Abnormal Uterine Bleeding

What is Abnormal Uterine Bleeding?

 Abnormal uterine bleeding is when you bleed outside of your regular menstrual cycle or have unusually heavy periods. This can happen at any age and is a common reason people with a uterus visit their doctors.  It may be a sign of an underlying health problem that needs medical treatment.

What’s Considered Normal and Abnormal?

• On average menstrual bleeding lasts up to 7 days, with cycles every 21 to 35 days.
• Abnormal bleeding may include:
  • Bleeding or spotting between periods or after sex.
  • Heavy bleeding during periods, such as soaking through pads or tampons every hour for several hours in a row.
  • Menstrual cycles shorter than 21 days or longer than 35 days.
  • Missing periods for 3 to 6 months (not due to pregnancy).
  • Bleeding after menopause (menopause is considered to have occurred if you have stopped bleeding for more than 1 year).

Types of Abnormal Bleeding

• Chronic Abnormal Bleeding: Regularly occurring symptoms for at least six months.
• Acute Abnormal Bleeding: Sudden and severe symptoms, such as needing to change pads or tampons every hour for several hours. If accompanied by symptoms like chest pain or dizziness, it requires immediate medical attention.

Common Causes

• Hormonal Issues: Irregularities often occur when hormonal balance is off, such as during the onset of puberty and perimenopause. Issues like polycystic ovary syndrome (PCOS) and hypothyroidism can also disrupt normal cycles and cause heavy or irregular bleeding.  Another common cause is irregular ovulation (meaning you do not have a monthly hormonal surge leading to egg release).
• Structural Issues in the Uterus:
  • Fibroids – benign muscle growths in the uterus
  • Polyps – benign growths on the cervical or uterine wall.
  • Adenomyosis – a condition that occurs when the inner lining of the uterus invades the muscle wall of the uterus
• Bleeding Disorders:  when your body cannot clot properly such as von Willebrand Disease
• Medications and Devices: Blood thinners, aspirin, and certain birth controls like the copper intrauterine device (IUD) can increase menstrual bleeding.
• Cancer: Endometrial cancer is a serious but rare cause of abnormal bleeding, especially in postmenopausal women. Endometrial intraepithelial neoplasia (EIN), a precursor to cancer, also causes abnormal bleeding.
• Other causes: Endometriosis, Ectopic Pregnancy, Miscarriage, and Pelvic Inflammatory Disorder.

Diagnosing Abnormal Uterine Bleeding

The process of diagnosing abnormal uterine bleeding typically involves:

• Medical and Family History: Gathering detailed information about your health history, menstrual cycles, and any symptoms you’re experiencing. Your doctor will also ask about any medications you take and your family’s medical history to check for hereditary conditions.
• Physical and Pelvic Exams: These exams help check for any physical signs of disorders that might cause bleeding, such as fibroids or other abnormalities.
• Blood Tests: To check for anemia, thyroid problems, blood clotting issues, and hormonal imbalances.
• Ultrasound: This imaging test uses sound waves to create pictures of the uterus, ovaries, and pelvis to identify abnormalities like fibroids and polyps.
• Additional Diagnostic Tests: Depending on your symptoms and medical history, your doctor might recommend a hysteroscopy to look inside the uterus, an endometrial biopsy to sample the lining of the uterus, or other specialized imaging tests like a sonohysterography, a MRI or CT scan.

Treatment

Treatment depends on the cause of the bleeding, your age, and whether you wish to carry a pregnancy in the future. Options include:

• Medications:
  • Hormonal birth control methods: These help regulate menstrual cycles and reduce menstrual flow. They can be pills, patches, rings, or IUDs.
  • Gonadotropin-releasing hormone (GnRH) agonists: Reduce the size of fibroids and temporarily stop menstrual periods.
  • Tranexamic acid: Reduces heavy menstrual bleeding.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs): Reduce menstrual pain and decrease blood flow.
• Surgical Procedures:
  • Endometrial Ablation: Destroys the lining of the uterus to reduce or stop menstrual flow.
  • Myomectomy: Removes fibroids while preserving the uterus, suitable for women who wish to have children.
  • Hysterectomy: Complete removal of the uterus, after which a woman cannot get pregnant and menstrual periods stop.
  • Uterine Artery Embolization (UAE): Blocks blood supply to fibroids, causing them to shrink and die.

Managing Abnormal Bleeding

Managing symptoms often starts with medications. In cases where treatment doesn’t resolve the issue, surgical options may be explored. Regular follow-ups with your healthcare provider are important to manage this condition effectively.

Uterine Fibroids

Uterine fibroids, also known as leiomyomas, are non-cancerous growths in the uterus. They are very common and can vary in size from very small to large masses that can distort and enlarge the uterus. Fibroids can be located inside the uterus, on its surface, or within its walls.  80% of people with a uterus will have a fibroid in their lifetime. Not all cause problems and it depends on the size and location whether it will lead to health problems.

Types of Fibroids

Fibroids, also known as leiomyomas or myomas, develop from the muscle tissue of the uterus. They can be:

• Submucosal: inside the lining of the uterus
• Intramural: within the walls of the uterus
• Subserosal: on the outer wall of the uterus
• Pedunculated: attached to a stem on the outer or inner surface of the uterus

Common Causes

While the exact cause of fibroids is unknown, factors include:

• Hormones: Estrogen and progesterone promote growth.
• Genetic changes: Many fibroids contain changes in genes that differ from normal uterine muscle cells.
• Family history: Having a family member with fibroids increases your risk.
• Ethnic origin: Fibroids are more common in Black women.

Symptoms

Many women with fibroids experience no symptoms. However, symptoms can include:

• Heavy, prolonged menstrual periods and bleeding between periods.
• Pelvic pain and pressure, such as lower back pain and frequent urination.

Complications

Although most fibroids do not cause problems, they can lead to:

• Pain and nausea when fibroids are attached to the uterus by a stem and may twist.
• Rapid growth or degeneration of fibroids causing severe pain.
• Rarely, fibroids may be associated with cancer.

Fibroids and Pregnancy

While fibroids can present challenges during pregnancy, many women with fibroids experience healthy pregnancies. The specific issues that may arise include:

• Miscarriage: The pregnancy ends before 20 weeks.
• Preterm birth: Delivery before 37 weeks of pregnancy.
• Breech birth: The baby is positioned feet-first during birth which can complicate delivery. 

However, a significant number of pregnant women with fibroids do not encounter these issues and successfully deliver healthy babies. During pregnancy, fibroids may grow due to increased hormone levels, leading to discomfort or feelings of pressure, yet most of these changes are manageable.

Diagnosing Fibroids

Fibroids are often found during a pelvic exam. Diagnostic tests include:

• Ultrasound: Uses sound waves to create a picture of the uterus.
• MRI: Provides detailed images of the uterus.
• Hysteroscopy: A small camera examines the inside of the uterus.
• Other imaging tests like CT scans or X-rays can also be used but are less common.

Treatment Options

Treatment depends on the size, location, and symptoms of the fibroids:

• Medications: Help manage symptoms but do not eliminate fibroids.
  • Birth control pills: Regulate menstruation and reduce heavy bleeding.
  • GnRH agonists: Temporarily shrink fibroids and stop menstruation, used mainly before surgery.
  • Tranexamic acid: Reduces the amount of blood lost during menstruation without stopping periods.
• Surgical Options: Include myomectomy (removal of fibroids while preserving the uterus) and hysterectomy (removal of the uterus).
• Minimally Invasive Procedures: Such as uterine artery embolization (UAE), which cuts off blood supply to fibroids, causing them to shrink.

Managing Fibroids

If fibroids cause mild symptoms, treatment may not be necessary. Lifestyle changes and medication can help manage symptoms. It’s important for women with fibroids, especially those who experience symptoms, to have regular check-ups to monitor their condition.

Adenomyosis

Adenomyosis (ad-uh-no-my-O-sis) occurs when the endometrial tissue (inner lining of the uterus) grows or invades into the muscle wall of the uterus. Similar to the inner lining of the uterus this tissue builds up, breaks down and bleeds with our hormonal cycles. This can lead to a larger uterus, painful and heavy periods. It is also linked to infertility.

Causes

It is unknown why this disease process occurs. There are theories as to why this happens:

• Invasive tissue growth directly: such as with cesarean scars or other uterine procedures that interrupt the inner lining from the muscle wall, causing a path for direct growth
• Genetic: there can be a family history of adenomyosis
• Developmental: endometrial tissue placed into the muscle wall while the uterus is being formed in a developing fetus
• Uterine inflammation related to childbirth: Postpartum there may be inflammation that breaks down the boundary between the inner lining and muscle wall of the uterus leading to invasion of growth
• Stem cell origins: bone marrow stem cells might invade the uterine muscle

Its growth depends on estrogen circulating in the body, for many people this condition improves with menopause due to the estrogen levels lowering.

Risk Factors

• Prior uterine surgeries: cesarean sections, fibroid removals, dilation and curettage (D&C) procedures
• Childbirth
• Age – 40-50 years is the most common age to find this condition, it can be found at any age after menses

Symptoms

People with adenomyosis can have a range of symptoms: some experience no symptoms, some have mild discomfort and others have debilitating severe pain and bleeding.

Symptoms include: 

• Heavy or prolonged menstrual bleeding
• Severe cramping or sharp pains during menses (also known as dysmenorrhea)
• Chronic Pelvic Pain
• Painful intercourse (also known as dyspareunia)
• Uterine enlargement causing tenderness or pressure in your pelvic or abdomen region

Complications

If you have heavy or prolonged menstrual bleeding that occurs with your periods you can develop chronic anemia. Anemia is low blood count in your body causing shortness of breath, fatigue and other medical complications.

Pain from adenomyosis for some can be severe enough to disrupt their lifestyle, functioning on those days where it is active.

Infertility and pregnancy losses can occur from adenomyosis

In pregnancy adenomyosis has been linked to higher risk of preterm delivery, preterm labor, and other complications. This does not mean these complications will occur, we monitor for these complications during the pregnancy with your prenatal care. 

Diagnosing Adenomyosis

If symptoms suggest adenomyosis, an obstetrician-gynecologist (OB-GYN) may conduct a pelvic exam and rule out other conditions such as fibroid tumors (leiomyomas), uterine-like cells growing outside the uterus, and growths in the uterine lining (endometrial polyps).

Your provider will obtain a medical, surgical and family history to see if you have risk factors for this disease. Ultrasound imaging or MRI (magnetic resonance imaging) of the uterus may be obtained.

The only way to confirm adenomyosis is surgery, by examining the uterus after it has been removed by a procedure called a hysterectomy.

Treatment Options for Adenomyosis

Treatment depends on symptom severity, disease extent, and whether the patient wants to have pregnancy potential.

Treatment options include:

• Medications:
  • Pain relievers (NSAIDs like ibuprofen) to ease pain.
  • Hormonal medications like birth control pills, progestins, or gonadotropin-releasing hormone (GnRH) agonists and antagonists, which reduce estrogen and may slow tissue growth. These medications don’t eliminate existing adenomyosis but can reduce pain and prolong time until a surgery
• Surgery:
  • If a small amount of disease called an adenomyoma this can be removed from the uterus and the uterus repaired where this was removed
  • More commonly the disease is not focal or small and needs a hysterectomy – removal of the uterus. You do not need your ovaries removed with your uterus and so you will not go through menopause. (ovaries produce your hormones) This does mean you will not be able to carry a pregnancy after a hysterectomy.