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Should I Be Worried About Abnormal Uterine Bleeding?

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By SHELLY HOLMSTROM, M.D.

Published: March 21, 2008

Unusual uterine bleeding — bleeding that occurs between periods or menstrual bleeding that is longer or heavier than normal — causes anxiety for many women. Regular menstrual cycles in women not using hormonal forms of contraception rely on the process of ovulation, and a variety of hormones in women's bodies help to regulate this complex process. The end result is regular shedding of the lining of the uterus (endometrium), also known as a menstrual cycle.

When women do not ovulate, regular shedding of the endometrium does not occur and irregular bleeding — varying from spotting to excessive flow — can result. Some causes for not ovulating (anovulation) include obesity, anorexia nervosa or weight loss, excessive stress, polycystic ovarian syndrome, thyroid disease, early menopause, and certain forms of radiation and chemotherapy. Although anovulation is most common when periods first begin and near menopause, it can occur any time during the reproductive years. Some women do not ovulate when they breastfeed. Women also do not ovulate when they become pregnant.

Evaluation and treatment of abnormal bleeding depends upon the underlying cause of the abnormality. Uterine fibroids, endometrial polyps or inflammation, cervical or vaginal cancer, uterine pre-cancer or cancer, and abnormal pregnancies (miscarriage or ectopic) can all cause abnormal bleeding not related to ovulation. The physician must rule out these clinical conditions before abnormal bleeding can be attributed to anovulation. In addition to a thorough medical history and physical examination, a pelvic sonogram, Pap test, endometrial biopsy, pregnancy test and simple blood tests may be performed to help with the diagnosis.

Treatment of abnormal bleeding due to hormonal changes or irregularities depends on a woman's age. Adolescent (ages 13 to 18 years) and reproductive-age women (ages 19 to 39) can be treated very successfully with cyclic progestin medication or low-dose birth control pills. Women of later reproductive age (40 to menopause) often can safely use these medications or may benefit from hormone replacement therapy if they experience hot flashes. Nonsteroidal anti-inflammatory medications, like ibuprofen or naproxen, may also be used to decrease menstrual bleeding and cramping.

Some postmenopausal women taking hormone replacement therapy or oral contraceptives to alleviate hot flashes or other symptoms continue to experience cyclical withdrawal bleeding. If a woman is not on these medications and experiences bleeding after menopause, she should always be evaluated by her physician to rule out endometrial cancer.

When excessive bleeding does not respond to medical treatment, women who have completed their childbearing often are offered surgical options to remove abnormal uterine structures such as fibroids or polyps. The two most frequently performed surgeries for uterine bleeding caused by irregular growths and benign tumors are endometrial ablation and hysterectomy. Endometrial ablation, which uses heat, freezing or a laser to destroy the lining of the uterus, is an outpatient procedure with a shorter recovery time than a hysterectomy. A hysterectomy can be done abdominally or through several minimally-invasive techniques developed to avoid a large abdominal incision. The minimally-invasive hysterectomy is performed combining laparoscopic and vaginal approaches or with the laparoscope only.

Since no two patients are alike, it is important for a woman experiencing irregular uterine bleeding to seek the guidance of a physician familiar with her individual situation.

Dr. Holmstrom is an assistant professor in the Department of Obstetrics and Gynecology at USF Health.

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