Abnormal Uterine Bleeding
What is abnormal uterine bleeding?
Excessive menstrual bleeding or bleeding that occurs between menstrual periods is abnormal uterine bleeding. Once a woman who is not taking hormone therapy enters menopause and the menstrual cycles have ended, any uterine bleeding is also considered abnormal.
What causes abnormal uterine bleeding?
Causes of abnormal uterine bleeding include pregnancy, a menstrual cycle where an egg is not released, cancer, infection, trauma, bleeding disorders, uterine scarring, fibroids or polyps. Most conditions can occur at any age, but some are more likely to occur at a particular time in a woman's life.
Bleeding before the first period in a girl's life is always abnormal. It may be caused by trauma, presence of a foreign body, irritation of the genital area, or urinary tract problems. Bleeding can also occur as a result of sexual abuse. Many girls have episodes of irregular bleeding during the first few months after their first menstrual period. This usually resolves without treatment when the girl's hormones normalize. If bleeding persists beyond this time, or if the bleeding is heavy, further evaluation is needed.
Many different conditions can cause abnormal bleeding in women between adolescence and menopause:
- Hormonal changes can cause the endometrium to grow and produce excess tissue, increasing the chances that polyps or endometrial hyperplasia (thickened lining of the uterus) will develop and lead to abnormal bleeding.
- Breakthrough bleeding can occur in women who use hormonal birth control methods.
- Infection is another possible cause of abnormal bleeding, especially if it occurs after sexual activity.
- Before menstrual periods end, a woman passes through a period of menopausal transition. Women in the menopausal transition are at risk for other conditions that cause abnormal bleeding, including cancer.
Causes of abnormal bleeding during menopause include:
- atrophy (excessive thinning) of the tissue lining the vagina and uterus
- cancer of the uterine lining (endometrium) or cervix
- polyps or fibroids
- endometrial hyperplasia or overgrowth
- infection of the uterus or cervix
- use of blood thinners or anticoagulants
- side effects of radiation therapy
Women who take hormone replacement therapy may experience cyclical bleeding. Any other bleeding that occurs during menopause is abnormal and should be investigated.
How is abnormal menstrual bleeding diagnosed?
Your physician will ask you questions about your symptoms, your medical history, and your family history. Your physician will perform a pelvic examination to confirm that the bleeding is from the uterus and examine the size and shape of the uterus. He or she will also look for any obvious lesions (cuts, sores, or tumors) and examine the cervix to look for signs of cervical bleeding. An endometrial biopsy is often performed in women over age 35 to rule out endometrial cancer or abnormal endometrial growths. A biopsy may also be performed in women younger than 35 if they have risk factors for endometrial cancer, including obesity, chronic anovulation, history of breast cancer, tamoxifen use, and a family history of breast or colon cancer.
An ultrasound may be done to confirm the presence of uterine fibroids and to measure and evaluate the lining of the uterus.
A saline infusion sonogram is a transvaginal ultrasound performed after sterile saline is passed into the uterus. This procedure gives a better picture of the inside of the uterus, and small lesions can be more easily detected. However, because tissue samples cannot be obtained during the procedure, a final diagnosis is not always possible and additional evaluation, including hysteroscopy with dilation and curettage (D&C) may be necessary.
In premenopausal women, a pregnancy test is performed. If there is any abnormal vaginal discharge, a cervical culture may be performed. Blood tests may also be done to determine if there are problems with blood clotting or other conditions, such as thyroid disease, liver disease, or kidney problems.
Because hormonal irregularities can contribute to abnormal uterine bleeding, testing may be recommended to determine if the woman ovulates (produces an egg) during each monthly cycle.
A hysteroscopy is when a small camera is inserted through the cervix and into the uterus. Fluid is injected to expand the uterus and to allow the physician to see the inside of the uterus. Tissue samples may be taken. Anesthesia is used to minimize discomfort during the procedure. In most cases, hysteroscopy is performed along with a D&C.
How is abnormal menstrual bleeding treated?
Treatment depends on the cause of the abnormal bleeding. Treatment methods include:
- Combined hormonal methods (such as birth control pills, patches and rings) are often used to treat abnormal uterine bleeding. These hormones may be used in women who do not ovulate regularly to establish regular bleeding cycles and prevent excessive growth of the endometrium.
- Dilation and curettage can sometimes be used as a treatment for prolonged or excessive bleeding that is due to hormonal changes and that is unresponsive to other treatments.
- Endomentrial ablation or another surgical procedure may be recommended for women who have completed childbearing and have heavy menstrual periods. This procedure is done under anesthesia, and uses heat, cold, or a laser to destroy the lining of the uterus.
- Women with fibroids can have surgical treatment of their fibroids, either by removing the fibroids (myomectomy) or reducing the blood supply to the fibroids (uterine artery embolization).
- Women who desire definitive treatment or for whom the other options are not possible given the size, number, and location of their fibroids may require removal of their uterus (hysterectomy).