Article updated and reviewed by Christina S. Chu, MD, Assistant Professor, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Pennsylvania on May 9, 2005.
Abnormal uterine bleeding is one of the most common gynecologic problems. Abnormal uterine bleeding may be heavier or longer than usual or occur at unexpected times. In about one quarter of cases, a specific cause can be found: some abnormal uterine bleeding is a result of illness that affects the whole body, such as thyroid disease, liver disease, or problems with blood clotting; other common causes of abnormal uterine bleeding include problems of the reproductive organs, such as pregnancy, cancer, fibroids, ovarian cysts, or the use of birth control devices or hormone replacement therapy. When a specific problem cannot be diagnosed, the term dysfunctional uterine bleeding (DUB), or anovulatory bleeding, is used.
Estrogen is a hormone that stimulates growth of the uterine lining. Usually, patients with DUB have menstrual cycles that are longer than usual, which allows the lining of the uterus to be exposed to estrogen for long periods of time. After ovulation has occurred, another hormone called progesterone is produced by the ovary. Progesterone causes changes that prepare the uterine lining for menstruation, so that the entire surface layer can fall off neatly, all within a few days. DUB occurs when there is an imbalance of hormones so that there is no regular monthly release of an egg. In this situation, without the action of progesterone, steady estrogen exposure allows the lining of the uterus to overgrow, with no orderly preparation for menstruation so that bleeding can begin from one area, followed a few days later by bleeding from another area.
Steady estrogen exposure results in growth of the lining, but some areas may be thicker than others, or out of synchrony, so that bleeding can begin from one area, followed a few days later by bleeding from another area.
In some cases, bleeding is light, although unpredictable and possibly prolonged. Moderate to heavy bleeding persistent enough to cause anemia is not uncommon. In some cases, hemorrhage can be severe enough to require hospitalization and even blood transfusion.
Women with irregular bleeding should keep a calendar to record when and how heavily they are bleeding. A physical examination by a physician is important to assess the bleeding, and to check for causes of abnormal uterine bleeding. Some patients (particularly those over the age of 35, anyone with a prolonged history of irregular bleeding, and those with severe bleeding) may need a biopsy of the uterine lining to check for abnormalities. A physician may also recommend pelvic ultrasound to examine the ovaries and the thickness of the endometrial lining, and other tests such as sonohysterography or hysteroscopy combined with D&C to further assess abnormalities within the uterine cavity.
Once other causes of abnormal uterine bleeding are excluded, treatment of DUB will depend upon the severity of bleeding, and the age of the patient. In teenagers and young women with light irregular bleeding, most will begin to have improvement in their symptoms within a few years, so only careful record keeping may be necessary. For other young women whose bleeding is heavier and more irregular, birth control pills may make bleeding more regular and provide birth control at the same time. Patients who can’t take birth control pills or who do not need birth control may be treated with a monthly dose of progesterone (such as medroxyprogesterone acetate) to bring on a regular period. Several months of therapy may be necessary to regulate cycles with this method. Women with anemia should also receive oral iron supplements.
In cases of acute, severe bleeding, the first goal is to make sure that the patient is stable. Blood transfusion may occasionally be necessary to treat critical anemia. To control the bleeding, hormonal therapy is almost always effective, though the patient must recognize that bleeding must eventually occur. In general, estrogen is given first, with progesterone added later to stabilize the lining of the uterus. Several regimens are effective. Some physicians may prescribe intravenous estrogen, and others may prescribe oral birth control pills every six hours for several days to control bleeding followed by a gradual taper to one pill a day until a period is allowed to occur by stopping the pill. When hormonal therapy is not able to control bleeding, endometrial biopsy or D&C should be performed to exclude other causes of bleeding.
For women over the age of 35, DUB is less common, and other causes such as fibroids, polyps, or endometrial hyperplasia (a precancerous condition of the lining of the uterus) should be investigated. Once the diagnosis of DUB is made, oral contraceptive pills are often very successful in managing symptoms.
Women with DUB who do not ovulate every month, who wish to become pregnant, may take fertility drugs to induce ovulation. This may control bleeding and aid in conception.
Several surgical methods are available to manage DUB. D&C may be successful to help manage acute bleeding that is not helped by medications, but the effect usually only lasts for the current bleeding episode. When D&C is necessary for severe bleeding, estrogen and progestins should be started immediately to help with control of future menstrual cycles. As mentioned previously, hysteroscopy (placing a small camera into the uterus to help see the uterine cavity) may be performed to help identify specific sources of bleeding.
Endometrial ablation is a method to destroy the lining of the uterus in order to stop or drastically decrease bleeding. This may be accomplished by putting a hot balloon placed in the endometrial cavity to burn the lining, or by a procedure to burn or cut out the endometrium with other instruments. About 50-75% of patients may stop having periods after endometrial ablation, at least initially, and 20-30% of patients note an acceptable decrease in the amount of bleeding. Unfortunately, 10% of patients see no improvement in their symptoms. Endometrial ablation should only be considered by women who don’t want to have more children, and who have had a biopsy to make sure that endometrial hyperplasia and cancer are not the causes of the bleeding.
Occasionally, women who have finished having children may also consider hysterectomy, especially if anemia is severe, symptoms are not helped by medication, or if patients can’t tolerate the side effects of hormonal medications. Though endometrial ablation may result in shorter hospital stays and fewer complications in the short term, patients undergoing hysterectomy appear to have significantly better improvement in their symptoms and satisfaction in the long term. Up to 40% of women undergoing endometrial ablation may require another operation within 4 years because of recurrence of unacceptable symptoms.
What is the cause of the abnormal bleeding?
Is this estrogen-related?
Is progestin needed also?
Do you recommend birth control pills?
What should I expect with my next menstrual period?
Will it be normal?
Editorial review provided by VeriMed Healthcare Network.