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BackTable / OBGYN / Article
Consulting Patients on Heavy Menstrual Bleeding: Symptoms & Treatment Options
Faith Taylor • Updated Sep 16, 2025 • 38 hits
Heavy menstrual bleeding is a common concern for many patients, yet misconceptions about what is “normal” often delay treatment. Menstrual symptoms are highly subjective and difficult to compare, leading some patients to dismiss their potentially concerning bleeding as benign while others hesitate to seek care out of fear or embarrassment.
In this article, Dr. Ted Anderson outlines his approach to addressing these misconceptions in consultation. He also presents less invasive treatment options for patients, such as endometrial ablation and hormonal IUDs, and explains which patients are best suited for ablation to achieve safe and effective outcomes.
This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable OBGYN Brief
• The concept of “normal” bleeding is subjective, so consultations should focus on whether symptoms interfere with a patient’s daily life.
• Physicians can address misconceptions by validating concerns, explaining options clearly, and setting realistic expectations.
• Endometrial ablation provides a less invasive alternative for patients who are not candidates for hysterectomy.
• New cryoablation systems such as Cerene improve comfort and satisfaction while reducing bleeding to manageable levels.
• Hormonal IUDs, including the Mirena, effectively reduce bleeding, lower hysterectomy rates, and offer reversibility.
• The best candidates for ablation are typically women over 40 with benign, anatomically normal uteri who have completed childbearing and use reliable contraception.
• Ablation should be avoided in patients with significant pelvic pain, suspected malignancy, uterine anomalies, or those at high risk for endometrial cancer.
Table of Contents
(1) Addressing Menstruation Misconceptions in Gynecological Consultation
(2) Non-invasive Treatment Options: Ablation & IUDs
(3) Clinical Considerations in Selecting Patients for Global Endometrial Ablation
Addressing Menstruation Misconceptions in Gynecological Consultation
When patients present with abnormal menstruation or bleeding, misconceptions often complicate the conversation. The concept of “normal” bleeding is subjective, as many women assume their experience is typical simply because it is their only frame of reference. Dr. Anderson advises moving away from the question of whether bleeding is normal and instead asking whether it bothers the patient or disrupts daily life. If it does, further evaluation and treatment should be considered.
To address these misconceptions, physicians can focus on partnership in the consultation. Validating patient concerns, clearly explaining available options, and setting realistic expectations help ensure that patients understand their choices. Dr. Anderson stresses that patients should leave the consultation feeling informed and supported, confident that the selected treatment aligns with their needs and goals.
[Dr. Ted Anderson]
Yes, and the problem is women don't necessarily know what normal is. It's not something that people talk about more now than before, but we're beginning to get a little bit more-
[Dr. Mark Hoffman]
What are you even talking about? It's hard to know it's a lot for me or a little for me, it's a-- I'm not seeing what anyone else has got. It's a very private problem, which makes it more challenging.
[Dr. Ted Anderson]
Sure. How many times have you had a patient who came in and says, "I just thought this was normal."
[Dr. Mark Hoffman]
Every clinic day, there's one.
[Dr. Ted Anderson]
"I'm having this problem, I'm in pain. Is that normal?" I'm like, "What you're describing doesn't sound much fun, normal or not. It sounds like we can try to help you out, and see what we can do." Yes, it's a very subjective thing. It's not like you said, it's something we don't spend a lot of time. From what I understand, my patients are spending a lot of time chatting with their friends about.
[Dr. Mark Hoffman]
Measuring the amount of blood loss has always been sort of a challenge. There are a lot of very intricate ways that you can do that, but there's onerous, and difficult to do the analytical tools that you can use to measure actual blood loss.
There's a great study that was done in the 1960s where they looked at patients' perception of their blood loss, versus their actual blood loss. What they found is that about 20% of people who had actual documented menorrhagia, meaning, a large amount of blood, more than 80 CCS of blood was defined at that time, but 20% of those people thought that was normal. On the other hand, about 50% of people who had minimal blood loss thought they were hemorrhaging to death.
The moral to that story is that a little bit of blood in the toilet looks like hemorrhage if it's your blood. People don't have a way of gauging what normal menstrual bleeding is. I sort of define it as, if a patient feels that their menstrual bleeding is interrupting the things that they need to do or want to do, it needs to be treated. That's a very easy question.
[Dr. Ted Anderson]
If it bothers you, then it's significant to me.
[Dr. Mark Hoffman]
Now, I'm not saying we need to do a hysterectomy, but we need to have some sort of option that we can offer these patients, whether it's hormonal or whether it's a IUD, whether it's an ablation or whatever, that treats everything going on, including their abnormal bleeding, but minimizes the downstream consequences as well.
[Dr. Ted Anderson]
Normal, for me, is zero. Anything more than that, I'm listening. Whatever you tell me is a problem for you, I will just believe you. It's amazing when you tell that to patients, "Whatever you tell me, I'm just going to believe it." They look at me like I'm first person that's ever said that like, "Well, what do I have?"
Patients have become very suspicious of medicine, in general. I think, the media has a lot to do with that, and patient's perception that we're trying to be controlling, or that we're trying to push drugs or whatever, I think is a big problem that we have to overcome.
[Dr. Mark Hoffman]
I think some of us have done that.
[Dr. Ted Anderson]
I think it's also a business. The idea that we get paid more for one treatment, over the other is a little bit of a conflict of interest. If I was a patient going to see a surgeon, and I tell my patients, "You should be not skeptical, but at least have your eyes open when you come see us, because the reality is I can tell you about it, but that's the reality of our business. Be willing to ask questions, ask those tough questions."
It's important for us as physicians to partner with our patients. Like I said, try to educate our patients, and help them make a decision that works for them, and then reassure them that we're on their side. We're going to help them get the treatment that they feel like is right for them, but we have to be able to give them options, and realistic expectations of those.
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Non-invasive Treatment Options: Ablation & IUDs
For patients who cannot undergo major surgery endometrial ablation offers a less invasive option to control bleeding and avoid hysterectomy. In medically fragile patients, global ablation can stabilize symptoms quickly with minimal stress. Newer cryoablation systems, such as Cerene Cryotherapy Device, have further advanced this approach by allowing treatment in the office with little discomfort. While amenorrhea rates remain low, patient satisfaction is high because bleeding is reduced to a manageable level.
Hormonal IUDs, like the Mirena, provide another effective alternative by decreasing heavy bleeding, reducing hysterectomy rates, and offering reversibility. Although some patients express concerns about hormone dysregulation or device placement, these IUDs have proven safe and effective – making them a valuable non-surgical option.
[Dr. Mark Hoffman]
What about I've had a couple instances where we have patients who are truly non-operative, liver failure, ascites, all these things, and they're bleeding because they're on blood thinners, or because their liver liver function is terrible. They're not making the necessary clotting factors and things like that, where they're a likely atrophic because they can be older menopausal, so Mirena is not a good option. I've done a couple what I've sort of-- I don't know if I've heard it or termed it, like a rescue ablation.
[Dr. Ted Anderson]
Absolutely, it's a last-ditch effort to try to avoid a hysterectomy.
[Dr. Mark Hoffman]
There's been a few of those that worked really well, like it was one like multiple DNC's and all these things, and progesterone's been tried and I'm going, "That that's not going to help," but we do it. We have not solved the liver failure, but it's one thing that has allowed us to not come in with a hysterectomy either. Chronic anemia and transfusions, that's been a situation where I have done it in patients who would otherwise check a lot of the do not use boxes in this, but that's been really useful.
[Dr. Ted Anderson]
Yes, you're absolutely right. I've done the same thing, and it's a great tool to have in your armamentarium, because occasionally, they're great patients because they're probably not going to regenerate their endometrium very well. They're sick as stink to begin with, and this is something you can do that's not very invasive, is not very taxing on their system to do a quick ablation, particularly a global ablation, and get them in and out of the operating room quickly. Now that's going to stabilize them enough that they can have whatever therapy they need, and so often, that can become a good friend of the internist or whoever's taking care of that patient to at least stop that portion of their disease process.
It's a good option to have. That goes back to the concept you have to think about this in terms of relative harm, and relative good that you do for a patient. You mentioned the Mirena. I think the Mirena is one of the greatest inventions of all time. It's been one of the reasons we've been able to reduce hysterectomies, and also reduce endometrial ablations, because its effectiveness is probably better than some of the endometrial ablations, and it's reversible. What more could you ask for?
Sometimes patients are a little hesitant to use it, because they're nervous about the hormones. They don't understand how it works. They're nervous about having an object inside the uterus. They think it might be actually a contraceptive ,which is really designed to be a contraceptive, but it's not a report a patient, and so we have to explain that to patients. I think the Mirena IUD and other progestin eluding IUDs are wonderful options for treating abnormal bleeding. It has been one of the pieces of the equation that you need to consider when you're thinking about alternatives with an endometrial ablation.
[Dr. Mark Hoffman]
I echo that. I think that leaving a gestational IUD Mirena is one of the most incredible medical advancements devices ever created to do all the things. It treats a problem of heavy periods. Oh, by the way, it's birth control, oh, by the way, it's the lowest possible hormone dose we have, oh, by the way, it's no pill you have to remember, oh, by the way, your periods go away, just like while we're at it.
I think about the Dalkon Shield, and the impact, just the generational impact. I was in residency around the time they were doing a lot of research on the Mirena, and really sort of pushing it back out into the market, and getting to work with people like Mishka Terplan, who had really dug into the data on the Dalkon Shield. Reading about the guy who, I guess, put it out, did he spend time in prison, or at least got in trouble for falsifying some of the data that it actually wasn't as bad. It wasn't that threads were a problem. They actually went back and reanalyzed the data, and it was actually safe the whole time.
There were other reasons why those women got sick, but what the media and all those things can do to really scare a generation of women away from a pretty great, and the Dalkon Shield's not the Mirena. They're very, very different, but just IUDs, in general. Copper IUDs have been around since Egyptian times?
[Dr. Ted Anderson]
I know. It's amazing, and they're very effective. They have such little impact on your body. Have you ever seen a Dalkon Shield?
[Dr. Mark Hoffman]
Yes. I've never removed, but I've seen a photo of one. I've taken out a Chinese steel ring before. I've never seen a Dalkon Shield come out of a baby.
[Dr. Ted Anderson]
The Chinese have some interesting-looking IUDs
.
[Dr. Mark Hoffman]
There's a great poster. It's got all the ones from all over the world. It's fascinating. It's amazing to see what shapes they've come in.
[Dr. Ted Anderson]
I remember taking a Dalkon Shield out of a patient who was about 60-something years old. She had that Dalkon Shield in for over 50 years. It just never bothered to take it out. Now she was starting to have this serious discharge. We went in and took out the Dalkon Shield. It's a pretty nasty looking thing. It's really regressive.
[Dr. Mark Hoffman]:
It's like a fish or something like that, right? It looks like it was never meant to come out.
[Dr. Ted Anderson]
I know.
[Dr. Mark Hoffman]
Was it supposed to come out?
[Dr. Ted Anderson]
I don't see how you would get it out, normally. It had these shields that sort of angled down, and it would sort of prevent it from coming out. The Chinese rings, I'm pretty sure were not supposed to come out. The one that I took out in the office, she was committed, and we had talked. We had a hysteroscope and I saw the hook on it. I put my foot in the table, like I was doing a forcep, and I kept checking on her like, "You okay?" She was just kind of nodding.
She was very stoic, and I had to keep checking to make sure I wasn't pulling her uterus out with me. That thing was very comfortable where it was, and was not interested in coming out. To think about those versus Marina, it's just like, man, it's pretty easy. Listen, two guys talking about it. I've never had one before. I get there's more to it than that. I'm actually trying to figure out. I'm working with some biomedical engineering students about a better way to place IUDs, because I think we deserve that, at least to look into it. It's a phenomenal device without question. It's an incredible device.
[Dr. Mark Hoffman]
Absolutely. I think patients accept it pretty well also, regardless of age, because it's so versatile. It really brings up a great point about looking at alternatives, and the downstream consequences. Because when you get into the problems with endometrial ablations is all these companies came out with these devices that are giving more and more energy, and more powerful energy, particularly burning energy, which creates scarring. The number one problem that we see is that you begin getting scarring inside the cavity, and destruction of the architecture of the endometrium and the uterine lining, and the uterus itself. So that when they come back in with a problem such as bleeding, and we know that over half of people will have some bleeding afterwards, we really have lost the ability to evaluate that.
We can't, with absolute certainty, tell patients, "You don't have cancer." Now, we know historically that an endometrial ablation will somewhat decrease your likelihood of developing cancer, but it doesn't eliminate it. What we find is about 20% of patients who have a hysterectomy after an endometrial ablation have that hysterectomy strictly because we cannot prove to that patient they don't have cancer. They're having some bleeding. We have a very low threshold for going ahead with the hysterectomy, because we cannot assure them that there's nothing wrong.
That has led to sort of a rethinking of what are we doing with endometrial ablations, and should we actually be using amenorrhea as our endpoint? Should that be the metric that we use to consider success, or is it better to maybe retool our thought process and say, "Let's find something that decreases your bleeding, makes your bleeding more manageable, but does not preclude our ability to evaluate the cavity later." That's what we've seen with a couple of the more recent ablation tools that have come out. For example, a new cryoablation technique that came out a few years ago called Serene.
We've had Barbara on the show to talk about it, which I hadn't tried. Have you used it?
[Dr. Ted Anderson]
I have. I was actually involved in the FDA trial.
[Dr. Mark Hoffman]
That's what I thought.
[Dr. Ted Anderson]
I'll have to say that I was totally blown away. It wasn't anything that I expected it to be. It's essentially painless to do in the office.
[Dr. Mark Hoffman]
Because it numbs, right? As opposed to burning. It's actually like an analgesic as well.
[Dr. Ted Anderson]
Exactly. We had patients who came in and had forgotten to take their pre-meds, their non-steroids or whatever. They said, "Well, let's just go ahead and do it while we're here." I'm like, "Okay." I'm doing this ablation, and we're just sitting here talking about their kids and, life in general, and they're not having any pain whatsoever.
Now, about 30 minutes, when things begin to thaw, they begin to get some serious cramping, but it only lasts for about 30 minutes, and it's over with.
[Dr. Mark Hoffman]
Do they hang out for a while afterwards, or do you just-
[Dr. Ted Anderson]
Yes, we did keep them there just because we wanted to find out exactly that question, but it wasn't something that was unmanageable. They said it's just like really bad cramps. We gave them some Toradol or something, and they did fine. Then what we found is that to our surprise, we only had a pretty low amenorrhea rate, probably 13% to 14%, but we're getting to satisfaction rate. The satisfaction rate was still in the 90 percentile. People were saying, "Look, it's reduced my bleeding to the point where I can live with it."
[Dr. Mark Hoffman]
Avoid a major surgery, and they can go on about their life.
Clinical Considerations in Selecting Patients for Global Endometrial Ablation
Successful endometrial ablation begins with choosing the right patient. Dr. Ted Anderson notes that age is the strongest predictor of success, with patients over 40 consistently doing better than younger women. Those with prolonged bleeding, chronic pelvic pain, or dysmenorrhea often have poor outcomes, frequently requiring hysterectomy for pain rather than bleeding.
A history of multiple cesarean sections or uterine surgery does not always exclude patients, but anatomical abnormalities, hyperplasia, or cancer risk typically do. The ideal candidate has completed childbearing, uses appropriate contraception, and has a benign and anatomically normal uterus. Counseling is essential, since ablation does not prevent pregnancy, and outcomes can be poor if pregnancy occurs afterward.
[Dr. Mark Hoffman]
What is a good patient for global endometrial ablation? I think you and I both in our practices see a lot of patients who may not have been well selected for the procedure, and not an insignificant chunk of our case volume, at least more so a few years ago, but I was getting a lot of ablation failures in my practice. It's not necessarily that the ablation didn't do what it was supposed to do, it didn't do what the patient was counseled it would do. It's a big difference.
[Dr. Ted Anderson]
Yes, and I think that's on us, because we did not know enough about ablation to really counsel them appropriately. We were giving them information that we knew, we just did not know what we didn't know at the time, and this has come out over a long period of time.
Now, there's something that my daughter taught me. My daughter is an advertising specialist. There's something called the hype curve, and this is something that in every technology that is introduced. You see sort of a rapid increase in utilization and uptake. Then a slope where it begins to go down again, and this is what we call the slope of heightened expectations. You get something that works, and then you immediately think what else can I use this for? This is great. I'm going to use this on all these patients, and then you begin to start seeing these failures and you realize, maybe there's some situations where that isn't appropriate. That's where the research really begins, and you get then what we call the slope of enlightenment, and that's where people have now pulled back from doing endometrial ablations.
Now we're starting to get the studies that show, what is the right patient? Who should we not do ablations on? Then we get better selection. As we get better selection and we start seeing greater utilization, but appropriate utilization, that goes back up again. Eventually levels off into a plateau which is often what the manufacturers told you to do in the first place.
[Dr. Mark Hoffman]
Yes, nuts. It's interesting.
[Dr. Ted Anderson]
What we found over years through multiple people looking at different scenarios is that there are some really good predictors. The best predictor is age, and so we find that people do substantially better with endometrial ablation if they're over 40. I almost never do endometrial ablations on anyone under 40 anymore. Occasionally I will, but I warn them that they likely are not going to get the expected result.
People who have very prolonged bleeding tend to not do as well with endometrial ablations, as people who have shorter bleeding less than seven days or so. People who have dysmenorrhea or chronic pelvic pain, those people are often going to fail endometrial ablation as well, not necessarily because of bleeding, but because of increased pain. Because they're sensitized, and so, they're going to end up with hysterectomy. People who've had multiple prior C-sections, or have had multiple uterine operations, of course, we think myomectomy is being a contraindications for endometrial ablation, but it's not really. It depends on if you have full thickness scarring in the endometrium or whatever, but still a lot of the global endometrial ablations have been shown to be safe in those patients. Or people who have prior sterilization, because that's the risk of this post sterilization tubal syndrome.
[Dr. Mark Hoffman]
Is that still recommended? I feel like I'd heard, it's been a little while since I've looked at it, but the more recent data that I recalled was that you looked at everything those who had tubals and those didn't, and it was similar, so, I need to recheck my sources, though.
Can you talk a little bit about what we know about that, about post tubal sterilization ablation syndrome?
[Dr. Ted Anderson]
Yes. This goes back to the McCausland's and the techniques where we used endometrial ablation that did not get up into the cornea very well. All of the technologies that came out after the thermal balloon, really sort of approached that, or address that issue, so we saw less and less of the post ablation syndrome after that, because we got the better global ablation of the endometrium.
[Dr. Mark Hoffman]
Makes sense.
[Dr. Ted Anderson]
We saw less of that, but the early on, it was a big problem. Obviously, people who have uterine anomalies are not appropriate candidates for global ablation. People who are at increased risk for endometrial cancer, you should not do endometrial ablations on. People who have a history of hyperplasia, you should not do endometrial ablations on those people as well.
The ideal candidate is someone who's over 40, who has a parity of less than 5, who has a benign endometrium, biopsy proven benign endometrium, and an anatomically normal uterus, has completed their childbearing, has adequate contraception, because endometrial ablation is not considered a contraception, and you don't want to get pregnant after it, because placentation will generally be abnormal. It's not that it doesn't because fetal anomalies, but it causes fetal demise, because you have insufficient placentation.
People who are unresponsive to hormonal therapy, or a contradiction to hormonal therapy, and your desire to avoid a hysterectomy. Sometimes we might say it might be a poor candidate for hysterectomy. The problem is that one's a little bit of a gray zone. Sometimes the person who's a bad candidate for hysterectomy, let's say, the morbidly obese diabetic patient is also not a good candidate for endometrial ablation, because when it fails, your hysterectomy is the only option at that point.
[Dr. Mark Hoffman]
That's what we were talking about earlier. I think about Mirena's protective lining, and it's not the only thing you got left right. I think that's something that--
[Dr. Ted Anderson]
Exactly.
Podcast Contributors
Dr. Ted Anderson
Dr. Ted Anderson is an OBGYN and professor at Vanderbilt in Nashville, Tenessee.
Dr. Mark Hoffman
Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.
Dr. Amy Park
Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.
Cite This Podcast
BackTable, LLC (Producer). (2025, March 25). Ep. 80 – Endometrial Ablation: Past, Present & Future [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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