Abnormal uterine bleeding can be a symptom with multiple causes. Successful treatment requires careful evaluation to accurately diagnose the cause. Once the cause has been identified, treatment can be tailored to the patient’s needs and according to their desires.
Vaginal bleeding is considered abnormal if it is particularly heavy, prolonged, frequent, occurs between normal menstrual cycles, or occurs after intercourse or orgasms.
Vaginal bleeding is considered heavy when a woman saturates more than 5 sanitary pads daily. The normal frequency of menstrual bleeding, counting from the 1st day of bleeding one cycle to the 1st day of bleeding the next cycle, averages 28 days, but will normally range between 21 and 35 days. Frequency of menstrual bleeding either shorter than 21 days or longer than 35 days is abnormal and requires a further evaluation.
Women SHOULD NOT BLEED BETWEEN MENSTRUAL CYCLES. When this occurs, something is wrong that needs to be evaluated and treated. Similarly, bleeding after vaginal intercourse or orgasm is abnormal and requires diagnosis and treatment.
Common sources of abnormal uterine bleeding vary depending upon the age of the woman.
Teenagers, during the course of their first several years of menstruation, will frequently not be ovulating or be ovulating poorly. This condition is generally easily diagnosed by the patient keeping basal body temperature charts and is easily treated with mild hormonal medications. Generally, as a woman reaches her later teenage years, her ovulatory function regulates and becomes normal, this condition spontaneously corrects itself, and the medical therapy can be discontinued. Rarely, this condition is associated with a blood clotting problem with the young woman being a “bleeder”. One must be alert not to miss these individuals. Also at this age, polyps and fibroids are rarely encountered as are severe systemic diseases like kidney disease and poorly controlled diabetes.
Menstrual bleeding before age 9 is abnormal and requires further evaluation as does a failure to start menstrual periods by age 16.
As women progress into their 20’s, if they develop irregular bleeding, it can be associated with ovulation problems or anatomic problems. Frequently, a hormonal imbalance, such as an underactive or overactive thyroid gland, overproduction of male hormones, prolactin, PCOS, or extremes of weight (over or under, including anorexia) will manifest themselves as ovulation problems with irregular periods. Therefore, if basal body temperatures suggest associated ovulation problems, a full hormonal evaluation is indicated.
Anatomic problems, including polyps, fibroids, endometriosis, and adenomyosis also begin to occur in women during their 20’s. The suspicion that one of these anatomic entities is the cause of the abnormal bleeding increases significantly if the woman is ovulating normally based on her basal body temperature charting.
Early pregnancy, which must be ruled out in any woman who is menstruating, is also a much more prominent phenomena in women in their 20’s and 30’s. Early pregnancy problems that will give the presentation of abnormal vaginal bleeding include a threatened miscarriage and an ectopic pregnancy. A blood pregnancy test followed by office vaginal ultrasound will generally make these diagnosis quickly and accurately.
As women progress into their mid-30’s and 40’s, while they can continue with ovulatory and pregnancy problems and hormonal imbalances, the frequency of anatomic problems, in particular fibroids and polyps, increases sharply. It is also in this age group, that one must rule out the presence of uterine cancer or hyperplasia, the precursor state of uterine cancer. Therefore, after ruling out the presence of a pregnancy, any women age 35 or older must have the lining of the uterus sampled. This is done through an office procedure called an endometrial biopsy.
Once the endometrial biopsy results are known, and if they are negative, and the basal body temperature charting reveals the woman to be ovulatory, then searching for uterine fibroids, particularly those in the uterine cavity, and endometrial polyps becomes more rewarding. I find that the best test to determine the presence of fibroids or polyps in the uterine cavity is a hysterosalpingogram. This is an X-ray study performed in the radiology department where I inject dye through the cervix into the uterine cavity and out through the fallopian tubes. Five to seven X-rays are taken during this injection process. I find that this gives a much better picture of the uterine cavity than does an ultrasound or a saline infusion sonogram (a modified ultrasound). I also feel it is better than hysteroscopy (looking in the uterine cavity through the vagina) because it is often easy to miss a large fibroid in the uterine cavity. This will be easily seen with the x-ray.
If the endometrial biopsy reveals endometrial hyperplasia (a precancerous condition), this can often be successfully treated and reversed with a two-month course of progesterone. If cancer is present, then a hysterectomy is lifesaving.
If basal body temperature charting shows poor or no ovulation, a hormonal evaluation is performed. Depending on these results, treating the patient medically generally will solve the problem. These patients will respond to medical treatment the same as younger women do.
Women who are experiencing abnormal vaginal bleeding after menopause ALWAYS need an endometrial biopsy to make sure that cancer is not present. Provided this is not the case, then further treatment is tailored to their particular condition. As a subspecialty referral practitioner, I will frequently see ladies in this age range who are symptomatic from a uterine cavity fibroid or polyp. These are usually treated with simple hysteroscopic surgery (operating in the uterine cavity through the vagina) under local anesthesia with sedation (so that the patient does not experience any pain or remember anything). This simple surgery will result in a complete resolution of their bleeding problem.
If you have further questions regarding abnormal vaginal bleeding that either you or a friend may be experiencing, please do not hesitate to contact me to discuss it further.