Menopausal zone: Excessive bleeding can harm your health 
Dr Meenal Kumar

Shelly, 43, has been complaining of hot flashes for the last couple of years. Her experience has varied from 'a fleeting sense of warmth to a feeling of being consumed by fire'. Many a times a hot flash-induced facial flushing, sweating, chills and confusion sent her running to the gynaecologist. The doctor has often counselled her 'patience' since this could be a normal occurrence in the menopausal zone (the period after 40 years with the cessation of menses) due to the imbalance of oestrogen hormone. Hormone replacement could quell hot flashes, but it's not risk-free, the doctor opined. The doctor further advised her to take more of cold drinks and practice 'slow, deep, full breaths — at a rate of about six to eight breaths per minute'. However, Shelly's problems are far from over since more and more symptoms have been added to her troubles. The recent addition of heavy menstrual bleeding has given her a feeling of ill health, leading to the fear of cancer.

Fortunately, most of the excessive bleeding at the onset of the 'menopausal zone' (perimenopause; a few years before the cessation of menses) is not due to cancer. There are varied causes of excessive bleeding during this long phase; more serious ones like uterine cancer crop up in older women in the later part of the menopausal zone. Here we will focus on excessive bleeding in the perimenopause phase only.

The symptoms

Perimenopause varies greatly from woman to woman. The average duration is three to four years, although it can last just a few months or extend as long as a decade. Some women feel buffeted by hot flashes and are wiped out by heavy periods; many have no bothersome symptoms. Common symptoms that may afflict a perimenopausal woman are "hot flashes, irregular or missed periods, vaginal dryness, bladder irritability and worsening of loss of bladder control, emotional changes (irritability, mood swings, memory loss, depression), drying of skin, eyes or mouth, sleeplessness, decreased sex drive, obesity, constipation, indigestion and poor quality of life. While symptoms like hot flashes occur in 35-50 per cent of perimenopausal women, these are mere nuisance and do not sap one's health unlike heavy bleeding. With less progesterone to regulate the growth of the endometrium, the uterine lining may become thicker before it's shed, resulting in very heavy periods. Also, fibroids and endometriosis (the migration of endometrial tissue away from uterus), both of which are fuelled by estrogen, may become more troublesome and cause a heavy loss of blood.

Being perimenopausal is different from being menopausal. During perimenopause, errant menstrual periods are frequent. Periods are likely to get out of control and involve too much bleeding for too long. After the onset of menopause, no bleeding should occur. Excessive bleeding can be a tremendous nuisance, inconvenience and embarrassment if you are bleeding through your clothes, on to your bed clothing and having to spend a fortune on pads. However, panic of cancer or apprehension of losing uterus through surgery may be unjustified in most cases.

What is excessive bleeding?

During a normal menstrual cycle, an average woman loses 25-80 ml of blood. Most women change their pads around three times a day. A normal menstrual cycle is 21-35 days in duration, with bleeding lasting four-five days. When the loss is more than 80 ml or it lasts eight or more days, it is called excessive bleeding or menorrhagia. Chronic heavy or prolonged menstrual bleeding can interfere with daily activities, and raise concerns about uterine cancer. Studies indicate that about 10 per cent to 20 per cent of women report menorrhagia over 40 years of age with its peak between 45 and 49 years of age. Many women are referred to specialists for hysterectomy, a procedure involving surgical removal of uterus. But should uterus removal be practiced liberally?

It will be pertinent to mention here that several studies provide that bleeding will get better without the surgical removal of the uterus. Heavy bleeding gets stopped without treatment more frequently as women approach menopause. In a study, 17 per cent of women aged 40 to 44 got better without being treated; the rate jumped to 35 per cent in women aged 50 to 54. In any case, bleeding should not be ignored. Women should ask for medical help when they're bleeding heavily, without fear of hysterectomy.

Why excessive bleeding?

It may be caused by a hormonal imbalance or abnormalities at a sub-cellular level in the endometrium. Menorrhagia can also be caused by fibroids, polyps or adenomyosis. The Polycystic Ovary Syndrome (PCOS) is a condition where small cysts form on the ovaries, and this can cause heavy bleeding to occur, but with associated symptoms like weight gain, acne, male pattern hair-loss, and hair growth on the face. Birth control pills and intrauterine device (IUD) both have the possibility of causing heavy and excessive menstrual bleeding. Pelvic inflammatory disease (PID) can cause scarring of the organs and tissues, and if untreated can lead to excess bleeding. The causes can be fungal, viral, parasitic or, most commonly, bacterial. At times it can also be caused by sexually transmitted diseases. Besides excessive bleeding fever, pain felt in the lower abdomen or pelvic region, weakness and body aches may also occur.

Treatment

Three treatment options are:

Watchful waiting: A woman may choose to delay having any treatment, particularly if she is close to reaching menopause. Periodic pelvic examinations and ultrasounds can help track the progression of her fibroids. Use of vitamin K, calcium supplement or pills of tranexamic acid can lead to a significant reduction in menstrual blood loss and an increase in their health-related quality of life. Nonsteroidal anti-inflammatory drugs (NSAIDS — ibuprofen and naproxen sodium) may also be helpful in reducing blood loss in these women

Hormone therapy: Hormonal treatments such as oral contraceptives or a progestin-releasing IUD can help reduce heavy bleeding and pain. Gonadotropin releasing hormones (GnRH) stop ovulation, and thus the production of estrogen, and can reduce bleeding. Progesterone is a hormone made by the ovary that is effective in preventing excessive bleeding in women who do not ovulate regularly. A synthetic form of progesterone, called progestin, may be recommended to treat abnormal bleeding. In some cases, the progestin is given on a regular basis (every few months) to prevent excessive growth of the uterine lining and heavy menstrual bleeding. Progestins can be given as injection, implant, or intrauterine device (IUD). Some women completely stop having menstrual bleeding as a result of the IUD, which is reversible when the IUD is removed.

Surgery: There are many surgical options ranging from less invasive to very invasive. They include removal of the fibroid, removal of the endometrial lining (endometrial ablation), shrinking the blood supply to the fibroid (uterine artery embolization), and removal of the uterus (hysterectomy). However, surgical removal of uterus should be the last resort coming to the minds of the patient as well as the doctor.

The writer is a Chandigarh-based senior gynaecologist. Email: drkumar232@hotmail.com 

Hyaluronic acid injection brings relief in knee arthritis
Dr Ravinder Chadha

Osteoarthritis of the knee is an extremely common ailment affecting the elderly. The cartilage which protects the ends of the bones starts degenerating. The damaged cartilage lacks the ability to produce the lubricating fluid rendering the joint dry, stiff and painful. In severe cases, there is loss of cartilage leading to bone-to-bone-contact causing severe pain.

Common symptoms

Knee pain that worsens with prolonged sitting, climbing stairs, squatting or kneeling. Initially, pain subsides with rest, but as disease progresses, pain may occur both at rest and at night.

*Swelling

*Stiffness, especially after prolonged sitting and getting up.

*Decreased range of motion.

*Crackling sounds in the knee.

*Instability with buckling or giving out.

*lLocking or catching of the knee due to intra-articular loose bodies from degenerative pieces of cartilage shed into the joint.

Patients may develop ‘bowleg’ that may lead to a limp.

Patients remain on conservative treatment for prolonged periods like analgesics and cartilage building drugs (glucosamine/ diaceren). Often these patients face an uncertain situation while deciding about knee replacement surgery. Hyaluronic acid injections dramatically alleviate the symptoms of pain, stiffness, etc. Mechanism of action is by cushioning of the knee joints, by anti-inflammatory role and stimulation of production of hyaluronan. These injections replace the damaged joint fluid with a substance that has cushioning and lubricating abilities similar to normal, healthy joint fluid.

Hyaluronic acid is not a drug in the real sense of the word. It does not entail the same concerns or risk as certain other joint injections (eg steroids), but only the individuals experienced in giving joint injections should administer these. The only adverse reaction is temporary localised pain or swelling for 24-48 hours. Therefore, after injection it is advisable to avoid excessive weight bearing for a day or two.

These injections are available in pre-filled syringes, and the recommended dose is either single injection or one injection per week (total three or five injections).

Indication for usage

Most of the patients notice improvement in pain and stiffness after the injection.

It’s useful in prospective candidates for knee replacement in order to delay/postpone surgery.

Individuals intolerant to the side-effects of medicines.

For delaying knee replacement surgery in young patients.

Patients medically unfit to undertake total knee replacement due to obesity, diabetes, heart problems, etc.

Physical therapy like hyaluronic acid is also of immense importance. Strong muscles provide support rendering knee movement easy and painless.

The following exercises are ideal for improving muscle strength:

Straight leg raise — Sit well with your back in the chair. Straighten and raise the leg, hold it for a slow count of 10 then slowly lower it. Repeat at least 10 times with each leg. If this can be done easily, add a weight on the ankle.

Quadriceps stretching — while lying down, place a round pillow under the ankle. Push the back of the knee downward, hold for a count of 10, repeat 10 times.

Resisted knee extension — Loop the stretch band around the bottom of your foot, hold onto the ends while in a sitting position, and bend one knee about 30 degrees. Straighten the knee against the resistance of the tubing, pushing as hard as is reasonably comfortable. Repeat 10 times.

To conclude, it would be appropriate to say that conservative treatment in the form of physical therapy and hyaluronic acid will not only alleviate pain and stiffness in the knee joint but also help delay/ prevent surgical intervention.

The writer is a former doctor/physiotherapist, Indian cricket team. E-mail-chadhar587@gmail.com

Health Notes
What your face says about your health

Washington: An individual’s face not only gives nonverbal signals about someone’s true well-being from unconscious facial expressions, but the state of their skin also reveals a great deal about what’s going on inside, both physically and emotionally. In fact, practitioners of traditional Chinese medicine have used facial analysis as a diagnostic tool for centuries, marrying specific facial areas and features with organs and emotional states. So, when you get a recurring zit on the same part of your chin or have a perpetually congested or flaky forehead, your skin could be trying to tell you that there’s a deeper health concern in need of attention. — ANI

Exercise and early treatment can help ease pain of arthritis

London: Regular exercise and early treatment can help people suffering from arthritis to beat the pain of the disease, according to researchers. A review of scientific research concluded that physical activity could cut the risk of disability and help relieve the pain of a range of conditions, including arthritis, back pain and brittle bone disease. For some, the level of improvement increases with the number of exercise sessions, the researchers found. A second study also hailed the benefits of aggressive, early treatment for rheumatoid arthritis, the Daily Express reported. — ANI

Losing weight is like playing piano

London: Just like learning to play a musical instrument, losing weight requires behavioral changes and a certain amount of discipline, says an expert. “People need a motivation to lose weight and the New Year is an opportunity to start fresh,” said Dr. Jessica Bartfield, internal medicine and medical weight-loss specialist at Gottlieb Memorial Hospital, part of the Loyola University Health System. Bartfield is part of the Loyola Center for Metabolic Surgery and Bariatric Care that offers non-surgical as well as surgical weight loss programmes for patients. Patients in both programmes benefit from a dedicated team of medical professionals in psychology, nutrition, exercise physiology and more with an expertise in bariatrics. “Behaviour change is the cornerstone of healthy, successful weight loss and it takes about three months to establish a new behaviour,” said Bartfield. — ANI