Abnormal Uterine Bleeding
Under normal circumstances, a woman's uterus sheds a limited amount of blood during each menstrual period. Bleeding that occurs between menstrual periods, or excessive bleeding that occurs during menstruation, is considered abnormal uterine bleeding. Once a woman enters menopause and menstrual cycles have ended, any bleeding, other than the small amounts that can occur in women on hormone replacement therapy, is considered abnormal.
While most conditions that cause abnormal uterine bleeding can occur at any age, some are more likely to occur at particular times in a woman's life.
Premenopausal women are young girls who have not yet begun menstruating, women in their reproductive years and women in perimenopause or those who have begun the hormonal changes that eventually lead to menopause.
Bleeding in girls who have not yet begun to menstruate is always abnormal and can be caused by trauma, the 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 years after their periods begin and until a normal hormonal cycle and regular ovulation is established. If bleeding persists beyond this time, or if the bleeding is heavy, further evaluation is indicated.
Girls and women who use oral contraceptives may experience "breakthrough" bleeding between periods. If this occurs during the first months of oral contraceptive use, it may be due to changes in the lining of the uterus. If it persists for more than several months, a different oral contraceptive may be prescribed.
Breakthrough bleeding can also happen if the oral contraceptive is not taken regularly. If this occurs, the breakthrough bleeding may be an indication that the pill is not effective. Additional contraception may be necessary until the oral contraceptives are taken on a regular schedule and the breakthrough bleeding stops. If a woman experiences persistent breakthrough bleeding, further evaluation is indicated.
Many different conditions can cause abnormal bleeding in women between adolescence and menopause. Abrupt changes in hormone levels at the time of expected ovulation can cause vaginal spotting or small amounts of bleeding. As noted above, breakthrough bleeding can occur in women who use oral contraceptives.
In women who don't ovulate (anovulatory women), irregular changes in hormone levels can cause bleeding to occur intermittently and in varying amounts. Although anovulation is most common when periods first begin and during perimenopause, it can occur at any time during the reproductive years. Among women who ovulate normally, some experience excessive blood loss during their periods or bleed between periods. The most common causes of such bleeding are uterine fibroids or polyps. These irregular growths and benign tumors are composed of uterine tissue that distort the structure of the uterus and lead to abnormal uterine bleeding. Fibroids and polyps can also occur in anovulatory women.
Other causes of abnormal uterine bleeding in premenopausal women include:
cancer of the endometrium (lining of the uterus) or benign precancerous endometrial lesions
endometritis or inflammation of the endometrium
a pelvic or vaginal infection
clotting disorders such as von Willebrand disease, platelet abnormalities or problems with clotting factors
some systemic illnesses such as hypothyroidism, liver disease or chronic renal disease
Before menstruation stops completely and menopause begins, a woman passes through a period called perimenopause. During perimenopause, normal hormonal cycling begins to change and ovulation may be inconsistent. While estrogen secretion continues, progesterone secretion declines. These hormonal changes can cause the endometrium to proliferate or produce excess tissue, and increase the chance that polyps or fibroids that cause abnormal bleeding will develop. Women in perimenopause are also at risk for other conditions that cause abnormal bleeding, including cancer, infection and systemic illnesses. Further evaluation is indicated if a woman experiences persistent irregular menstrual cycles or an episode of profuse bleeding.
In addition, because women in perimenopause ovulate some of the time, pregnancy is still possible and can be a cause of abnormal bleeding. And since many women in perimenopause remain on oral contraceptive agents, breakthrough bleeding can occur as well.
A number of conditions can cause abnormal bleeding once a woman's periods have stopped and menopause has begun. Many women are on hormone replacement therapy at some point during menopause and may experience cyclical bleeding. Any other bleeding that occurs during menopause is abnormal and should be investigated. Some of the most common causes of abnormal bleeding during menopause include:
Atrophy or thinning of the tissue lining the vagina and uterus
Cancer of the uterine lining or endometrium
Polyps or fibroids
Endometrial hyperplasia or the rapid growth of extra endometrial tissue
Infection of the uterus
Use of blood thinners or anticoagulants
Side effects of radiation therapy
While taking a woman's medical history, her doctor will assess a number of factors that can help identify the cause of abnormal bleeding. These include the duration and quantity of the bleeding; factors that seem to bring on the bleeding; symptoms that occur along with the bleeding; the relationship between bleeding and sexual relations; whether there is a personal or family history of bleeding disorders; the woman's medical history and medications she is taking; and whether the woman has experienced a weight change related to an eating disorder, stress, excessive exercise or chronic illness.
The doctor will perform a physical exam to evaluate the woman's overall health and a pelvic exam to confirm that the bleeding is from the uterus and not from another site like the external genitals or the rectum.
Other tests include:
Lab tests may include a pregnancy test or cervical culture. Lab tests may also be conducted to determine whether there are problems with blood clotting or other systemic conditions, such as hypothyroidism, liver disease or kidney problems.
Because hormonal irregularities can contribute to abnormal uterine bleeding, tests may be performed in premenopausal women to determine whether they ovulate (produce an egg) during each monthly cycle. For example, a woman may be asked to record when her periods begin and end for several months and to note any premenstrual changes, like cramps or breast tenderness, that occur. She may also be asked to record her temperature with a special thermometer. Progesterone, which is released at the time of ovulation, causes a slight increase in temperature, and regular monitoring will detect whether this occurs on a cyclical basis. In addition, her progesterone level may be measured with a blood test.
Tests that assess the endometrium may be performed to rule out endometrial cancer and structural abnormalities such as uterine fibroids or polyps. Such tests include endometrial biopsy, transvaginal ultrasound, saline infusion sonography or sonohysterography, MRI and dilation and curettage.
The treatment of abnormal bleeding is targeted toward the underlying cause.
Oral contraceptives are often used to treat uterine bleeding that is due to hormonal changes or hormonal irregularities. Oral contraceptives or intrauterine contraceptive devices that secrete progestin may be used in anovulatory women to establish regular bleeding cycles and prevent excessive growth of the endometrium. In ovulating women, they may be used to treat excessive menstrual blood loss. Nonsteroidal anti-inflammatory drugs (NSAIDS) may also be helpful in reducing blood loss in these women.
Surgery may be necessary to remove structural lesions such as polyps or fibroids. Endometrial cancer, systemic diseases, clotting disorders or infections require specific, targeted treatment.
Your doctor is the best resource for important information related to your particular case. Because every patient is different, it is important that your situation is evaluated by someone who knows you as a whole person.