Abnormal Uterine Bleeding

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Abnormal Uterine Bleeding Resources

The Basics

What is abnormal uterine bleeding?

Abnormal uterine bleeding is any type of bleeding from the vagina that is not normal. This may mean that you are bleeding at times of the month other than your period, or that your period is unusually heavy. If you are changing a pad or tampon more than once every 1-2 hours, your period is unusually heavy. If your period lasts more than 7 days or fewer than 2 days, this is also abnormal uterine bleeding.

Abnormal uterine bleeding occurs in most women at some point in their lives. It is common in older women whose hormones are fluctuating due to the onset of perimenopause or menopause. Abnormal uterine bleeding is also common in the first year or two of menstruation. Vaginal bleeding in girls before the onset of the menses is abnormal. In postmenopausal women, vaginal bleeding that persists for 12 months after the cessation of the menses is abnormal. Other conditions may also cause abnormal uterine bleeding.

In general, we should avoid speculation about diagnoses...in particular when the diagnoses can be fatal.

Symptoms:

• Menstrual flow that soaks through one or more sanitary pads or tampons every hour for several consecutive hours
• The need to use double sanitary protection to control your menstrual flow
• Menstrual period that lasts longer than 7 days
• Menstrual flow that includes large blood clots
• Heavy menstrual flow that interferes with your regular lifestyle
• Constant pain in your lower abdomen during menstrual period
• Irregular menstrual periods
• Tiredness, fatigue, or shortness of breath (symptoms of anemia)

What are the different types of abnormal uterine bleeding?

Abnormal uterine bleeding is a broad term and there are many different types that range from very mild to extremely severe. Women who are concerned that they may have abnormal uterine bleeding, should be seen by their doctor.

• Pregnancy-related: Vaginal bleeding that occurs during pregnancy
• Oligomenorrhea: Vaginal bleeding occurs at intervals of more than 35 days
• Polymenorrhea: Vaginal bleeding occurs at intervals of less than 21 days
• Menorrhagia: Bleeding occurs at normal intervals (21–35 days), but there is an excessive flow (more than 80 mL) or excessive duration (more than 7 days)
• Menometrorrhagia: Bleeding occurs at irregular intervals and with heavy flow or duration
• Metrorrhagia or bleeding intermenstrual: Irregular bleeding occurs in between ovulatory cycles
• Midcycle spotting: Spotting that can occur just before ovulation, usually because of a decline in estrogen levels
• Postmenopausal bleeding: Bleeding recurs in menopausal women at least 1 year after the cessation of the cycles

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What causes abnormal uterine bleeding?

Because there are so many different types of abnormal uterine bleeding, the causes vary greatly. Abnormal bleeding may be caused by certain issues of the reproductive system. Fibroids and uterine polyps are two common problems women face. Some women can bleed abnormally as a result of adenomyosis, which is when the lining of the uterus grows into the wall of the uterus. Bleeding may be induced by medications, including anticoagulants, selective serotonin reuptake inhibitors, antipsychotics, corticosteroids, hormonal medications, and tamoxifen (Nolvadex). Herbal substances, including ginseng, ginkgo, and soy supplements may cause menstrual irregularities by altering estrogen levels.

The following table shows other possible causes specifically of the different types of abnormal uterine bleeding.

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Women and abnormal uterine bleeding: the statistics

• Menstrual disorders were the reason for 19.1% of 20.1 million visits to physician offices for gynecologic conditions over a 2-year period.
• A reported 25% of gynecologic surgeries involve abnormal uterine bleeding.
• In girls who experience abnormal uterine bleeding before the onset of menstruation, many cases involve lesions of the reproductive system, and some of these lesions may be malignant. In these cases, a thorough evaluation must be done.
• Menstrual irregularities are associated with thyroid disease.

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Ask your healthcare provider

Diagnosis and Treatment

Because there are so many possible causes of abnormal uterine bleeding, there are also many diagnosis techniques. Your healthcare provider will consider your age and your medical history when he/she chooses the diagnostic tests to order. If you may be pregnant, that will be the first test. It is a cheap and easy test, and is a common cause of abnormal uterine bleeding.

• Ultrasound: by doing an ultrasound exam of your pelvic area, the doctor will be able to see the uterus and ovaries. This may help locate the cause of the bleeding.
• Endometrial biopsy: This procedure is done by inserting a thin plastic tube (catheter) into the uterus. A section of the uterine lining (endometrium) is removed and sent to the lab. The test will show any changes in the cells, or if there are any cancerous cells.
• Hysteroscopy: A thin tube is inserted into the uterus. At the end of the tube is a tiny camera. The camera lets your doctor see the inside of your uterus to locate any abnormalities.
• D & C (Dilation and curettage): During this procedure, your cervix is stretched open so that a surgical tool can be inserted into the uterus. The tool scrapes the lining of the uterus, and the removed lining is checked for abnormal tissue. If the bleeding is very heavy, a D & C may be performed both to locate the problem and to treat the bleeding.

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Treatment

Once again, the causes of abnormal uterine bleeding are varied, and therefore, the treatments also differ greatly. However, the three main principles can be applied to all women:

1. control bleeding
2. preserve fertility
3. prevent recurrence

Hormone imbalance: If your doctor identifies that the problem causing the bleeding is a hormone imbalance, you may likely be prescribed with hormone therapy like birth control pills or progesterone.

Thyroid problems: Treatment for thyroid problems may help your abnormal uterine bleeding to abate. Treatments include antithyroid drugs, radioactive therapy, thyroid surgery, or a thyroidectomy.

Endometrial ablation: This treatment involves removal of the lining of your uterus, either ending menstruation or reducing your menstrual flow. Endometrial ablation is effective in stopping abnormal bleeding, but doesn’t affect fibroids outside the interior lining of the uterus.

Polyps: Uterine polyps can be removed in two ways. Surgical removal of the polyps entails the doctor inserting special instruments into the uterus to cut away and remove polyps. The removed polyp may then be sent to the lab for examination. If there are too many polyps to remove, if the doctor is unable to reach all the polyps, or if it is discovered that the polyps are cancerous, then it is possible that a hysterectomy is the best treatment.  This is a complete removal of the uterus.

Uterine fibroids are often harmless that no treatment may be necessary, though women should be aware that they have them and note any changes or symptoms. Medications for uterine fibroids target hormones that regulate the menstrual cycle. They may shrink fibroids and reduce abnormal uterine bleeding. Gonadotropin-releasing hormone agonists (Gn-RH agonists) causes estrogen and progesterone levels to fall, often stopping menstruation entirely.

DUB treatment (dysfunctional uterine bleeding)
Medical

Hormonal

• Estrogens, progestins, oral contraceptives
• Danazol


• GnRH agonists


• Levonorgestrel intrauterine system (LNG-IUS)

Nonhormonal

Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Antifibrinolytic agents

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Empower Yourself

Dealing with abnormal uterine bleeding

Abnormal uterine bleeding can be painful, uncomfortable, and inconvenient, but it does not need to take over your life. In addition to the treatments that may be available to you, you can be proactive in making yourself feel better.

• Get your rest. Your doctor may recommend rest if bleeding is excessive and disruptive to your normal schedule or lifestyle.
• Keep a record. Record the number of pads and tampons you use so that your doctor can determine the amount of bleeding. Change tampons regularly, at least every 4 to 6 hours.
• Avoid aspirin. Because aspirin may promote bleeding, avoid it. Ibuprofen (Advil, Motrin, others) often is more effective than aspirin in relieving menstrual discomforts.
• Stay informed. Get your blood count and iron levels measured every year to make sure they are normal. Also stay informed about new treatments.
• Iron supplements. If your iron levels are low, ask your doctor about taking supplements to counteract anemia.
• Eat healthfully and exercise. A healthful diet, together with exercise and enough rest, will help keep you in your best shape.

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Frequently asked questions

What is hysteroscopy?
Hysteroscopy is a diagnostic or therapeutic technique that allows doctors to visualize anatomic abnormalities in the uterus via a telescopic instrument. To aid in the visualization process, the healthcare professional may introduce water and carbon dioxide gas into the uterus to make visualization easier.

What is abnormal uterine bleeding?
Abnormal uterine bleeding can occur in women of all ages. It can be defined as the following:

• Cycles lasting less than 21 days. Menstrual cylces that are greater than 7 days
• Average blood loss greater or equal to 80 mL per cycle
• Any deviation from a woman’s regular cycle

What causes abnormal uterine bleeding?
Abnormal uterine bleeding can be caused by hormonal irregularities without a clear or defined anatomical abnormality, or functional bleeding, where there is a clear anatomical cause, including polyps, submucus fibroids, or cancer.

How do you diagnose the cause of abnormal uterine bleeding?
The initial diagnosis is made in the gynecologist’s office. The gynecologist will take a detailed history of symptoms and perform a pelvic examination. There are several tests that can be done in the office including:

• Uterine sampling or endometrial biopsy: the removal of small piece of uterine lining to analyze under a microscope
• Sonogram: a picture of the uterus and its lining using ultrasound (to detect fibroids and polyps)
• Fluid-enhanced sonogram: saline injected through the cervix into the endometrial cavity, then followed by sonogram to show anatomic abnormalities that push on the cavity
• Hysterogram: an X-ray performed by injecting radio opaque liquid through the cervix. This procedure diagnoses the same structures as the fluid-enhanced sonogram and also allows physicians to see if the fallopian tubes are blocked
• Hysteroscopy: visual examination of the endometrial cavity performed by infusing water and carbon dioxide gas into the uterus to make polyps and fibroids easily visible.

What are the treatment options for abnormal uterine bleeding?
If the bleeding is caused by hormonal irregularity, then it can be treated with medications such as progesterone or oral contraceptives. Duration of treatment depends on the cause of the hormonal irregularity.

What is a D&C?
A D&C, or dilatation and curettage, is a procedure whereby the opening of your cervix is stretched just enough so a surgical tool can be put into your uterus. The tool is used to scrape away the lining of your uterus. The removed lining is checked in a lab for abnormal tissue. A D&C is done under anesthesia (while you’re “asleep”). If you’re bleeding heavily, a D&C may be done both to find out the problem and to treat the bleeding. The D&C itself often makes heavy bleeding stop. Your doctor will decide if this procedure is necessary.

What is endometriosis?
Endometriosis is a disease characterized by the presence of tissue which is histologically identical to endometrium (the inner lining of the uterine wall) outside the uterine cavity. Usually, endometriosis is confined to the pelvic and lower abdominal cavity; however, it has occasionally been reported to be in other areas, as well. Endometriosis is one of the most common problems that gynecologists currently face.

What is dysfunctional uterine bleeding?
The term “dysfunctional uterine bleeding” is used to describe heavy vaginal bleeding that may not be caused caused by a serious medical problem. In most cases, heavy often irregular bleeding is related to abnormal hormone levels that throw off the menstrual cycle.

Dysfunctional uterine bleeding is not used to describe vaginal bleeding caused by medical conditions such as miscarriage, uterine growths such as fibroids, cancer of the cervix or uterus, or blood diseases. If you are experiencing heavy vaginal bleeding, your healthcare professional must rule out these other conditions before diagnosing you with dysfunctional uterine bleeding.

What causes dysfunctional uterine bleeding?
There are two types of dysfunctional uterine bleeding:

• Anovulatory (“not ovulating”). Progesterone is necessary for the ovary to regularly release an egg (ovulation), as well as for regulating menstrual bleeding. Low progesterone causes irregular and heavy menstrual bleeding. This type of dysfunctional uterine bleeding is common before age 20 and after age 40 (perimenopause). During these times of transition into and out of the fertile years, it's normal for progesterone levels to vary.
• Ovulatory. As many as 15% of ovulating women have abnormal uterine bleeding despite having normal levels of progesterone and other hormones. In these cases, no hormonal or other cause can be found.

What are symptoms of abnormal uterine bleeding?

You may have abnormal uterine bleeding if you have one or more of the following symptoms:

• Menstrual bleeding that occurs more often than every 21 days or farther apart than 35 days (a normal menstrual cycle is 24–35 days long)
• Menstrual bleeding that lasts longer than 7 days (normally 4–6 days)
• Blood loss of more than 80 mL each menstrual cycle (normally about 30 mL). If you are passing large clots or soaking a large pad per hour for 8 hours, your bleeding is considered heavy.

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Glossary of abnormal uterine bleeding terms

Ablation: Removal or excision. Ablation is usually carried out surgically. For example, surgical removal of the thyroid gland (a total thyroidectomy) is ablation of the thyroid. The word ablation comes from the Latin ablatum meaning to carry away.

Abnormal: Not normal. Deviating from the usual structure, position, condition, or behavior. In referring to a growth, abnormal may mean that it is cancerous or premalignant (likely to become cancer).

Adenomyosis: This is a common benign condition of the uterus in which the endometrium (the mucous membrane lining the inside of the uterus) grows into the myometrium (the uterine musculature located just outside the endometrium).

Benign: Not cancer. Not malignant. A benign tumor does not invade surrounding tissue or spread to other parts of the body. A benign tumor may grow but it stays put (in the same place).

Cervix: The neck of the womb.

Curettage: The removal of growths or other material from the wall of a cavity or other surface, as with a curet. A curet, or curette, is a spoon-shaped instrument with a sharp edge. The word “curette” comes from French and means a scraper. The verb “curer” means to scrape or clean.

Endometrial ablation: Removal of the lining of the uterus. Removing the uterine lining decreases menstrual flow.

Endometrium: Mucous membrane lining of the uterus.

Estrogen: The female sex hormone responsible for the development and maintenance of female reproductive organs, especially breast and uterus, and the secondary sex characteristics such as distribution of fat and hair patterns.

Fallopian tube: A duct that transports ovum from the ovary to the uterus.

Fibroids: Fibroids are common, benign tumors of smooth muscle in the uterus. Uterine fibroids are one of the most common reason for performing a hysterectomy. Fibroids do not produce symptoms in all women, but may lead to prolonged or heavy menstrual bleeding, pelvic pressure or pain, and rarely to infertility. In addition to hysterectomy, less invasive surgical procedures have been employed to remove uterine fibroids. Fibroids can be detected by radiologic testing, such as ultrasound, CAT scan, or magnetic resonance imaging (MRI). However, fibroids may not be needed to be removed at all.

Hormones: Hemical substances, produced by an organ, gland or special cells, that are carried through the bloodstream to regulate the activity of certain organs.

Hysterectomy: A surgical operation to remove the uterus and, sometimes, the cervix. Removal of the entire uterus and the cervix is referred to as a total hysterectomy. Removal of the body of the uterus without removing the cervix is referred to as a subtotal hysterectomy.

Intrauterine: In the uterus. As opposed to extrauterine: outside the uterus.

Intrauterine device (IUD): A small, T-shaped device, containing either copper or a hormone, that is inserted into the uterus to prevent pregnancy.

Irregular bleeding: Vaginal bleeding that occurs at the wrong time of the month, such as in between periods.

Menarche: The term given to the onset of menstruation in females. This occurs at puberty, which can be anywhere between the ages of 10 and 17.

Menopause: The termination of the menstrual cycle in women in midlife between the ages of 40 and 55 years.

Menstruation: The term given to the periodic discharge of blood, tissue fluid, and mucus from the endometrium (lining of the uterus) that usually lasts from 3 to 5 days. It is caused by a sudden reduction in estrogens and progesterone. Can also be referred to as the menstrual phase or menstrual cycle, or menses.

Ovary: A female gland that produces hormones and the female reproductive or germ cell (ova).

Ovulation: The release of a fertile ocum or egg from the ovary into the fallopian tube.

Ovum (plural) or Ova (singular): The female reproductive, egg or germ cell.

Pituitary gland: A gland located in the brain that regulates a wide range of bodily activities from growth to reproduction.

Progesterone: A female hormone and the principal that prepares the body for and sustains pregnancy. Progesterone prepares the lining (endometrium) of the uterus to receive and sustain the fertilized egg and so permits pregnancy.

Syndrome: A set of signs and symptoms that tend to occur together and which reflect the presence of a particular disease or an increased chance of developing a particular disease.

Uterine lining: The inner layer of the uterus; the cells that line the womb; anatomically termed the endometrium.
 
Uterus: The uterus is a hollow, pear-shaped organ located in a woman’s lower abdomen between the bladder and the rectum. The narrow, lower portion of the uterus is the cervix; the broader, upper part is the corpus.

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Resources and tools

Government Agencies

*Accepts Spanish calls

*National Women’s Health Information Center, OWH, HHS
8270 Willow Oaks Corporate Drive
Fairfax, VA 22031
Phone: (800) 994-9662
TDD: (888) 220-5446
Fax: (703) 663-6942
http://www.4woman.gov

Department of Health and Human Services
Food and Drug Administration
5600 Fishers Lane
Rockville, MD 20857
Phone: (888) INFO-FDA
http://www.fda.gov

Private Organizations

Planned Parenthood Federation of America
434 West 33rd St
New York, NY 10001
Phone: (212) 541-7800
Phone: (800) 230-7526
Fax: (212) 245-1845
http://www.plannedparenthood.org/

American College of Obstetricians and Gynecologists (ACOG) Resource
409 12th St, SW PO Box 96920
Washington, DC 20090-6920
Phone: (202) 638-557
Phone: (800) 762-2264 x 192
(for publications requests only)
http://www.acog.org/

Mayo Clinic
4500 San Pablo Road
Jacksonville, FL 32224
Phone: (904) 953-2000
http://www.mayoclinic.org

Newsletters, Magazines, Reports

Healthy Women Today
The National Women’s Health Information Center
http://www.womenshealth.gov/newsletter

Cleveland Clinic
Women’s Health Center Newsletter
http://www.clevelandclinic.org/womenshealth

Tools

Stress Assessment
Take this assessment to see what your stress levels are like.
http://www.mayoclinic.com/health/stress-assessment/SR00029

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