Abnormal Bleeding

What is normal vaginal bleeding?

Normal vaginal bleeding is the periodic blood that flows as a discharge from the woman's uterus. Normal vaginal bleeding is also called menorrhea. The process by which menorrhea occurs is called menstruation.

Normal vaginal bleeding occurs as a result of cyclic hormonal changes. The ovaries are the main source of female hormones, which control the development of female body characteristics such as the breasts, body shape, and body hair. The hormones also regulate the menstrual cycle. The ovary, or female gonad, is one of a pair of reproductive glands in women. They are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries produce eggs (ova) and female hormones. During each monthly menstrual cycle, an egg is released from one ovary. The egg travels from the ovary through a Fallopian tube to the uterus.

Unless pregnancy occurs, the cycle ends with the shedding of part of the inner lining of uterus, which results in menstruation. Although it is actually the end of the physical cycle, the first day of menstrual bleeding is designated as "day 1" of the menstrual cycle in medical jargon.

The time of the cycle during which menstruation occurs is referred to as menses. The menses occurs at approximately four week intervals, representing the menstrual cycle.

Menarche is the time in a girl's life when menstruation first begins. Menopause is the time in a woman's life when the function of the ovaries ceases. The average age of menopause is 51 years old.

What is abnormal vaginal bleeding?

Abnormal vaginal bleeding is a flow of blood from the vagina that occurs either at the wrong time during the month or in inappropriate amounts. In order to determine whether bleeding is abnormal, and its cause, the doctor must consider three questions: Is the woman pregnant, what is the pattern of the bleeding, is the woman ovulating?

Every woman who thinks she has an irregular menstrual bleeding pattern should think carefully about the specific characteristics of her vaginal bleeding in order to help her doctor evaluate her particular situation. Her doctor will require the details of her menstrual history.

The amount (volume) of bleeding can also be abnormal. A woman can either have too much bleeding (menorrhagia) or too little volume (hypomenorrhea). The combination of excessive bleeding combined with bleeding outside of the expected time of menstruation is referred to as menometrorrhagia.

Abnormal vaginal bleeding in women who are ovulating regularly, most commonly involve excessive, frequent, irregular, or decreased bleeding. Some of the common conditions that produce each of these symptoms are discussed below.

Excessively heavy menstrual bleeding (menorrhagia)

Excessively heavy menstrual bleeding, called menorrhagia, is menstrual bleeding of greater than 5 tablespoons per month. This condition occurs in about 10% of women. The most common pattern of menorrhagia is excessive bleeding that occurs in regular menstrual cycles and with normal ovulation.

There are several important reasons that menorrhagia should be evaluated by a doctor. First, menorrhagia can cause a woman substantial emotional distress and physical symptoms, such as severe cramping . Second, the blood loss can be so severe that it causes a dangerously lowered blood count (anemia), which can lead to medical complications and symptoms such as dizziness and fainting. Third, there can be dangerous causes of menorrhagia that require more urgent treatment.

Though not common, menorrhagia can be a sign of endometrial cancer. A potentially precancerous condition known as endometrial hyperplasia can also result in abnormal vaginal bleeding. This situation is more frequent in women who are over the age of 40.

Although there are many causes of menorrhagia, in most women, the specific cause of menorrhagia is not found even after a full medical evaluation. These women are said to have dysfunctional uterine bleeding. Although no specific cause of the abnormal vaginal bleeding is found in women with dysfunctional uterine bleeding, there are treatments available to reduce the severity of the condition.

How is irregular vaginal bleeding treated?

Treatment for irregular vaginal bleeding depends on the underlying cause. After the cause is determined, the doctor decides if treatment is actually necessary. Sometimes, all that is needed is for dangerous causes to be ruled out and to determine that the irregular vaginal bleeding does not bother the woman enough to warrant medication or treatment. If thyroid, liver, kidney, or blood clotting problems are discovered, treatment is directed toward these conditions.

Medications for treatment of irregular vaginal bleeding depend on the cause. Examples are described below:

• If the cause of the bleeding is lack of ovulation (anovulation), doctors may prescribe either progesterone to be taken at regular intervals, or an oral contraceptive, which contains progesterone, to achieve a proper hormonal balance. Such treatment dramatically decreases the risk of uterine cancer in women who do not ovulate.
• If the cause of irregular aginal bleeding is a precancerous change in the lining of the uterus, progesterone medications may be prescribed to reduce the buildup of precancerous uterine lining tissues in an attempt to avoid surgery.
• When a woman has been without menses for less than six months and is bleeding irregularly, the cause may be menopausal transition. During this transition, a woman is sometimes offered an oral contraceptive to establish a more regular bleeding pattern, to provide contraception until she completes menopause, and to relieve hot flashes. A woman who is found to be menopausal as the cause of her irregular bleeding may also receive menopause counseling if she has troubling symptoms.
• If the cause of irregular vaginal bleeding is polyps or other benign growths, these are sometimes removed surgically to control bleeding because they cannot be treated with medication.
• If the cause of bleeding is infection, antibiotics are necessary. Bleeding during pregnancy requires urgent evaluation by an obstetrician. Endometriosis can be treated with medications and/or surgery (such as laparoscopy).
• Sometimes, the cause of excessive bleeding is not apparent after completion of testing (dysfunctional uterine bleeding). In these cases, oral contraceptives can improve cycle control and lessen bleeding.
• If bleeding is excessive and cannot be controlled by medication, a surgical procedure called dilation and curettage (D&C) may be necessary. In addition to alleviating the excessive bleeding, the D&C provides additional information that can rule out abnormalities of the lining of the uterus.
• Occasionally, a hysterectomy is necessary when hormonal medications cannot control excessive bleeding. However, unless the cause is pre-cancerous or cancerous, this surgery should only be an option after other solutions have been tried.

Many new procedures are being developed to treat certain types of irregular vaginal bleeding. A hysteroscopy may be needed to look into the uterus or a procedure called a Endometrial Ablation or a Novasure Ablation (attach link here) may need to be done. Please ask your provider what treatment plan works best for you.