Abnormal Uterine Bleeding

Abnormal uterine bleeding is one of the most common reasons women see their doctors. It can occur at any age and has many causes. Some are easily treated, while others are more serious. Finding the cause is the first step in treatment. This pamphlet will explain:

• Causes of abnormal bleeding
• How it is diagnosed
• How it can be treated

If your cycles are irregular, see your doctor. Abnormal bleeding can have a number of causes.

The Normal Menstrual Cycle

During the menstrual cycle, two hormones, called estrogen and progesterone, are made by the ovaries. Each month, these hormones cause the endometrium to grow in preparation for a possible pregnancy. About 12–14 days before the start of the period, an egg is released from one of the ovaries. This is called ovulation. The egg then moves into one of the fallopian tubes. There it can be fertilized by a sperm. If it is not, pregnancy does not occur. The levels of hormones decrease. This decrease is a signal for the uterus to shed its lining. This shedding is the menstrual period.

The cycle begins with the first day of bleeding of one period and ends with the first day of the next. In most women, this cycle lasts about 28 days. Cycles that are shorter or longer by up to 7 days are normal.

Abnormal Bleeding

Bleeding in any of the following situations is abnormal:

• Bleeding between periods
• Bleeding after sex
• Spotting anytime in the menstrual cycle
• Bleeding heavier or for more days than normal
• Bleeding after menopause

Menstrual cycles that are longer than 35 days or shorter than 21 days are abnormal. The lack of periods for 3–6 months (amenorrhea) also is abnormal.

Abnormal bleeding can occur at any age. At certain times in a woman’s life it is common for periods to be somewhat irregular. They may not occur on schedule in the first few years after a girl starts to have them (around age 9–16 years). The cycle may get shorter near age 35 years. It often gets shorter as a woman nears menopause (around age 50 years). It also is normal then to skip periods or for bleeding to get lighter or heavier.

Causes

Abnormal bleeding can have many causes. Your doctor may start by checking for problems most common in your age group. Some of them are not serious and are easy to treat. Others can be more serious. All should be checked.

In some women, too much or not enough of a certain hormone can cause abnormal or heavy bleeding. This imbalance can be caused by many things, such as thyroid problems or some medications.

Other Causes of Abnormal Bleeding

Other causes of abnormal uterine bleeding include

• pregnancy
• miscarriage
• ectopic pregnancy
• problems linked to some birth control methods, such as an intrauterine device (IUD) or birth control pills
• infection of the uterus or cervix
• fibroids
• problems with blood clotting
• polyps
• certain types of cancers, such as cancer of the uterus, cervix, or vagina
• chronic medical conditions (for instance, thyroid problems and diabetes)

Diagnosis

To find the cause, your doctor will ask about your personal and family health history. You may be asked about these issues:

• Past or present illnesses
• Use of medications
• Use of birth control
• Weight, eating and exercise habits, and level of stress

Your doctor also will ask about your menstrual cycle. You can help by keeping track of it before your visit. Note the dates, length, and type (light, medium, heavy, or spotting) of your bleeding on a calendar (see “Menstrual Flow Diary”). Your doctor can use your notes to help pinpoint the problem.

You will have a physical exam. You also may have blood tests. These tests check your blood count and hormone levels and rule out some diseases of the blood. You also may have a test to see if you are pregnant. Based on your symptoms, other tests may be needed:

• Ultrasound—Sound waves are used to make a picture of the pelvic organs.
• Endometrial biopsy—Using a small or thin catheter (tube), tissue is taken from the lining of the uterus. It is looked at under a microscope.
• Sonohysterography—Fluid is placed in the uterus through a thin tube, while ultrasound images are made of the uterus.
• Hysteroscopy—A thin device is inserted through the vagina and the opening of the cervix. It lets the doctor view the inside of the uterus.
• Hysterosalpingography—Dye is injected into the uterus and fallopian tubes. Then an X-ray is taken.
• Dilation and curettage (D&C)—The opening of the cervix is enlarged. Tissue is gently scraped or suctioned from the lining of the uterus. It is examined under a microscope.
• Laparoscopy—A thin device like a telescope is inserted through a small cut just below or through the navel. The doctor can then view the inside of the abdomen.

Some of these tests can be done in your doctor’s office. Others may be done at a hospital or surgical center.

Treatment

Treatment will depend on many factors, including the cause of the bleeding. Your age and whether you want to have children also play a role. Treatment falls into three types. You may be given medications, such as hormones. You may need to have surgery. You may decide with your doctor to “watch and wait” before trying the other two treatments. Most women can be treated with medications.

To judge how well treatment is working, you may need to be tested again. If you think you might be pregnant, let your doctor know before you start any treatment.

Hormones

Hormones can control some abnormal bleeding. It may take a few months. Your periods may be heavier at first. However, they usually will lighten over time. If they do not, let your doctor know. The type of hormone you take will depend on whether you want to get pregnant as well as your age.

Hormones can be given in different ways. Your doctor may prescribe birth control pills to help make your periods more regular. Hormones also can be given as an injection, as a vaginal cream, or through an IUD that releases hormones. An IUD is a birth control device that is inserted in the uterus. The hormones in the IUD are released slowly and may control abnormal bleeding.

Bleeding may be caused by endometrial hyperplasia. This condition occurs when the lining of the uterus grows too thick. Progesterone can help treat and prevent it.

Other Medications

Nonsteroidal antiinflammatory drugs, like ibuprofen, may help control heavy bleeding. They also may be used to relieve menstrual cramps. If you have an infection, you will be given antibiotics.

Surgery

Some women may need to have surgery to remove growths (such as polyps or fibroids) that cause bleeding. This often can be done with hysteroscopy. Sometimes other techniques are used.

Endometrial ablation may be used to control bleeding. This treatment uses electricity, laser, heat, or freezing to destroy the lining of the uterus. It is intended to stop or reduce bleeding permanently. A woman may not be able to get pregnant after ablation. An endometrial biopsy is needed before ablation is considered.

Hysterectomy may be done when other forms of treatment have failed or they are not an option. This is major surgery. Afterward, a woman no longer has periods. She also cannot get pregnant. Discuss all of your options with your doctor before choosing a treatment.

Finally…

If you are having abnormal bleeding, see your doctor. Abnormal bleeding can have a number of causes. There is no way to tell why your bleeding is abnormal until your doctor examines you. Once the cause is found, it often can be treated with success. If it persists or returns, you should see your doctor again.

Glossary

Ectopic Pregnancy: A pregnancy in which the fertilized egg begins to grow in a place other than inside the uterus, usually in the fallopian tubes.

Endometrial Hyperplasia: A condition that occurs when the lining of the uterus (endometrium) grows too much.

Endometrium: The lining of the uterus.

Estrogen: A female hormone produced in the ovaries that stimulates the growth of the lining of the uterus.

Fallopian Tubes: Tubes through which an egg travels from the ovary to the uterus.

Fibroids: Benign (noncancerous) growths that form on the inside of the uterus, on its outer surface, or within the uterine wall itself.

Hysterectomy: Removal of the uterus.

Intrauterine device (IUD): A small device that is inserted and left inside the uterus to prevent pregnancy.

Menopause: The process in a woman’s life when ovaries stop functioning and menstruation stops.

Miscarriage: The spontaneous loss of a pregnancy before the fetus can survive outside the uterus.

Ovaries: Two glands, located on either side of the uterus, that contain the eggs released at ovulation and that produce hormones.

Polyps: Growths that develop from membrane tissue, such as that lining the inside of the uterus.

Progesterone: A female hormone that is produced in the ovaries and matures the lining of the uterus. When the level of progesterone decreases, menstruation occurs.

Uterus: A muscular organ located in the female pelvis that contains and nourishes the developing fetus.