctor.

What, you as the doctor, what information should we as the patient to come with to help you better kind of diagnosis our issues?

>>Dr.

Mildred Nelson: Well, a diary or a calendar, such as, you know, the regularity or cyclicity of your periods.

How long your periods are.

Do you change a pad once an hour.

And then, I say, how big are the clots you're passing?

And then, I always ask, compare it to a piece of fruit.

So, is it a pea, is it a grape, is it a strawberry, is it a kiwi, you know, is it an avocado.

So, you know, how big are those clots that you're passing.

What do you take for the cramps that you have.

Do you take just Tylenol, do you take an occasional Aspirin.

Are you taking eight Advil a day during your period.

So, how do you rank the discomfort that you're having on a scale of one to 10.

Do you have, and then I will ask about the family history.

Do you have any family history of this in your family.

I would ask if you have bleeding after intercourse, because that would signal something else of concern.

And I would ask if you have bleeding in between your periods.

So, one is the person who has increasingly heavy periods.

The second is the person who bleeds in between those periods.

And that could be concerning for something more serious, like uterine cancer or endometrial hyperplasia, which is an abnormal thickening in the lining of the uterus.

>>Lori Banks: So, come armed to the appointment with, you know, dates and write all that information down.

So, you as the doctor, how do you go about, once you gather all that information, how do you go about diagnosing what may be the source of the problem?

>>Dr.

Mildred Nelson: Well, you start with a physical examination.

You want to be sure that they have a negative Pap smear.

Cervical cancer can present with abnormal bleeding.

You want to get some evaluation of the uterine lining, which we call the endometrium.

Because, a lot of this pathology occurs right there.

I like non-invasive, painless approach, so generally I start with an ultrasound.

And that ultrasound can be of several varieties.

So, you can do just an abdominal ultrasound, but in today's world we most often do an abdominal ultrasound, as well as what's called a transvaginal ultrasound.

And if anybody's ever had a child, you know what-- >>Lori Banks: You know what that is.

>>Dr.

Mildred Nelson: What that is.

So, you put a probe in your vagina that really, you know, is sitting at your cervix and can image the uterine lining well.

And when you look at that, you're looking for anything outside the uterus that might clue you into a problem, such as endometriosis.

You're looking for the size of the uterus.

You're looking for the thickness in the muscle of the uterus, the wall of the uterus.

You're looking at the lining of the uterus, and how thick the lining of the uterus is.

And then, there's what we call the echo texture, or is it a smooth endometrial lining on ultrasound, or does it look really junky and irregular.

And sometimes if I'm suspicious, based upon the general ultrasound, I do a specialized kind of ultrasound called a saline infusion ultrasound, which sounds weird.

But you put a very teeny, tiny catheter or tube in the uterine cavity, and you push fluid in there.

And that fluid creates an interface on ultrasound, such that if you had a polyp, it would image very nicely.

Adenomyosis, which is endometriosis in the muscle of the uterus can sometimes be suspected when the echo texture of the muscle of the uterus is heterogenous or kind of muddled looking, or kind of a Swiss cheese sort of appearance.

Or you might see a little vessel coursing through the myometrium.

So, those things kind of give you a sense.

If you have, I mean, one of the things that you want to rule out with increasing change in your periods and increasing heaviness is obviously the most serious thing, which is uterine cancer.

And some sort of evaluation of the uterine lining by a tissue biopsy is important, especially if the ultrasound is suspicious.

And that's done either by an office, little biopsy instrument that goes into the uterine cavity, and you pull back a stylet, and it kind of sucks out a little aliquot of tissue.

Or you take the patient to the operating room and do a little outpatient procedure, where you look with a telescope.

I mean, literally with your eyes, and biopsy the uterine lining.

>>Lori Banks: So, you come back with all that information.

What sort of treatment options do you sort of go through?

>>Dr.

Mildred Nelson: Well, I mean I think different people make different choices.

So, I talk about the spectrum here.

So, some people like medical therapy, i.e., medication.

And options in medication, depending on what your risk factors are in your 40s, could include birth control pills, could include taking progesterone.

Sometimes we tell patients to take it for 10 days before your period.

Progesterone is kind of like a medical DNC.

It kind of thins the lining of the uterus, so that you have less of a period.

Sometimes we offer them a little bit more invasive therapy, such as certain IUD's, which we traditionally think of as a treatment for contraception.

But some of the newer IUD's have progesterone in the arms of the IUD.

Those hormones are minimally absorbed into your bloodstream.

So, if you don't like the hormonal side effects of oral therapy, this would be something you might want to consider.

And nowadays, they have IUD's that are good for five, maybe even up to 10 years.

And if you're 40, and menopause is 50, that might bridge that gap, right.

So, you just, so some women make that choice.

Some women will choose to have a procedure called an endometrial ablation procedure, which is an outpatient procedure where you basically destroy a certain amount of the uterine lining.

And that can be done in a variety of ways.

I tell patients you can freeze it, you can cook it, you can burn it.

In this community, the most common ways that it's done is either with a balloon that's put into your uterine cavity and circulates hot scalding water, or a little instrument that opens up into a fan, and you apply a current to it, and I don't want to gross you out, but it's like cooking a steak, searing a steak on the grill, right?

You put this fan in, and it basically sears with a very hot current the uterine lining, and destroys, I think about seven millimeters of depth of uterine lining.

>>Lori Banks: So, if you have that done, does it last?

Or is it something that you have to go in and have done every few years?

>>Dr.

Mildred Nelson: So, it isn't something you repeat.

It's a one-time thing.

It does not last forever in everybody.

It is somewhat of a newer procedure, so there isn't, you know, 50 years of data to say what happens to people that did it 50 years ago.

If your uterine lining is very thin when you go to do the procedure, the chances that you're going to have a longer term success rate are greater than if you just did it before the day your period was due.

So, I like to think of it as kind of mowing the lawn, since it's summer.

You know, when the grass is high, and you do the ablation, you don't really get down to the roots of where that endometrium comes from.

But if the lining is really thin, so, for example, if you pretreat the patient with progesterone or a month of birth control pills, which thins out the lining of the uterus, when you go to do the procedure, you have a greater chance of getting down to the root of where that uterine lining comes from.

And therefore, you have a greater chance of a long term success.

It also depends on how big your uterus is.

So, some people have, you know, we all come in different sizes and shapes.

Some people have little uteruses, some people have big uteruses.

Depends on if you do this ablation, and you find some fibroids in the uterine lining.

So, other things can decrease the success rate.

I think that the overall success rate of happy customers is about 85 to 90%.

So, there's the selection process, and then of those people you select to offer that to, a good 85 to 90% of people are, that's the end of the game for them.

>>Lori Banks; Has that procedure cut down on the number of hysterectomies that are done?

>>Dr.

Mildred Nelson: Yes.

I don't know the exact statistics for that, but I generally would say it probably decreases our hysterectomy rate by about 50%.

So, there's a group of people that would just live with their symptoms, and not choose to have a hysterectomy, right?

So, there's a group of people that we've really improved their quality of life through this procedure.

And then, there's a group of people that would have chosen hysterectomy because it's so discomforting for this process.

But I would say about 50% as a group.

>>Lori Banks: So, at what point, if you've tried, you know, medical therapies, you know, drugs, you've tried maybe the ablation, or maybe that's not an option, when does a hysterectomy become an option?

>>Dr.

Mildred Nelson: Well, I mean hysterectomy is an option for a whole host of reasons for people.

But generally, I think as a consumer, I think yo as the patient need to be involved in that decision making.

So, many women come in with the decision already made.

And I think if you're a failed ablation procedure-- >>Lori Banks: That's your option.

>>Dr.

Mildred Nelson: That'’’s definitely an option.

And I think if you said to me, "I don't want to do that ablation procedure, I want to just go to hysterectomy," I think that absolutely is an option, as well.

Ablation doesn't work for everybody.

So, depending on how big your uterus is, do you have other issues going on, do you have endometriosis outside the uterus.

So, if you're coming in with heavy periods and cramping, ablation procedures primarily treat heavy periods, secondarily cramping.

But if you're cramping with your periods is because of extra uterine or endometriosis outside your uterus, I'm not treating that with your ablation procedure.

So, I might fix your bleeding, but you still have cramping.

So, then are you happy, right?

So, it depends on the whole picture of the patient.

And I generally present options.

>>Lori Banks: Which is a good thing to have, are options.

So, are there anything, if there's women out there watching who may be in their early 20s, and they're hearing this, thinking, "Oh goodness, this is what I have to look forward to," is there anything that younger women can do to prevent any of this in their future?

>>Dr.

Mildred Nelson: So, I will say that the younger you are, that you would choose an ablation procedure, the higher the chance of failure.

So, if you're coming to me at 45, and I do an ablation procedure, well menopause is 50, right?

So, if you're coming to me at 40, I mean, your problem is going to go away in 10 years.

So, the question is what can we do for 10 years that buys you 10 years.

At 20, that's a bigger issue.

And at 20, heavy menstrual cycles may have, you know, a hormonal imbalance.

I'd be more likely, and then you want to preserve fertility.

So, ablation procedures do not present an option for fertility.

You cannot have children after that.

Well, you can get pregnant, but it can't carry a pregnancy to term.

So, I would lean more towards like a medical evaluation, hormonal tests, ultrasound, using medication to control it, such as birth control pills or IUD's, Nexplanon, which is an implantable hormonal device, before I would recommend ablation procedures.

>>Lori Banks: For someone who's a lot younger.

>>Dr.

Mildred Nelson: Yes.

>>Lori Banks: Okay, but I think the important thing, as you said, is just to keep on top of it.

And you know, if you are having issues, see your healthcare provider about it because there may be, as you said, more serious things going on.

>>Dr.

Mildred Nelson: I mean, really young people, I mean you can have an inheritable blood clotting disorder, which is very rare.

I diagnosed it once in 25 years, but it does occur.

So, there's lots of different things that you want to look at when they're younger and having these symptoms.

>>Lori Banks: Alright, well Dr. Nelson, thank you so much for coming on Being Well for the first time.

We'd love to have you back again.

And thank you for watching.

And remember that we're always online any time, at youtube.com/weiu.

We'll see you next time.

Sarah Bush Lincoln Health System, supporting healthy lifestyles.

Eating a heart healthy diet, staying active, managing stress, and regular check-ups are ways of reducing your health risks.

Proper health is important to all at Sarah Bush Lincoln Health System.

Information available at sarahbush.org.

Dr. Ruben Boyajian, located at 904 Medical Park Drive in Effingham, specializing in breast care, surgical oncology, as well as general and laparoscopic surgery.

More information online, or at 347-2255.

>>Singing Voices: Rediscover Paris.

>>Lori Banks: Our patient care and investments in medical technology show our ongoing commitment to the communities of East Central Illinois.

Paris Community Hospital Family Medical Center.

[music plays]