Abnormal Bleeding

Abnormal Bleeding

Don’t Let Abnormal Bleeding Put Your Life on Hold

The normal interval between menstrual periods is 21 to 35 days. Most women have a duration of flow of no more than seven days, and lose no more than 80 cc (or 2.8 fluid ounces) of blood with each cycle. Women with an interval of less than 21 days or greater than 35 days, with a menstrual flow duration greater than seven days, and/or with more than 80 cc of blood loss have abnormal bleeding.

Some abnormal bleeding can be treated with birth control while more severe cases may require Dilation and Curettage (D&C), endometrial resection, myomectomy, or hysterectomy.

Abnormal Bleeding Causes

Most commonly, abnormal vaginal bleeding is caused by benign abnormalities of the uterus or cervix. Benign conditions include fibroids, polyps, adenomyosis, and infection. Occasionally, malignant and premalignant conditions are the cause of abnormal bleeding. Such conditions include endometrial hyperplasia, endometrial carcinoma, and cervical carcinoma.

Systemic conditions, such as bleeding disorders, liver disease, pregnancy, and some medications, such as oral contraceptives, can cause irregular bleeding. Hormonal disorders such as polycystic ovary syndrome (PCOS), premature ovarian failure, and thyroid and pituitary abnormalities can also cause abnormal bleeding. When no organic cause of abnormal bleeding is identified, the patient is diagnosed with dysfunctional uterine bleeding (DUB).

Abnormal Bleeding Symptoms

Symptoms of abnormal bleeding include:

  • Abnormal periods or bleeding between menses
  • Heavy menstrual flow
  • Large clots
  • Menstrual flow lasting longer than seven days
  • Any bleeding after menopause
  • Any bleeding after intercourse
  • Interval between periods lasting greater than 35 days
  • Only having four to nine periods in a year

Abnormal Bleeding Diagnosis

The patient’s age as well as the pattern of abnormal menstrual bleeding is extremely important in identifying the cause. A careful medical history is obtained to evaluate the frequency and the amount of bleeding. Blood tests such as blood count, clotting factors, and iron levels can also be helpful in diagnosing abnormal bleeding and can identify the patients who need to be treated with iron supplementation.

Physical exams are performed to identify cervical or uterine masses or lesions:
  • Pelvic exams can be helpful in diagnosing some conditions, such as vaginal vault prolapse, as well as assessing the cervix and vagina
    • However, pelvic exams are not very accurate for diagnosing early-stage endometriosis or for evaluating the size, number, and location of fibroids and pelvic exams can miss more worrisome problems like ovarian masses —  ultrasound should be considered in any patient with abnormal bleeding or if pathology is suspected
  • Transvaginal ultrasound is a simple, noninvasive test that yields a large amount of information regarding the uterus, tubes, and ovaries, and can measure the thickness of the endometrial lining
    • The thickness of the endometrial lining can vary considerably for patients of reproductive age and should be less than 5 mm in postmenopausal patients
  • Hysteroscopy — where a small camera is inserted into the uterine cavity through the cervical canal — is useful in evaluating the uterine cavity and identifying polyps, fibroids, hyperplasia, and malignant lesions
    • If polyps or fibroids are identified, they can be removed by hysteroscopic resection
  • D&C may follow hysteroscopy if there is no evidence of an obvious abnormality within the uterine cavity and the tissue obtained from curettage is then sent for pathologic evaluation

Abnormal Bleeding Treatments

The treatment of abnormal bleeding is personalized for each patient and is based on the underlying cause of bleeding. Patients with DUB are usually treated with medical therapy, since there is not a specific lesion (organic cause) amenable to surgical therapy. Those who fail to respond to medical therapy should consider surgical options. Patients with anatomic causes of abnormal bleeding, such as fibroids, polyps, or cancer, are managed with surgical therapy. If a systemic (e.g., liver disease) or hormonal condition (e.g., thyroid disease) is the cause of abnormal bleeding, treatment of that condition will usually resolve the abnormal bleeding.

Medical Treatments Available1
  • Birth control pills are often used to treat abnormal bleeding that is due to hormonal irregularities
    • Birth control pills have many benefits and are safe for long-term use. Progesterone-only pills and intrauterine devices (IUDs) are used in women with a thickened uterine lining. Progesterone keeps the lining thin and can prevent the development of hyperplasia and uterine cancer.
  • NSAIDs such as ibuprofen and naproxen, which are given for the duration of menstrual bleeding, have been shown to decrease blood loss during the menstrual period
    • NSAIDs are more effective when combined with birth control pills to control bleeding
Surgical Treatments Available1
  • Dilation and curettage (D&C) is the fastest way to stop acute blood loss from the uterus
    • Those patients with severe bleeding and not responsive to medical therapy should have the procedure done to stop the bleeding. D&C provides only short-term relief from DUB. Medical therapy should be instituted after the bleeding has been controlled. Hysteroscopy at the time of D&C may help identify an organic cause of bleeding, such as a uterine polyp or fibroid, which can be removed during the same procedure.
  • Endometrial ablation is the destruction of the endometrial lining with thermal energy and should be considered in patients with DUB who have failed to respond to medical therapy
    • Energy-delivering devices include cryotherapy, circulating hot fluid, thermal balloons, radiofrequency electrosurgery, microwave energy, and diode laser energy, as well as monopolar and bipolar devices. Endometrial ablation can be performed in the office with local anesthesia and IV sedation or in the operating room with IV sedation or general anesthesia. Endometrial ablation should only be used in patients who do not desire fertility but desire to retain the uterus. Patients with multiple and/or large fibroids or patients with other organic causes of abnormal bleeding (such as adenomyosis) should not undergo this procedure. An 80 percent success rate can be achieved in select patients. Twenty percent of patients will require either another ablative procedure or hysterectomy2.
  • Undergoing a hysterectomy is best for patients who are not candidates for endometrial ablation, who are not interested in future childbearing, and who desire a guaranteed cure for their condition
    • Hysterectomy refers to removal of the uterus only — the ovaries are not removed and will continue to make estrogen, the female hormone. It is estrogen, not the uterus, which prevents patients from going into menopause.
  • Myomectomy, or the removal of fibroids while preserving the uterus, is usually reserved for patients who desire to preserve fertility

The CIGC Difference

When you suffer from abnormal bleeding, it is stressful not knowing why. When the bleeding is severe, it is important to find a GYN specialist whom you trust to avoid further complications.

Specialists not OBGYNs

At The Center for Innovative GYN Care® (CIGC®), we are completely focused on performing minimally invasive GYN techniques and procedures for optimal care and rapid recovery. Our surgeons specialize in GYN surgery for complications like abnormal bleeding. While the OBGYNs main focus is obstetrics, our sole focus is advanced gynecological surgery. The average OBGYN performs only 10 to 15 hysterectomies per year, while our surgeons average 400 per year. Surgical volume along with advanced techniques and procedures are important for success.  Read more about why patients from all over the US and the world travel to CIGC for surgical care. 

CIGC physicians will discuss all treatment options available, and, working together with patients, will decide on the best approach for each individual problem. CIGC surgeons will also make sure that you are fully informed about the treatment you receive, whether it is a simple prescription for birth control pills or a D&C.

A safe and speedy recovery is our priority. CIGC physicians have extensive experience with each procedure and have seen all possible outcomes, so they can ensure your comfort by telling you what to expect. As a patient, it is your decision where to get treated. As experts in this field, we urge you to visit us and find peace of mind in the form of superior expertise and years of experience.

Abnormal Bleeding FAQs

What causes abnormal bleeding?

Abnormal bleeding may be caused by a number of GYN conditions, depending on the age of the patient. For patients who are premenopausal, or before menopause, the most common causes include hormone imbalances, fibroids, adenomyosis, endometrial hyperplasia, polyps in the uterus, and, less commonly,  cancer in the uterus. In menopausal patients, the main causes of abnormal bleeding include atrophy of the vagina causing bleeding, endometrial hyperplasia or overgrowth of the uterine lining, cancer in the uterus, and cervical cancer.

What are the symptoms of abnormal bleeding?

Very heavy bleeding, large clots with menstrual cycles, extended periods (longer than seven days), or bleeding between menstrual cycles are symptoms of abnormal bleeding. In menopausal patients, bleeding should not occur, even if it is very light or low in volume, and a consultation with your physician is necessary. This is because menopausal patients have a higher incidence of precancerous and cancerous conditions of the uterine lining that require immediate diagnosis and treatment.

Should an ultrasound be performed for the evaluation of abnormal bleeding?

Yes, an ultrasound is one of the best tests to evaluate and determine the root of abnormal bleeding. An ultrasound of the uterus allows for the evaluation of fibroids, polyps, thickening of the uterine lining that may indicate hyperplasia or malignancy, and in some cases can identify adenomyosis as well. Pelvic exams may be helpful if a cervical cause of bleeding is present, but are less accurate for the evaluation of fibroids, and will not help to determine if the uterine lining is thick, or if polyps or adenomyosis are present.

What other tests are needed to determine the cause and treatment of abnormal bleeding?

A sample of the uterine lining is needed in some patients of reproductive age with abnormal bleeding to rule out hyperplasia or cancer. All patients who are postmenopausal will need to have a sample taken, or biopsy, of the uterine lining. This is because these patients are at higher risk of precancerous conditions or cancer of the uterus, which require surgical therapy. A complete blood count (CBC) test is also needed to determine if there is anemia, which is a low red blood cell count.

How is this sampling performed?

An endometrial biopsy is the removal of a small amount of tissue from the uterine lining for evaluation by a pathologist. This is an office procedure, and is usually well tolerated but can cause extensive cramping and pain for some patients. A hysteroscopy — an evaluation of the uterine cavity with a camera and light — with a biopsy is more accurate in determining the root of abnormal bleeding than endometrial biopsy alone.  A D&C, also known as dilation and curettage, removes a larger area of tissue from the uterine lining and may help to control bleeding. Sedation, usually in an operating room, is required to perform a D&C.

How is abnormal bleeding treated?

For patients with a hormonal imbalance, medical therapy is usually helpful in controlling abnormal bleeding. Birth control pills and many other hormonal therapies stop abnormal bleeding caused by hormonal imbalance by preventing ovulation. This also provides contraception. Other forms of medical therapy include birth control patches, IUDs, long acting progesterone implants such as Nexplanon, injections such as Depo-Provera, and others. Other causes of bleeding are usually treated by removing the cause of the problem. Fibroids are a very common cause of abnormal bleeding, and, in many cases, will ultimately require surgical removal to be controlled.

Ready for a Consultation

If you think you have abnormal bleeding, our specialists are ready to provide an evaluation of your symptoms and condition(s) and recommend an appropriate solution.

References:

1 Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Committee Opinion No. 557. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2013;121:891–6.

2 Famuyide A. Endometrial Ablation. J Minim Invasive Gynecol. 2018 Feb;25(2):299-307