ABNORMAL UTERINE BLEEDING
Background
The inside of the uterus has two layers. The thin inner layer is called the endometrium. The thick outer muscular wall is the myometrium. Menstruation (your “period”) normally occurs about 14 days after ovulation. In women who ovulate and menstruate regularly, the endometrium thickens every month in preparation for pregnancy. If the woman does not become pregnant, the endometrial lining is shed during the menstrual period. With menopause, ovulation stops and the lining stops growing and shedding.
What is normal bleeding?
There is a range of normal bleeding – some women have short, light periods and others have longer, heavy periods. Your period may also change over time.
Normal menstrual bleeding has the following features:
Your period lasts for 3-8 days
Your period comes again every 21-35 days (measured from the first day of one period to the first day of the next)
The total blood loss over the course of the period is around 2-3 tablespoons but secretions of other fluids can make it seem more
Causes of abnormal uterine bleeding
Most conditions that cause abnormal uterine bleeding can occur at any age, but some are more likely to occur at a particular time in a woman's life.
Young girls — Bleeding before menarche (when periods begin) is always abnormal. It may be caused by trauma, a foreign body (such as toys, coins, or toilet tissue), irritation of the genital area (due to bubble bath, soaps, lotions, or infection), or urinary tract problems. Bleeding can also occur as a result of sexual abuse.
Adolescents — 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 hormonal cycle and ovulation normalizes. If irregular bleeding persists beyond this time, or if the bleeding is heavy, further evaluation is needed.
Abnormal bleeding in teens can also be caused by any of the conditions that cause bleeding in all premenopausal women, including: pregnancy, infection, and bleeding disorder or other medical illnesses. These and other causes are discussed in the next section.
Premenopausal women — Many different conditions can cause abnormal bleeding in women between adolescence and menopause. Abrupt changes in hormone levels at the time of ovulation can cause vaginal spotting, or small amounts of bleeding. Erratic or unpredictable bleeding can also occur in premenopausal women who use hormonal birth control methods.
Some women do not ovulate regularly and may experience unpredictable light or heavy vaginal bleeding. Although irregular ovulation is most common when periods first begin and during perimenopause, it can occur at any time during the reproductive years.
Some women who ovulate regularly experience excessive blood loss during their periods or bleed between periods. The most common causes of such bleeding are uterine fibroids, uterine adenomyosis, or endometrial polyps. Fibroids are benign masses in the muscle layer of the uterus (myometrium), while adenomyosis is a condition in which the lining of the uterus (endometrium) grows into the myometrium. Endometrial polyps are fleshy (usually benign) growths of tissue which project into the uterine cavity. These conditions are common causes of abnormal uterine bleeding. Fibroids, adenomyosis and polyps can also occur in anovulatory women.
Other causes of abnormal uterine bleeding in premenopausal women include:
Pregnancy
Cancer or precancer of the cervix or the endometrium (lining of the uterus)
Infection or inflammation of the cervix or endometrium
Clotting disorders such as use of anticoagulant medications, von Willebrand disease, platelet abnormalities, or problems with clotting factors
Medical illnesses such as hypothyroidism, liver disease, or chronic renal disease
Hormonal birth control — Women who use hormonal birth control (eg, pills, ring, patch) may experience "breakthrough" bleeding between periods. It commonly occurs during the first few months as the lining of the uterus adjusts to the hormonal medication. If it persists for more than a few months, evaluation may be needed and/or a different birth control pill may be recommended. Initially, women using injectable contraception often experience irregular bleeding; over time, bleeding stops occurring in such women. Irregular bleeding is common in women using the contraceptive implant (not yet available in Canada). In women using progestin-releasing intrauterine devices (IUDs), bleeding is often irregular at first. Over time, bleeding becomes lighter; long-term, such women often experience scant bleeding, spotting, or no bleeding. Infections of the cervix (including those caused by chlamydia or trichomoniasis) can cause irregular bleeding, particularly after sexual intercourse.
Breakthrough bleeding can also happen if a hormonal birth control method is forgotten or taken late. In this situation, there is a risk that the woman could become pregnant if she has sex. An alternate or "back-up" form of birth control (eg, condoms) is recommended if the pill/patch/shot is not taken on time.
Women in the menopausal transition — Before menstrual periods end, a woman passes through a period called the menopausal transition or perimenopause. During the menopausal transition, the timing of periods begins to change as ovulation becomes less regular. While ovaries in perimenopausal women continue to make estrogen, progesterone secretion declines. These 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 that can progress to cancer) will develop and potentially cause abnormal bleeding. The menopausal transition is a time when women are more likely to experience abnormal uterine bleeding. All of the other conditions above can also affect women in the menopausal transition, so further evaluation is needed in women with persistent irregular menstrual cycles or an episode of profuse bleeding.
Evaluation of abnormal uterine bleeding
Initial assessment — Your doctor will take a thorough history to evaluate your background medical history, gynecologic history, and the details of the bleeding and other associated symptoms. Your doctor will then perform a physical examination to evaluate your overall health and a pelvic examination, and this examination may involve a Pap smear, swabs, or endometrial biopsy if deemed relevant.
Potential initial tests that may be done:
Pap smear
Cervical and/or vaginal swabs to rule out infection
Endometrial biopsy: This helps to assess for precancerous or cancerous changes in the endometrial lining. During the biopsy, a thin instrument is inserted through the vagina and cervix into the uterus to obtain a small sample of endometrial tissue. The biopsy (which often causes temporary uterine cramping) can be performed in a health care provider's office without anesthesia if tolerated. Because only a small portion of the endometrium is sampled, the biopsy may miss some causes of bleeding and other tests are sometimes necessary
Blood tests: Pregnancy test, thyroid function (and other hormone levels that may interfere with ovulation), a blood count and iron levels (to see if the bleeding has caused anemia) are commonly done
Pelvic ultrasound, sometimes done with a probe inserted into the vagina, and sometimes other imaging tests
Additional tests sometimes required:
Hysteroscopy — During hysteroscopy, a small scope is inserted through the cervix and into the uterus. Air or 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 typically used to minimize discomfort during the procedure, and for this reason this procedure is typically done as a day procedure in an operating room.
Dilation and curettage (D&C) — In a D&C, the cervix or opening of the uterus is dilated and instruments are inserted and used to remove endometrial or uterine tissue. A D&C usually requires anesthesia.
Treatment of abnormal uterine bleeding
The treatment of abnormal bleeding depends on the cause.
Tranexamic acid - This medication is used only on heavy days of bleeding. It is NOT a hormone. It just slows down the amount of bleeding.
Anti-inflammatory medication - NSAIDs such as ibuprofen or naproxen, may also be helpful in reducing blood loss and cramping
Birth control pills — Birth control pills are often used to treat uterine bleeding that is due to hormonal changes or hormonal irregularities. Birth control pills may be used in women who do not ovulate regularly to establish regular bleeding cycles and prevent excessive growth of the endometrium. In women who do ovulate, they may be used to treat excessive menstrual bleeding.
During the menopausal transition, birth control pills or other hormonal therapy may be used to regulate the menstrual cycle and prevent excessive growth of the endometrium.
Progesterone — Progesterone is a hormone made by the ovary that is effective in preventing or treating excessive bleeding in women who do not ovulate regularly. A synthetic form of progesterone, called progestin, may be recommended to treat abnormal bleeding. Progestins are usually given as pills (eg, medroxyprogesterone acetate, norethindrone acetate) and are taken once a day for 10 to 12 days each month or taken continuously (every day). In women taking monthly cyclical progestin therapy, vaginal bleeding may occur cyclically. Cyclical progestin therapy does not provide consistent birth control. In women using cyclical progestin therapy and experiencing cyclical bleeding, if the expected bleeding does not occur, the possibility of pregnancy should be explored. Progestins may also be given in other ways, such as in an injection, an implant, or an intrauterine device (IUD).
Intrauterine device — An IUD that secretes progestin (eg, Mirena) may be recommended for women who have abnormal uterine bleeding. IUDs are T-shaped devices inserted by a health care provider through the vagina and cervix into the uterus. IUDs include an attached plastic string that projects through the cervix, enabling the woman to check that the device remains in place.
Progestin-releasing IUDs decrease menstrual blood loss by more than 50 percent and decrease pain associated with periods. Some women completely stop having menstrual bleeding as a result of the IUD, which is reversible when the IUD is removed. Use of progestin-releasing IUDs allows some women with abnormal uterine bleeding to avoid surgery.
Surgery — Surgery may be necessary to remove abnormal uterine structures (eg, fibroids, polyps). Women who have completed childbearing and have heavy menstrual bleeding can consider a surgical procedure such as endometrial ablation. This procedure is performed in an operating room as a same-day surgery, and uses heat, cold, electrical energy, or a laser to destroy the lining of the uterus.
Women with fibroids can have surgical treatment of their fibroids, either by removing the fibroid(s) (eg, myomectomy) or by reducing the blood supply of the fibroids (eg, uterine artery embolization). The most definitive surgical treatment for abnormal uterine bleeding is hysterectomy, or removal of the entire uterus. At the time of hysterectomy, the ovaries may be left in place or removed. Hysterectomy may be performed by laparoscopy ("belly button surgery"), through the vagina, or by an open incision on the abdomen.
Adapted from: www.uptodate.com: Patient education: Abnormal uterine bleeding (Beyond the Basics) Author: Andrew M Kaunitz, MD. Topic last updated Jan. 2019.
ADDITIONAL RESOURCES
https://www.acog.org/Patients/FAQs/Abnormal-Uterine-Bleeding?IsMobileSet=falsets)
Many “period tracking” apps are available for download and are useful to have to review with your gynecologist.
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