Extract from Women Are Unaware of Alternatives to Hysterectomy for Menorrhagia
December 4, 2000 MedscapeWire

http://womenshealth.medscape.com/MedscapeWire/2000/1200/medwire.1204.Women.html

According to a recent survey by the Society for Women's Health Research (SWHR), two thirds of American women are unaware of alternatives to hysterectomy for treating excessive menstrual bleeding. Presently 1 in 5 women is affected by excessive menstrual bleeding, or menorrhagia, and experience unmanageable bleeding resulting in a constant need to change sanitary products. 

Due to the frequency with which hysterectomy is performed for excessive menstrual bleeding, SWHR examined physicians' and patients' awareness of hysterectomy as well as alternative options. Survey results show that doctors recommend hysterectomies to about 1 in 4 women. Of those, 82% accept their doctor's recommendation. The survey also revealed that more than one third of women who had a hysterectomy did not discuss potential alternatives with their doctor. However, the majority of physicians (75%) supported their patient's efforts to research alternatives.

There are wide variations in the drugs prescribed in general practice for the management of menorrhagia, in the referral patterns for this condition, and in population-based rates of hysterectomy. Such variation in the management of a common complaint is an indication for guideline development. 

http://www.aafp.org/afp/991001ap/1371.html

The most probable etiology of abnormal uterine bleeding relates to the patient's reproductive age, as does the likelihood of serious endometrial pathology. The specific diagnostic approach depends on whether the patient is premenopausal, perimenopausal or postmenopausal. In premenopausal women with normal findings on physical examination, the most likely diagnosis is dysfunctional uterine bleeding (DUB) secondary to anovulation, and the diagnostic investigation is targeted at identifying the etiology of anovulation. In perimenopausal patients, endometrial biopsy and other methods of detecting endometrial hyperplasia or carcinoma must be considered early in the investigation. Uterine pathology, particularly endometrial carcinoma, is common in postmenopausal women with abnormal uterine bleeding. Thus, in this age group, endometrial biopsy or transvaginal ultrasonography is included in the initial investigation. Premenopausal women with DUB may respond to oral contraceptives, cyclic medroxyprogesterone therapy or cyclic clomiphene. Perimenopausal women may also be treated with low-dose oral contraceptives or medroxyprogesterone. Erratic bleeding during hormone replacement therapy in postmenopausal women with no demonstrable pathology may respond to manipulation of the hormone regimen. (Am Fam Physician 1999;60:1371-82.)

• Assessment of blood loss

"Women seeking treatment for menorrhagia often do not have greater blood losses than average. In a population study, 26% of women with normal menstrual loss (<60 mL) considered their periods heavy, while 40% of those with heavy losses (> 80mL) considered their periods to be moderate or light." 
• Causes 
• Diagnosis
• Dilatation and curettage 
• Outpatient endometrial sampling 
• Hysteroscopy 
• Vaginal ultrasonography. 
"Management of women with menorrhagia may be more effective if psychosocial factors (depression, work difficulties, heavy smoking [> 20 per day], excessive alcohol intake, and sexual problems) are taken into consideration." 
• Drug therapy
• Surgery:

For a much denser medical (and long...) article you might try 
 Contemporary Concepts in Managing Menorrhagia
Authors: Arjav A. Shah, MD, David A. Grainger, MD, University of Kansas School of Medicine-Wichita
http://womenshealth.medscape.com/Medscape/WomensHealth/journal/1996/v01.n12/w127.grainger/w127.grainger.html

Note: on your first visit to the Medscape site, you need to register (free) - look at the top left of the Home Page. After that, you may choose to be "remembered", or not as you prefer.
Part of editorial comment

"The article by Shah and Grainger is a detailed review of menorrhagia and offers valuable, specific alternative therapies. Since in the majority of patients abnormal uterine bleeding is of benign etiology, hysterectomy may be an inappropriate overtreatment. Until we know more about the immediate and long-term effects of hysterectomy, we should re-evaluate our currently held philosophy and instead develop a healthy respect for the uterus as an important endocrine and sex organ, not merely a pouch to carry babies." 

April 2002http://www.medscape.com/viewarticle/430765_1 (requires free registration)
Time Course of Pain After Uterine Artery Embolization for Fibroid Disease describes an investigation to establish a baseline for pain control after UAE. Women considering the procedure should be aware of the context which triggered the study.

.............The embolization procedure itself is largely painless. However, patients do experience significant crampy pain for several hours after embolization.[3] This pain is almost always severe enough to require intravenous narcotics...............
............Postembolization pain control has been a major challenge in the acceptance of UAE for fibroid disease.

Expected Results
      As of this time, approximately 2000 to 3000 patients have had this procedure world-wide. Initial results suggest thatymptoms will be improve in 90% of patients with the large majority of patients markedly improved. Most patients have rated this procedure as very tolerable. The expected average reduction in the volume of the fibroids is 50% in three months, with reduction in the overall uterine volume of about 35%. The long-term outcome is not known, in that the arteries could reopen or collateral vessels could be recruited which might allow regrowth of the fibroids. As of yet this has not been reported in the published series but only short term follow-up is available. Therefore, it is not yet known if the fibroids can regrow.

.....The team concludes that while uterine artery embolization appears to provide successful treatment for some women suffering from uterine fibroids, "it is associated with considerable analgesic requirements, a longer recovery period than many patients realise, and potentially fatal complications." Br J Obstet Gynaecol 2000;107:1166-1170.

Note: a footnote to the highly recommended illustrated description of the procedure at http://www.obgyn.net/women/articles/indman/indman_uae.htm
states: 

Editor's Note: Because of deaths  and other major complications of uterine artery embolisation in the UK it is only given a category C rating (must only be done in a randomised controlled trial) by SERNIP, UK regulating body.

---

This well balanced article discusses pros, cons and uncertainties of the procedure in an interesting easy to understand way. (Tishy)

 Extract below from http://www.womens-health.co.uk/mirena.htmThe parent site also has a comprehensive section on fibroids.
Although the IUS was originally developed as a contraceptive, the discovery that it  leads to much lighter periods was a great bonus. Many gynaecologists now suggest the Mirena as a treatment for heavy periods if tablet treatment doesn't work. 

After 3 months use, the average blood loss is 85% less, and by 12 months the flow is reduced by 97% every cycle [2]. About one third of women using the IUS will not have any periods at all. Although women initially find it a bit unusual not having periods, it doesn't cause any problems. There is no 'build up' of blood, because the  hormone in the IUS prevents the lining of the womb from building up at all. Often it is the excessive thickening of this lining that is the cause of the problems in the first place.

                  One study looked at 54 women who had heavy periods and were awaiting hysterectomy [3]. They all used the Mirena, and just under 70% were taken off the  waiting list because they were happy with the treatment. In another study of 50 similar women, 82% avoided major surgery [4].

Gynecare describe it as being a one-time  treatment done on an out patient basis under local anaesthetic. A balloon catheter is inserted vaginally into the uterus and inflated with sterile solution, which is then heated to 87 degrees Celsius for eight minutes. The balloon is then deflated and the catheter is withdrawn and discarded. The intended thermal ablation of the uterine lining results from the contact of the endometrium with the heated ballon. The procedure renders the woman sterile so is only of use where no further children are desired. 

An alternative site describing the procedure is at http://www.ihr.com/bafertil/articles/ubtstudy.html