The inside of the uterus has two layers. The thin inner layer is called the endometrium. The thick outer muscular wall is the myometrium (myo = muscle). Menstruation occurs 12 to 14 days after ovulation (period when ripe egg is released from ovaries). 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. Under normal circumstances, a woman’s uterus sheds a limited amount of blood during each menstrual period (less than 5 tablespoons or 80 mL). Bleeding that occurs erratically or excessive regular menstrual bleeding is considered to be abnormal uterine bleeding. Once a woman (not on any hormonal therapy) enters menopause and the menstrual cycles have ended, any uterine bleeding is considered abnormal. Abnormal uterine bleeding can be caused by many different conditions.
What is a normal menstrual cycle?
A normal menstrual period generally lasts up to 7 days. The normal length of the full menstrual cycle is typically between 25 and 34 days (i.e. if you count the first day of your period as day 1 until the day before the next period starts).
When is bleeding abnormal?
Bleeding in any of the following situations is considered abnormal uterine bleeding:
- Bleeding or spotting between periods
- Bleeding or spotting after sex
- Heavy bleeding during your period
- Menstrual cycles that are longer than 34 days or shorter than 25 days
- Irregular bleeding with no identifiable cycle
- Extended cycle with bleeding for more than 8 – 9 days
- Bleeding after the menopause
At what ages is abnormal bleeding more common?
Abnormal bleeding can occur at any age. However, at certain times in a woman’s life it is common for periods to be somewhat irregular. Periods may not occur regularly at first in young girls (around age 9–14 years). During peri-menopause (beginning in the mid–40’s), the number of days between periods may change. It also is normal to skip periods or for bleeding to get lighter or heavier during the peri-menopausal transition.
What causes abnormal bleeding?
Some of the causes of abnormal bleeding may include the following (see picture above):
- Polyp – a soft (usually benign) growth of the inner lining (endometrium) of the womb.
- Adenomyosis – a condition in which the endometrium grows into the wall (muscle) of the uterus.
- Leiomyoma – a smooth muscle growth (tumour) usually benign, developing from the muscular wall of the womb.
- Malignancy – certain types of cancers that might arise from the uterus or cervix
- Coagulopathy – different types of bleeding disorders
- Ovulatory – problems with ovulation or rather the absence of it
- Endometrial – bleeding arising from the uterine lining in the absence of any visible pathology e.g. during certain types of infections
- Iatrogenic – bleeding linked to medication e.g. birth control pills or the intrauterine device (IUD).
- Other – pregnancy related conditions e.g. miscarriage or tubal pregnancy.
Your gynaecologist 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 and more difficult to treat.
How is abnormal bleeding diagnosed?
Your gynaecologist or other health care professional will ask about your health history and your menstrual cycle. It may be helpful to keep track of your menstrual cycle before your visit. Note the dates, length, and type (light, medium, heavy, or spotting) of your bleeding on a calendar. You also can use a smartphone app designed to track menstrual cycles. You will have a physical and pelvic exam and may also need some blood tests (depending on the severity).
What tests may be needed to diagnose abnormal bleeding?
Based on your symptoms and your age, other tests may be needed. Some of these tests can be done at our offices while others may be done at a hospital:
- Papsmear – A (non-painful) method (performed at the office) where some cells are scraped off from the cervix in order to screen for potentially pre-cancerous or cancerous cells.
- Transvaginal ultrasound exam – A probe (not painful) placed inside the vagina to create a picture from the pelvic organs using sound waves.
- Hysteroscopy – A thin, lighted scope is inserted through the vagina and the opening of the cervix (see section on hysteroscopy).
- Endometrial biopsy – A small sample of the endometrium is removed with an object looking like a long, thin straw and evaluated by the pathologists. This procedure is often performed in women age 40 or older to rule out endometrial pathology.
What medications are used to help control abnormal bleeding?
Medications often are tried first to treat irregular or heavy menstrual bleeding. These medications that may be used include the following:
- Tranexamic acid – This medication decreases heavy menstrual bleeding. A short course should be taken only on the very heavy days. About 30 – 60 % reduction in blood flow can be anticipated.
- Anti-inflammatory drugs – These drugs, which include ibuprofen, may lighten heavy bleeding (20 – 40% decrease) but mainly acts to relieve menstrual cramps.
- Combined hormonal birth control methods – Birth control pills, the skin patch, and the vaginal ring contain estrogen and progesterone hormones. These hormones can decrease menstrual flow (40 – 70 %) and are very helpful to make periods more regular.
- Progesterone containing intra-uterine device – this device has no effect on regularity of cycles but will decrease the menstrual flow by 80 – 90 %
- Gonadotrophin-releasing hormone (GnRH) agonists – These drugs can stop the menstrual cycle altogether and reduce the size of leiomyomas. This is a short-term option only.
- Antibiotics – If you have an infection, you may be given an antibiotic.
- Special medications – For example if you have a bleeding disorder, your treatment may include medication to help your blood clot.
What types of surgery are performed to treat abnormal bleeding?
If medication does not reduce your bleeding, a surgical procedure may be needed. Surgery may also be necessary to remove abnormal uterine structures (e.g. leiomyomas or polyps). There are different types of surgical procedures depending on your condition, your age, and whether you want to have more children.
- Endometrial ablation is a procedure aimed at damaging the lining of the uterus permanently by destroying it with heat, cold or electrical energy. It stops the menstruation altogether in 50 – 60% of patients and causes an 80 – 90 % reduction in bleeding in the rest. A patient should NOT get pregnant after this procedure and therefore a sterilization is often performed at the same time. This is a very good option in patients in their 40’s especially if no other reason for the bleeding can be found. This is performed in an operating theatre under general anaesthesia but the patients can usually go home the same afternoon.
- Hysterectomy or surgical removal of the uterus is the most definitive surgical treatment for abnormal uterine bleeding and the only treatment option to guarantee the absence of further bleeding. This is indicated for specific conditions (e.g. cancer) or when conservative treatments have failed. After the uterus is removed, a woman can no longer get pregnant. If the ovaries are left in place, she will not be menopausal and will therefore not need any hormonal replacement (until the time of normal menopause). Nowadays we can perform the hysterectomy via laparoscopy (see section on laparoscopy) which is minimally invasive (key-hole surgery). This is performed under general anaesthesia and the patient can often go home on the first post-operative day. Sick leave is only needed for 2 – 3 weeks after which the patient can return to her normal duties.
- Uterine artery embolization is a procedure used to treat leiomyomas. Tiny particles are injected into the blood vessels (feeding the uterus) through a catheter in the groin. The particles aim to cut off the blood supply to the womb and the leiomyomas. However, this treatment is extremely expensive and even though symptoms initially improves they often recur in the future.