After prenatal care and regular checkups, the most common reason women visit the Ob/Gyn is for evaluation of abnormal bleeding. It’s defined simply as bleeding that occurs at any time other than when you would expect to have your menstrual period or menstrual bleeding that lasts longer or is heavier than normal. Most of the possible causes of abnormal bleeding aren’t especially worrisome. Yet abnormal bleeding also can be a warning sign of cancer. So to be sure you don’t have a serious disease, it’s important to see your doctor should your bleeding ever become abnormal. If there’s a significant change in your menstrual pattern, such as bleeding when you don’t expect it or needing sanitary pads two or more days longer than usual, have it checked. If your periods are irregular because you’re nearing menopause or if you’ve reached it, see the chart below.
To determine the cause of abnormal bleeding, an Ob/Gyn first considers symptoms and history and also performs a pelvic exam. Age is a factor. In women younger than 35, it’s fairly rare for bleeding to be caused by a disease like cancer. The possibility of pregnancy is always taken into account; many pregnancy complications can cause bleeding.
If a younger woman isn’t pregnant and the pelvic exam shows nothing suspicious, chances are the bleeding is related to an irregularity of the menstrual cycle. Each month, the endometrium, or lining of the uterus, grows in preparation for pregnancy. If pregnancy doesn’t occur, the endometrium breaks down and sheds as menstrual bleeding. But a variety of factors can throw hormones out of balance and prevent the ovary from releasing an egg. In the absence of ovulation, the endometrium becomes thicker than usual. When it’s shed, the bleeding may be heavy or irregular. This common condition, called dysfunctional uterine bleeding, can be treated with hormone therapy or surgery. Sometimes it’s necessary to treat an underlying cause, such as an underactive thyroid.
As a woman gets older, the likelihood rises that abnormal bleeding is a sign of a malignant or premalignant disease. The main concern is cancer of the endometrium, the second most common cancer of the female reproductive system.
To rule it out, a tissue sample must be obtained from inside the uterus. Usually this is done by endometrial biopsy, which takes only a minute and requires no anesthesia. Sometimes hysteroscopy is performed at the same time. Hysteroscopy allows the Ob/Gyn to see inside the uterus using a thin telescope inserted through the vagina. Another procedure is dilation and curettage, or D&C, which requires anesthesia. This may be needed if endometrial biopsy doesn’t reveal the cause of the bleeding.
If the D&C results are normal, hormone therapy may be recommended to treat the bleeding. If precancerous tissue is found, the choice of treatment includes hormone therapy and/or hysterectomy, depending on the woman’s age and condition. If cancer is diagnosed, hysterectomy is usually needed.
Less serious causes of abnormal bleeding in women in their late reproductive years are polyps and fibroids. Polyps, benign overgrowths of the uterine lining, can be treated by D&C and/or hysteroscopy. Fibroids, benign overgrowths of the uterine muscle, may shrink after menopause. Depending on severity, age and other factors, the recommended treatment may range from “watchful waiting” to medication to surgery.
In women who are past menopause and not on HRT, the most common cause of abnormal bleeding is atrophy of the vagina—thinning of the vaginal walls due to lack of estrogen.
For women of any age, abnormal bleeding usually doesn’t mean endometrial cancer. And even when it does, this cancer can be treated successfully 90 percent of the time if it’s caught early. So if you ever experience abnormal bleeding, see your doctor.