Abnormal Uterine Bleeding

Abnormal uterine bleeding can be a chronic condition, which means that it has happened often for at least the past 6 months.

Sudden, unusual episodes of abnormal  bleeding also can occur. This is called acute abnormal uterine bleeding. If you
are changing pads or tampons every hour for more than 2 hours in a row, and you also have chest pain, have shortness of breath, and are lightheaded or dizzy, seek  emergency medical care right away.

Abnormal bleeding can occur at any age. But at certain times in a woman’s life it

is common for periods to be somewhat irregular:

• Periods may not occur regularly when a girl first starts having them (around age 9 to 14).
• During perimenopause (around age 50), the number of days between periods may change. It is common to skip periods or for bleeding to get lighter or heavier at this time.

Although these changes may be expected, you should talk with

your obstetrician–gynecologist (ob-gyn) about any abnormal uterine bleeding.

Some of the causes of abnormal bleeding include the following:

• Problems with ovulation—Lack of ovulation can cause irregular, sometimes heavy, menstrual bleeding. If you do not ovulate for several menstrual cycles, areas of the endometrium (the tissue that lines the uterus) can become too thick. This condition can occur during the first few years after you start having periods and during perimenopause. It also can occur in women with certain medical conditions, such as polycystic ovary syndrome PCOS) and hypothyroidism.
• Fibroids and polyps—Fibroids are noncancerous growths that form from the muscle tissue of the uterus. Polyps are another type of noncancerous growth. They can be found inside the uterus or on the cervix. Both can cause irregular or heavy menstrual bleeding.
• Adenomyosis—In this condition, the endometrium grows into the wall of the uterus. Signs and symptoms may include heavy menstrual bleeding and menstrual pain that worsens with age.
• Bleeding disorders—When a woman’s blood does not clot properly, there can be heavy bleeding. You may have a bleeding disorder if you have had heavy periods since you first started menstruating. Other signs include heavy bleeding after childbirth or during surgery, gum bleeding after dental work, easy bruising, and frequent nosebleeds. 
• Medications—Hormonal birth control methods can cause changes in bleeding, including breakthrough bleeding (bleeding at a time other than your period). Some medications, such as blood thinners and aspirin, can cause heavy menstrual bleeding. The copper intrauterine device (IUD) can cause heavier menstrual bleeding, especially during the first year of use.
• Cancer—Abnormal uterine bleeding can be an early sign of endometrial cancer. Most cases of endometrial cancer occur in women in their mid-60s who are past menopause. It usually is diagnosed at an early stage when treatment is most effective. A condition that can lead to endometrial cancer is called endometrial intraepithelial neoplasia (EIN). It also causes abnormal uterine bleeding. Treatment of this condition can prevent endometrial cancer.
• Other causes— Endometriosis and other problems related to the endometrium can cause heavy menstrual bleeding. Other causes of abnormal uterine bleeding include those related to pregnancy, such as ectopic pregnancy and miscarriage.  Pelvic inflammatory disease (PID) also can be a cause. Sometimes, there is more than one cause.

Your ob-gyn should ask about your personal and family health history, such as past and present illnesses and surgical
procedures, pregnancy history, medications, including those you buy over the counter, and your birth control method. 

Information about when bleeding occurs and the amount of bleeding also is helpful. If possible, keep track for several weeks 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.

If you have an acute episode of heavy bleeding, you should be treated right away to control it. If you have lost a great deal of blood, you may need to be given fluids or a blood transfusion. 

You should have a physical exam, including a pelvic exam. Lab tests may be done. A blood test called a complete blood count (CBC) can help determine if you have anemia or an infection. You may have tests for certain bleeding disorders. You may have a pregnancy test and tests for sexually transmitted infections (STIs).

Based on your symptoms and your age, other tests may be needed:

• Ultrasound exam—Sound waves are used to make a picture of the pelvic organs. 
• Hysteroscopy—A thin, lighted scope is inserted through the vagina and the opening of the cervix. It allows your ob-gyn to see the inside of the uterus. 
• Endometrial biopsy—A sample of the endometrium is removed and looked at under a microscope. 
• Sonohysterography—Fluid is placed in the uterus through a thin tube while ultrasound images are made of the uterus. 
• Magnetic resonance imaging (MRI)—This imaging test uses powerful magnets to create images of the internal organs. 
• Computed tomography (CT)—This X-ray procedure shows internal organs and structures in cross section.

Medications often are tried first to treat irregular or heavy menstrual bleeding. Some of them also prevent pregnancy. This can be useful if you need a birth control method. The medications that may be used include the following: 

• Hormonal birth control methods—Irregular bleeding and heavy bleeding caused by problems with ovulation, PCOS, and fibroids often can be managed with certain hormonal birth control methods.

1. Combined hormonal birth control pills, the skin patch, and the vaginal ring contain both estrogen and progestin. They can lighten menstrual flow and help make periods more regular. Taken continuously, they can reduce the number of periods you have or stop them completely. 
2. Progestin-only hormonal methods, including the hormonal IUD, pills, and injection, also may reduce bleeding. The IUD and injection may stop bleeding completely after 1 year of use.

• Hormone therapy can be helpful for heavy menstrual bleeding that occurs during perimenopause and can treat other perimenopausal symptoms, such as hot flashes, night sweats, and vaginal dryness. Perimenopausal women also can take the hormonal birth control methods discussed above. You still may have periods while taking hormone therapy, but they usually are lighter and more predictable. Hormone therapy has risks, including an increased risk of heart attack, stroke, and cancer. Before deciding to use hormone therapy, it is important to weigh the benefits and risks based on your symptoms and your personal and family medical history.

• Gonadotropin-releasing hormone (GnRH) agonists—These drugs can stop the menstrual cycle and reduce the size of fibroids. They are used only for short periods (less than 6 months). Their effect on fibroids is temporary. Once you stop taking the drug, fibroids usually return to their original size. 
• Tranexamic acid—This prescription medication treats heavy menstrual bleeding. It comes in a tablet and is taken each month at the start of the menstrual period. 
• Nonsteroidal anti-inflammatory drugs (NSAIDs)—These drugs, which include ibuprofen, also may help control heavy bleeding and relieve menstrual cramps.
• If you have a bleeding disorder, your treatment may include medications to help your blood clot.
• If you have an infection, you may be given an antibiotic.

If medication does not reduce your bleeding, a surgical procedure may be needed. There are different types of surgery depending on your condition, your age, and whether you want to get pregnant in the future.

• Endometrial ablation destroys the lining of the uterus. It stops or reduces the total amount of bleeding. Pregnancy is not likely after ablation, but it can happen. If it does, the risk of serious complications, including life-threatening bleeding, is greatly increased. If you have this procedure, you will need to use birth control until after menopause. Sterilization (permanent birth control) may be a good option to prevent pregnancy for women who get ablation. Another risk is that it may be harder to detect endometrial cancer after ablation.

Fibroid treatments that do not remove the uterus:

1. Uterine artery embolization: The blood vessels to the uterus are blocked, stopping the blood flow that allows fibroids to grow. 
2. MRI-guided ultrasound surgery: Ultrasound waves are used to destroy fibroids. 
3. Myomectomy: This surgery removes just the fibroids, not the uterus. A drawback is that fibroids may regrow after this surgery. This procedure can be used to remove fibroids or stop bleeding caused by fibroids in some cases.
4. Hysterectomy is the removal of the uterus. This surgery is used to treat fibroids and adenomyosis when other types of treatment have failed or are not an option. It also is used to treat endometrial cancer. A hysterectomy can be done in different ways: through the vagina, through the abdomen, or with laparoscopy. After the uterus is removed, a woman can no longer get pregnant and will no longer have periods.