Diagnosing and evaluating abnormal uterine bleeding

Abnormal uterine bleeding is a common reason women see their doctors. Abnormal bleeding can occur at any age of life and has many causes; some are easily treated, while others are more serious. Women should consult with their health care providers if ever they have bleeding concerns.

The first step in diagnosing abnormal bleeding is to recognize normal and abnormal menstrual patterns for women in their reproductive years. Normal menstrual cycles usually start every 21 to 35 days; that is, a woman gets one period every three to five weeks. Bleeding that is more or less frequent than this is abnormal. In addition, bleeding between a woman’s regular cycles is not normal. Other important considerations include how much and how long a woman bleeds. Periods which cause women to bleed excessive amounts (technically, more than 80cc of blood per cycle) or that last more than seven days, are too heavy. Spotting-only or missing a cycle altogether is too little.

There are times in women’s lives when they may be more likely to have to abnormal uterine bleeding. In the years immediately after a woman starts menstruating and again in the years before she enters menopause (defined as 12 months without a period), women may have irregular cycles due to the changes in hormonal regulation in the body. In addition, as women age, their chance of having a medical condition, structural lesion or other cause of irregular bleeding may increase. Regardless of age, any woman whose regular cycle suddenly changes is best advised to ask a doctor about it. Women who have any amount of bleeding after menopause should seek an evaluation.

There are many causes of abnormal uterine bleeding, most of them benign. Pregnancy, changes in the hormonal cycle and structural abnormalities are common causes. Abnormal lesions or structures in and around the uterus (for example, endometrial polyps or uterine fibroids) can interfere with the body’s natural way of slowing or stopping a woman’s period, resulting in excessive bleeding. They can also cause women to bleed between periods and other disruptive symptoms.

Numerous medical problems which affect the body’s hormones or overall health also cause changes in menstrual bleeding. Specific conditions which result in abnormal clotting may predispose women to heavy periods and medications that thin the blood may have similar effects. Certain infections in the uterus and cervix can trigger bleeding. Rarely, abnormal bleeding may be a sign of cancer.

There are many causes for abnormal uterine bleeding – that’s why a thorough patient history by your health care provider is the first step in evaluating this problem. Your care provider will ask about the changes that are occurring, how long the changes have taken place and what other symptoms you may be experiencing. They may also ask about you medical and surgical history, family history, pregnancy history, sexual history and any possible use of drugs, including tobacco.

Your care provider will also perform a physical examination from head to (almost) toe. When conducting a pelvic exam, the doctor is checking for evidence of pregnancy, infection or any structural causes of uterine bleeding. A pap smear is included if you have not recently had one. A biopsy of the lining of the uterus can also be done to rule out infection or cancer and may be recommended depending on your risk for these problems.

Further evaluation also includes blood tests. Checking for anemia, infection, vitamin deficiencies and other hormone imbalances can help in the diagnosis as well as management of abnormal bleeding.

Pelvic ultrasound is commonly ordered to check the uterus, cervix, tubes and ovaries for structural lesions that might be too small to be detected by examination alone. Ultrasound is performed both abdominally and through the vagina. While some women find this test uncomfortable, it is the best, easiest and least-invasive way to evaluate the reproductive tract with “pictures.”

Evaluation of the inside of the uterus may also include hysteroscopy. Hysteroscopy is a procedure which involves looking into the uterus with a camera. There are no cuts made for this procedure and it can often be performed in the office. By directly looking at the lining of the uterus and cervix, a physician can identify a polyp or a fibroid or other abnormal lesion. In some cases, it may even be possible to remove such a lesion in the office. While hysteroscopy can cause some cramping, it is generally well tolerated.

Overall, abnormal uterine bleeding in women of reproductive age is usually benign, but it often can and should be treated. For these reasons, women are encouraged to seek care if they are having bleeding concerns. Any woman who has bleeding in menopause should see her doctor for an evaluation.

Gretchen Makai, M.D., is Christiana Care’s director of minimally invasive gynecologic surgery and a physician at the Christiana Care Center for Women’s Health.