Low Menstrual Flow: Treatment Options and Considerations

Hypomenorrhea

Since January of this year, my menstrual flow has decreased with each cycle after giving birth.
I have been diagnosed with polycystic ovary syndrome (PCOS), and my doctor prescribed 28-day contraceptive pills to regulate my menstrual cycle.
I have been taking them for two months, but my period still only lasts three days with just a few drops of blood, and my sanitary pads are almost clean.
My thyroid tests are normal.
On November 7, I underwent a hysterosalpingography, which showed that my right fallopian tube is blocked, and the shape of my uterus has a missing corner on the right side, so it is not triangular.
The doctor mentioned adhesions and advised that if I want to conceive, I should undergo hysteroscopy; if not, I should continue medication to regulate my menstrual flow.
My question is, I have been taking Estradiol/Norethindrone acetate for over two months now, but my menstrual flow has not improved.
If the decreased menstrual flow is due to uterine adhesions, can medication really improve the menstrual flow issue, or is hysteroscopy the only effective solution? If surgery is the only option, I am considering trying to conceive again, but I hope to wait until after next summer.
Should I wait until next summer to have the surgery to avoid the risk of adhesions recurring and needing another procedure?

Yu Ling, 30~39 year old female. Ask Date: 2017/11/15

Dr. Huang Jianzhong reply Obstetrics and Gynecology

In January of this year, I gave birth, and since then, my menstrual flow has decreased with each cycle.
I have polycystic ovary syndrome, and my doctor prescribed 28-day contraceptive pills to regulate my menstruation.
I have been taking them for two months, but my period still only lasts three days with just a few drops each day, and my sanitary pads are almost clean.
My thyroid tests are normal.
On November 7, I underwent a hysterosalpingography, which showed that my right fallopian tube is blocked, and the shape of my uterus is not triangular as the right side is missing a corner.
The doctor mentioned there is adhesion.
If I want to conceive, I should undergo hysteroscopy; if not, I should continue taking medication to regulate my menstrual flow.
My question is, I have been taking Estradiol/Norethindrone acetate for over two months now, and my menstrual flow has not improved.
If the decrease in menstrual flow is due to uterine adhesions, can medication really improve the menstrual flow issue? Or is hysteroscopy the only true solution? If surgery is the only option, I would like to have another child, but I hope to wait until after next summer.
Should I wait until next summer to have the surgery to avoid the risk of adhesion recurrence and needing another surgery? Answer: Your concerns are very reasonable; please discuss them with your attending physician.

Reply Date: 2017/11/15

More Info

Understanding low menstrual flow, particularly in the context of polycystic ovary syndrome (PCOS) and potential uterine adhesions, requires a comprehensive approach that considers both medical and surgical options. Your situation, characterized by low menstrual flow following childbirth and the use of hormonal contraceptives, raises several important considerations.

Firstly, it is essential to understand that hormonal treatments, such as the combination of estradiol and norethindrone acetate you are currently taking, are often prescribed to regulate menstrual cycles and improve flow. However, if the underlying issue is related to anatomical changes in the uterus, such as adhesions (which can occur after childbirth or due to conditions like Asherman's syndrome), hormonal therapy alone may not be sufficient to resolve the problem. In such cases, the effectiveness of hormonal treatments can be limited, as they may not address the physical barriers that impede normal menstrual flow.

The fact that you have been experiencing very light periods for several months, despite being on hormonal therapy, suggests that there may be a more significant underlying issue that needs to be addressed. The presence of adhesions, as indicated by your physician, could be a contributing factor to your low menstrual flow. Adhesions can cause the uterine lining to be less responsive to hormonal changes, leading to reduced menstrual bleeding.

In terms of treatment options, there are a few pathways to consider:
1. Surgical Intervention: If your physician has indicated that there are adhesions present and that they are contributing to your menstrual issues, a hysteroscopy may be warranted. This minimally invasive procedure allows for direct visualization of the uterine cavity and the opportunity to remove any adhesions. This could potentially restore normal menstrual flow and improve your chances of conception if you are planning to conceive in the future.

2. Continuation of Hormonal Therapy: While you are currently on hormonal therapy, it may be beneficial to discuss with your physician the possibility of adjusting the dosage or trying a different formulation if you do not see improvement. However, if the primary issue is anatomical, this may only provide temporary relief.

3. Timing of Surgery: If you are considering another pregnancy, it is crucial to discuss the timing of any surgical intervention with your healthcare provider. Ideally, if surgery is necessary, it should be performed before you attempt to conceive to ensure that your uterine environment is optimal for implantation. However, if you are planning to wait until next summer to conceive, you may want to consider scheduling the surgery sooner rather than later to allow your body time to heal and to minimize the risk of adhesion recurrence.

4. Monitoring and Follow-Up: Regular follow-up with your healthcare provider is essential. They may recommend additional imaging or tests to monitor your condition and ensure that any treatment you pursue is effective.

In conclusion, while hormonal therapy can help regulate menstrual cycles, it may not be sufficient if there are underlying structural issues such as adhesions. A hysteroscopic evaluation and potential surgical intervention may be necessary to address these concerns effectively. It is advisable to have a thorough discussion with your healthcare provider about the best course of action based on your specific circumstances, including your desire to conceive in the future.

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