OHIP hinders therapy for uterine bleeding

Originally published in The Ottawa Citizen August 13, 2002

Original Title: Only Women Bleed

Dysfunctional Uterine Bleeding (DUB) is the leading cause of low blood iron and red blood cell levels (iron-deficiency anemia), causes painful menstrual cramps (dysmennorhea) and has great impact on work, social, home and sex life. DUB is defined as abnormal bleeding from within the uterus that is not caused by any pelvic diseases such as cancers, infections, general medical disorders, noncancerous growths, anatomic abnormalities such as fibroids or abnormal hormonal conditions. It is most commonly seen at either end of a woman’s reproductive years.

The diagnosis of DUB is one of exclusion once all other possible causes are eliminated using specific blood tests, ultrasounds, biopsy of the uterine lining (endometrium) and hysteroscopy (a fibreoptic camera that peers inside the uterus). The key hormones that influence the endometrium are estrogen and progesterone. Conventional treatments focus on controlling their effect upon the uterus in order to reduce bleeding.

Once DUB is confirmed, various treatment regimens are available. Nonsteroidal anti-inflammatory drugs (NSAIDS) such as Ibuprofen (Advil, Motrin), Naproxen (Naprosyn, Anaprox) alone can reduce bleeding by about 30 percent. Cyklokapron reduces blood loss by a different mechanism.

Birth control pills can reduce flow by as much as 50 percent but cannot be used for smokers over age 35 because of the increased risk of developing blood clots. These women may benefit from Depo-Provera, a progesterone only injection given every 12 weeks. Intrauterine devices (IUDs) impregnated with progesterone can reduce blood flow by up to 97 percent.

The success rate of medical therapy is about 50 to 60 percent. Treatments can last years right up until menopause and have side effects in 40 percent of the time. In can be an expensive long-term proposition in terms of time and money requiring numerous visits to the physician’s office for monitoring.

Surgical options are the next step if medical therapy fails.

Surgical Endometrial Ablation (SEA) is highly skill dependent. Few gynecologists perform this procedure. Using a fibreoptic scope the surgeon removes the entire endometrial layer. Complications include hemorrhage, infection, perforation of the uterus and heart failure due to the amount of fluids used during the procedure.

The final option is hysterectomy with all its inherent post-operative, physical and psychological complications. These last two procedures are quite a drastic approach to the problem. Granted for some this may be the only option but reside in the last-resort category.

There is another procedure that could prevent the need for surgery. Thermal Endometrial Ablation using Uterine Balloon Therapy (UBT) works by applying heat directly against the endometrium.

The procedure is similar to an IUD insertion. A soft inflatable balloon attached to a thin catheter is inserted into the uterus. It is then filled with up to 30 millilitres (one ounce) of water. The water is heated to 87 °C and evenly distributes the heat within the uterine cavity. It takes 8 minutes and is done under local anesthesia. To date there have not been any intra-operative complications. Within seven to ten days the endometrium will slough off resulting in a small period. Like SEA, it is 80 to 90 percent effective after 6 months but without the associated complications. Women can usually return to work the next day. Most will have a pinkish and watery vaginal discharge for two to four weeks. UBT is safe, effective, inexpensive over the long term and restores quality of life with minimal discomfort.

UBT is not an option for women who want to have children. Pregnancies can be dangerous for both the fetus and mother after UBT.

Sonohysterography or Saline Infusion Sonography (SIS) is an essential specialized ultrasound that reveals the complete contours of the uterine cavity. The results of the SIS are superior to conventional ultrasounds in the decision making for UBT. The results determine if UBT can be performed safely. It is advisable to perform SIS prior to offering UBT.

However SIS is no longer an insured service. OHIP states that the existing billing codes were never meant for SIS. Until there is a code approved by the tariff committee for this procedure, they will no longer reimburse the clinic or physicians for it. So now the Ottawa General OB/GYN ultrasound department and the Civic campus no longer provide this service.

The Bank Street Ultrasound Centre will provide SIS for a fee. This fee has been set by the Ontario Radiology Society at $300 to cover the cost of the scan, consulting fee, and the equipment.

UBT is available only at the Ottawa Hospital, General campus by a number of gynecologists under general anesthesia. Drs. Guy d’Anjou and Douglas Black use local anesthesia in about 50 percent of selected patients. But it cannot be done as safely since OHIP will not allow SIS.

Drs. d’Anjou and Black hope to open a Menorrhagia clinic at the newly created Riverside Hospital Woman’s Centre. It is their hope that SIS can be incorporated into the Centre. People should not have to suffer because of bureaucratic roadblocks.

© Dr. Barry Dworkin 2002

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