Abnormal uterine bleeding is a common complaint for women of childbearing age that are not pregnant. In order to understand the bleeding, we need to first look at the normal menstrual cycle. Sometime between the ages of 10 to 16 your body will begin producing hormones that initiate and regulate your menstrual cycle.
During those first few years, the menstrual cycle is usually anovulatory. That means the menstrual cycle is not hormonally able to release an egg from the ovary on a regular schedule. Vaginal bleeding will start at the end of the cycle because of normal hormonal changes with a reduction in progesterone. When that happens, your body sheds the lining that was built up earlier in the cycle.
After the first 1-2 years of having cycles, your body usually develops a pattern of bleeding that occurs every 21-35 days. We count this from the start of one cycle to the start of the next meaning that if your cycle started on the first of the month and then again on the 28th of the month they would be 28 days apart.
Bleeding that falls outside of those 21-35 days, lasts longer than 7 days, or is heavy enough to cause anemia is considered abnormal. To find out if you have anemia your provider will obtain a complete blood count.
All abnormal vaginal bleeding is not heavy, for some women the bleeding may just be irregular. This means that you are having cycles that are less than 21 or more than 35 days apart. Cycles that last more than 7 days of bright red bleeding also need evaluation. If you are skipping cycles for months at a time your provider will likely order other labs to evaluate your hormonal status.
Medical and family History
Occasionally, your family history may yield important information to diagnose a problem such as abnormal uterine bleeding. Anatomic problems like uterine fibroids or endometriosis can frequently be found in other female members of your family.
Medical conditions such as thyroid disease and blood clotting disorders are also found to occur more frequently in some families. Obesity is another factor related to heavy cycles because estrogen is stored in fat cells and therefore women with excess fat cells my have higher estrogen levels.
Evaluation
Heavy cycles may be caused by hormonal or anatomic problems. Uterine fibroids (covered in another SA article), or less common problems like adenomyosis or endometrial (uterine lining) polyps are examples of anatomic problems that can cause abnormal uterine bleeding. Other medical conditions as noted above that may cause abnormal uterine bleeding are blood coagulation (“blood clotting”) disorders or hypothyroidism.
If you see your women’s health provider, they will probably ask questions to evaluate the type of abnormal bleeding you are having and perform a pelvic examination, if possible. A complete blood count can determine if you are anemic which is helpful to know in managing the bleeding.
Other medical conditions may be evaluated with blood work including thyroid problems, blood clotting disorders or hormone levels. A transvaginal ultrasound obtains an image of your pelvis and measures the lining of your uterus. This scan can identify anatomic problems such as uterine fibroids, polys or a thickened endometrium.
Treatment
The goal is to improve the abnormal bleeding so that your quality of life is better. The first line of management for abnormal uterine bleeding is usually to control hormones with a device like an IUD or birth control pills. There is not one treatment that works perfectly for everyone. We are all different.
It may take time to identify the best hormonal treatment for you. Be patient as your provider works with you during this time. If the bleeding is not satisfactorily improved or anatomic abnormalities of the uterus are identified, sometimes there are surgical options that should be considered.
Women over the age of 40 with abnormal bleeding may require other evaluation to provide information and guidance for treatment. One recommendation is an endometrial biopsy. This procedure is a way to check the type of tissue found in the uterine lining. The biopsy is a small sample of the lining that is obtained during a speculum exam when a thin catheter is passed through the cervix.
This type of biopsy is done without cutting tissue as with most other biopsies. It is obtained quickly and causes minimal cramping. The goal of obtaining this information is to prove that there are no abnormal uterine cells in the sample. This procedure is often performed in the office. Anesthesia is not needed. The sample is sent to the lab with the report available in a few days.
If you are having abnormal uterine bleeding it is a good idea to make an appointment with your women’s health care provider to discuss what you are experiencing. Prior to the appointment monitor your cycles so that you are able to describe what is happening.
Write down how often your cycles are coming, how many days you have bright red bleeding, how long you can use a tampon or pad before saturation and other changes that you are having. It is also good to know how long you have been having the symptoms. You will want to tell them of any new changes in your medical history or new medications you are taking.
