Abnormal Uterine Bleeding

One woman in five suffers from abnormal uterine bleeding. This problem usually occurs during adolescence and around menopause.

What is abnormal uterine bleeding?

A normal menstrual cycle – the interval between the first day of your period and the first day of the next period – is 21 to 40 days. Periods normally last 2 to 7 days. Normal blood loss is 20 to 60 mL, which is far from easy to calculate!

It is therefore considered that abnormal uterine bleeding is present:

  • If the cycle is shorter than 21 days or longer than 40 days
  • If there is bleeding between periods
  • If the period lasts more than 7 days
  • If the amount of total blood loss is more than 80 mL (roughly, more than 6 saturated sanitary pads or tampons per day)

 

What is the cause?

The first thing to consider is the possibility of pregnancy and complications.

If this is not the case, your doctor will run through a short list to rule out:

  • External causes (certain types of hormone/non-hormone medication, certain natural products or IUDs). Contraceptives and hormone therapy can sometimes cause excessive thinning of the endometrium (the inner layer of the uterus) and streaking.
  • Systemic disease (thyroid disease; coagulation, liver or kidney problems, etc.)
  • Gynecological causes (ovulation, STDs, fibroma, polyps, endometriosis, atrophy, cancer)

 

If all the findings are negative, dysfunctional uterine bleeding would be diagnosed. This is a very common condition, especially during adolescence and around menopause. It simply means that all your organs are healthy, but are not functioning in an optimal manner (ovarian dysfunction).

Your doctor will fill out an in-depth questionnaire and perform a detailed examination to determine if the bleeding is anovulatory (no ovulation, therefore irregular cycles) or ovulatory (regular cycles).

The investigation will include blood tests to rule out pregnancy, determine whether you have anemia or lack iron, and evaluate whether your thyroid is normal. Depending on the results, your doctor may consider further tests are needed: cervical cytology (Pap test) and STD screening (chlamydia and gonorrhea), transvesical/endovaginal pelvic ultrasound, and a biopsy of the endometrium (with or without hysteroscopy).

Some women have a higher risk of endometrial cancer:

  • Over age 40
  • Weight of 90 kg or more
  • Infertility – absence of pregnancy
  • Taking estrogen without progesterone
  • Taking tamoxifen
  • Polycystic ovary syndrome
  • Family history of colon or endometrial cancer
  • Diabetes
  • Hypertension (high blood pressure)

 

Biopsy of the endometrium, with or without hysteroscopy (examination of the interior of the uterus using a fibre optics device about 3 mm in diameter inserted through the cervix), will be appropriate for:

  • Any abnormal bleeding in a woman over 40 years of age or at risk of endometrial cancer
  • Any unexpected bleeding during menopause while on hormone therapy (although it is normal to have irregular bleeding during the first 6 months of continuous hormone therapy or if there is a change in hormone therapy. This should be discussed with your doctor)
  • Any endovaginal pelvic ultrasound showing an endometrium thicker than 4 mm during menopause.

 

What is the treatment?

1. A non-gynecological problem will be treated by your doctor or the appropriate specialist.

2. Gynecological conditions will be treated according to their cause:

  • Cervical or uterine polyps are small growths that can be easily removed with or without anesthesia, depending on their location
  • Uterine fibroma can be treated medically (often in the same way as dysfunction bleeding – see below) or surgically
  • Atrophy (thinning of the mucous membrane) is treated by local or systemic hormone therapy. Vaginal atrophy can be treated by Replens (an over-the-counter lubricant)
  • Infections are treated with antibiotics
  • Cancers are treated surgically, with or without radiation therapy or chemotherapy

 

3. The treatment of dysfunctional uterine bleeding differs depending on whether it is ovulatory or not.

  • An iron supplement might be indicated
  • Treatment is often hormonal: oral contraceptives, the Mirena® IUD (which significantly decreases pain, reduces menstrual blood flow by 95% and can even thin the endometrium sufficiently so that menstruation no longer occurs), progesterone tablets are non-estrogen contraceptives, like Micronor®; some can occasionally be injected (e.g. Depoprovera®)

 

Other treatments that are sometimes employed are Ponstan®, Anaprox®, or anti-inflammatories (Advil is recommended not only for pain relief but also to reduce menstrual flow)

Your doctor can also prescribe more specific medication for heavy-flow days (DanazolÒ, Cyklokapron®, Synarel®, Zoladex®) or LHRH analogues (Lupron®, Cyclomen®) that block the pituitary gland, cause artificial menopause and reduce fibroma (used mainly prior to a hysterectomy).

If there is no response to medical treatment and/or in agreement with your doctor, surgical procedures like endometrial ablation (destruction by natural routes of the lining of the uterus – day surgery) or a hysterectomy (ablation of the uterus) can be considered.

Danièle Rousseau

Gynecologist

CH Fleury et Opmedic Laval



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