What are some different forms of abnormal bleeding?
STEVE COHEN, MD: In order to define abnormal uterine bleeding, we need to define what normal uterine bleeding is. Normal uterine bleeding is a menstrual cycle that occurs for approximately three to five days every three to five weeks and has a reasonable amount of flow-maybe three tablespoons. So, abnormal bleeding then becomes anything that differs from that.
LINDA BRADLEY, MD: Most women with normal menstrual cycles are able to work and not miss activities because of bleeding. Most women will change a tampon or a pad maybe four or five times a day. Some may change it more often for hygienic reasons, but not because they're saturating through. So anything beyond that could be characterized as abnormal bleeding.
KEITH ISAACSON, MD: I would also add that women who are menopausal and have not had their periods for over a year, but are experiencing uterine bleeding, should be evaluated. In that patient population, you need to rule out serious diseases such as cancer.
What are some of the causes of abnormal uterine bleeding?
GRACE JANIK, MD: Hormonal abnormalities represent one category of causes. Polycystic ovarian disease is a syndrome that causes women to ovulate on an irregular basis, and women with this disease may produce too much male hormone, resulting in excessive hair growth and some obesity.
Polyps-tissue buildups in the endometrial lining-are another cause of abnormal bleeding. Fibroids can also cause abnormal bleeding; they are smooth muscle tumors that extrude into the cavity or a part of the wall of the uterus. Finally, abnormal bleeding may be caused by a cancer or pre-cancer condition.
Those are the main groupings that are associated with abnormal bleeding.
LINDA BRADLEY, MD: Also, lots of women are using aspirin and herbal products that may cause excessive bleeding. If you're taking anything over-the-counter, you want to let your physician know, because these other things could be the cause of the bleeding. It's not always the uterus.
How is the cause of abnormal bleeding identified?
There are a number of laboratory tests to evaluate for hormonal causes of abnormal bleeding. In addition, there are several techniques used to evaluate the other causes, and I think we want to be broadminded about our workup in terms of what technology we use. Ultrasound can be used, and there is another procedure that's added to the ultrasound called saline infusion sonography that complements hysteroscopy. Hysteroscopy involves sending a tiny investigative camera into the uterus. If the patient has a normal uterus, hysteroscopy certainly allows full evaluation of the uterine lining.
What is the current treatment for polyps?
GRACE JANIK, MD: There are two options with polyps. One is to remove them in the office, which requires an operative hysteroscope-so a little bit bigger than the diagnostic, but still very well tolerated. Once the hysteroscope has been inserted into the uterine cavity, the procedure involves passing a grasper, or a small scissor, through and detaching the polyp from the wall.
This procedure can also be done in an operating room setting. IV sedation or general anesthesia is used, and the polyps can then be removed.
Is having a fibroid cause for alarm?
LINDA BRADLEY, MD: The important thing to remember about uterine fibroids is that they are rarely cancerous. Unfortunately, some doctors use words like "tumors" and "pelvic masses", and these words are very frightening.
The word "tumor", in the context we use it when talking about the uterus, rarely means "cancerous". One out of a thousand women has a cancerous fibroid.
What if a woman has a fairly good-sized fibroid? What are the treatment options?
KEITH ISAACSON, MD: There are a few options. She can have a hysterectomy, which is surgical removal of the entire uterus, and that is, of course, the extreme option. It will remove the fibroid and the fibroid will never come back.
But she can also have a therapeutic hysteroscopy, in which a larger hysteroscope is placed through the cervix and the fibroid is actually shaved out using electrical current.
She could also have a uterine artery embolization, in which the blood vessels that supply the uterus are actually occluded with very tiny particles. When you cut off the blood supply to the uterus, it turns out the muscle of the uterus does not die, but often the fibroids will. This is a better option for patients who have very large fibroids or who have symptoms of pressure on their bladder or on their bowel. But it also can work for patients with abnormal uterine bleeding.
GRACE JANIK, MD: Myomectomy is also a choice. In that procedure, you remove the fibroids that are in the wall of the uterus and reconstruct the uterus. And you preserve fertility.
So there are a number of treatment options for abnormal bleeding.
STEVE COHEN, MD: Yes, and you've got to be suspicious of a doctor who offers you only one option. Something is not quite right.
