Abnormal Uterine Bleeding: Know the Facts

What is a normal menstrual cycle?

The menstrual cycle begins with the first day of bleeding of one period and ends with the first day of the next period. In most women, this cycle lasts about 28 days. Cycles that are shorter or longer by up to 7 days are normal.

What is abnormal uterine bleeding?

Bleeding in any of the following situations:

• Bleeding between periods
• Bleeding after sex
• Bleeding heavier or for more days than normal
• Any bleeding after menopause

Menstrual cycles that are longer than 35 days, or shorter than 21 days, are abnormal. The lack of periods for 3-6 months (amenorrhea) is also abnormal.

When is this common?

Abnormal uterine bleeding can occur at any age; however, at certain times in a woman’s life it is common for periods to be somewhat irregular. They may not occur on schedule in the first few years (around ages 9-16). Cycle length may change as a woman nears menopause (around age 50). It also is normal to skip periods or for bleeding to get lighter or heavier at this time.

What causes abnormal uterine bleeding?

• Pregnancy
• Miscarriage
• Ectopic pregnancy (fertilized egg begins to grow in a place other than inside the uterus, usually in the fallopian tubes)
• Adenomyosis (tissue that normally lines the uterus begins to grow in the muscle wall of the uterus)
• Endometriosis (uterine lining growth outside of the uterus)
• Certain birth control methods such as an IUD or the pill
• Infection of the uterus or cervix
• Fibroids (noncancerous growths that form on the inside, outer surface, or the wall of the uterus)
• Coagulopathy (problems with blood clotting)
• Polyps (growths that develop from membrane tissue)
• Endometrial hyperplasia (the lining of the uterus grows too much and can become precancerous)
• Cancer such as uterine, cervical or vaginal
• Polycystic ovary syndrome
• Abnormal weight (both very low and very high BMI)

How is it diagnosed?

Your health care provider will ask about your personal and family health history as well as 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.

You will have a physical exam. You may also have an ultrasound and blood test done. These tests will count the hormone levels and rule out some diseases of the blood. A pregnancy test may also be done.

How is it tested?

The type of tests completed will be based on your symptoms.

• Ultrasound
• Sonohysterography—fluid is placed in the uterus through a thin tube, while ultrasound images are made of the uterus. We recommend ibuprofen be taken before this exam.
• Hysteroscopy—device inserted into the vagina to view the inside of the uterus. This can be completed in our office or operating room.
• Endometrial biopsy—tissue is taken from the lining of the uterus.
• Dilation & curettage (D&C)—the cervix is dilated and instruments are inserted and used to remove endometrial or uterine tissue. It can sometimes be used as a treatment for prolonged or excessive bleeding that is due to hormonal changes and that is unresponsive to other treatments. This may be done in the office or in the OR with anesthesia. Most women may return to normal activities with a day or two.

Factors to consider

Most women can be treated with medications; others may need surgery. The type of treatment depends on certain factors:

• The cause of the bleeding
• Your age
• Whether you want to have children

Treatment Options

Birth Control Pills

• Often used to treat uterine bleeding that is due to hormonal changes or hormonal irregularities. May be used in women who do not ovulate regularly to establish regular bleeding cycles and prevent excessive growth of the endometrium. In women who do ovulate, they may be used to treat excessive menstrual bleeding. Non-steroidal anti-inflammatory drugs (NSAIDs, i.e. ibuprofen, naproxen) may also be helpful in reducing blood loss and cramping in these women.
• During the menopausal transition, birth control pills or other hormonal therapy may be used to regulate the menstrual cycle and prevent excessive growth of the endometrium. 

Progesterone

• A hormone made by the ovary that is effective in preventing or treating excessive bleeding in women who do not ovulate regularly. A synthetic form of progesterone, called progestin, may be recommended to treat abnormal bleeding. Progestins are usually given as pills and are taken once a day for 10 to 12 days each month or two, or taken continuously (every day). In women taking monthly cyclical progestin therapy, vaginal bleeding may begin before the 7th day of progestin treatment if the uterine lining is overgrown; otherwise, it may not be seen until several days after the last progestin tablet is taken. In some cases, the progestin is given on a regular basis to prevent excessive growth of the uterine lining and heavy menstrual bleeding. If no bleeding is seen after progestin treatment, the possibility of pregnancy or other hormonal imbalances should be explored.
• Progestins may also be given in other ways, such as an injection, implant, or an intrauterine device.

Intrauterine Device

• An intrauterine contraceptive device (IUD) that secretes progestin (ex. Mirena, Liletta, or Skyla) may be recommended for women who have abnormal uterine bleeding. IUDs are T-shaped devices inserted by a healthcare provider through the vagina and cervix into the uterus. IUDs include an attached plastic string that projects through the cervix, enabling the woman to check that the device remains in place.
• Progestin-releasing IUDs decrease menstrual blood loss by more than 50% and decrease pain associated with periods. Some women completely stop having menstrual bleeding as a result of the IUD, which is reversible when the IUD is removed.

Surgery

• Surgery, such as hysteroscopy, may be necessary to remove abnormal uterine structures (ex. fibroids, polyps). Women who have completed childbearing and have heavy menstrual bleeding can consider a surgical procedure such as endometrial ablation. This procedure may be performed in a gynecologist’s office or in an operating room as a same-day surgery, and uses heat, cold, electrical energy, or a laser to destroy the lining of the uterus.
• Hysterectomy may be done when other forms of treatment have failed or they are not an option. Hysterectomy is a major surgery that removes the uterus, that typically requires 3-6 weeks for recovery. Afterwards, a woman no longer has periods and cannot get pregnant.