This pamphlet will explain:

Causes of abnormal bleeding How it is diagnosed How it can be treated

If you notice that your cycles have become irregular, see your doctor. Abnormal bleeding has a number of causes.

The Menstrual Cycle

During the menstrual cycle, estrogen and progesterone—two hormones made by the ovaries—cause changes in the endometrium (the lining of the uterus). Each month, about 12–14 days before the start of the menstrual period, an egg is released from one of the ovaries. This is called ovulation. The egg then moves into one of the fallopian tubes where it can be fertilized by a sperm. If the egg is not fertilized, pregnancy does not occur and the levels of hormones decrease. This decrease signals the uterus to shed its lining. This shedding is the monthly menstrual period.

The menstrual cycle begins with the first day of the bleeding of one period and ends with the first day of the next period. An average cycle lasts about 28 days, but it can be longer or shorter. If the cycle is longer than 35 days or shorter than 21 days, it is considered abnormal. The absence of menstrual periods for 3 normal cycles or 6 months (amenorrhea) also is abnormal and may have numerous causes. Let your doctor know if you do not get your period. Abnormal uterine bleeding also includes:

• Bleeding between periods
• Bleeding after sex
• Spotting anytime in the menstrual cycle
• Bleeding heavier or longer than normal

Abnormal bleeding can occur at any age. There are times in a woman's life when it is common for periods to be somewhat irregular. Periods often are not regular the first few years after a girl begins to have periods (around 9–16 years of age). Beginning as early as 35 years of age and more commonly when a woman nears menopause (around 50 years of age), it is normal for her menstrual cycle to become shorter. It also is normal for her to skip periods or for bleeding to become lighter. If bleeding becomes heavier, however, it should be checked.

Causes

There are many causes of abnormal bleeding (see box). Your doctor may begin looking for the cause of abnormal bleeding by checking for problems most common in your age group. Some of these problems are not serious and can be easily treated. Others can be more serious. All should be checked.

In some women, abnormal or heavy bleeding occurs because of a problem with hormones. This can occur when the body makes too much or not enough of a certain hormone. This can be caused by thyroid problems or the use of some medications.

Other Causes of Abnormal Bleeding Other causes of abnormal uterine bleeding include: Pregnancy Miscarriage Ectopic pregnancy Problems linked to some birth control methods, such as an intrauterine device (IUD) or birth control pills Infection of the uterus or cervix Fibroids Problems with blood clotting Polyps Certain types of cancers, such as cancer of the uterus, cervix, or vagina Chronic medical conditions (for instance, thyroid problems and diabetes)

Diagnosis

To diagnose abnormal bleeding, your doctor will need to know your personal and family health history. You may be asked about:

• Past or present illnesses
• Use of medications
• Use of birth control
• Weight, eating and exercise habits, and level of stress

You will have a physical exam. You also may have blood tests to check your blood count and hormone levels and a pregnancy test (to see if you are pregnant). One or more of the following tests also may be needed based on your symptoms:

• Endometrial biopsy—Using a catheter (tube), a small amount of tissue is gently scraped from the lining of the uterus. It is looked at under a microscope.
• Ultrasound—Sound waves are used to create a picture of the pelvic organs. The device may be placed on the abdomen or in the vagina.
• Sonohysterography—Fluid is placed into the uterus through a thin catheter. Sound waves then are used to create a picture of the uterus.
• Hysteroscopy—A thin telescope-like device is inserted through the vagina and cervix to view the inside of the uterus.
• Dilation and curettage (D&C)—The opening of the cervix is enlarged. Tissue is gently scraped or suctioned from the lining of the uterus. It is examined under the microscope.
• Hysterosalpingography—Dye is injected into the uterus and fallopian tubes for an X-ray test.
• Laparoscopy—A slender telescope-like device is inserted through a small cut just below or through the navel to view the inside of the abdomen.

Treatment

Treatment for abnormal bleeding will depend on many factors, including the cause, your age, the severity of the bleeding, and whether you want to have children. You may be given hormones or other medications, or surgery may be needed.

After a few menstrual cycles, your doctor should be able to judge how well treatment is working. You may need to be tested again. If you think you might be pregnant, let your doctor know before you start any therapy.

Hormones

Your doctor may prescribe birth control pills to help your periods to be more regular. They also may improve other symptoms. Progesterone can help prevent and treat endometrial hyperplasia.

It may take a few months for hormones to control the bleeding. Your periods may be heavier for the first few months. However, they will lighten over time. The type of hormone given to you will depend on whether you want to become pregnant.

Other Medications

Nonsteroidal antiinflammatory drugs, like ibuprofen, may help control heavy bleeding. They also may be used to relieve menstrual cramps. If you have an infection, you will be given antibiotics.

Surgery

Some women with abnormal uterine bleeding may need to have surgery to remove growths (such as polyps or fibroids) that are causing the bleeding. This often can be done with hysteroscopy, but sometimes other surgery is needed.

Endometrial ablation also is used to treat abnormal uterine bleeding. This treatment uses electricity, laser, heat, or freezing to destroy the lining of the uterus. It is intended to stop or reduce bleeding permanently. An endometrial biopsy is needed before treatment. A woman may not be able to get pregnant after ablation.

Hysterectomy—removal of the uterus—is another procedure that may be used to treat abnormal bleeding. This may be done when other forms of treatments have failed or are not an option.

Hysterectomy is major surgery. After this procedure, a woman will no longer have periods. She also will not be able to get pregnant. Before you decide on treatment, think about all your options.

Finally...

If you notice that your cycles have become irregular, see your doctor. Abnormal bleeding has a number of causes. There is no way of telling why your bleeding is abnormal until your doctor examines you. Once the cause is found, abnormal bleeding often can be treated with success. If it persists or returns, you should see your doctor again.

Glossary

Ectopic Pregnancy: A pregnancy in which the fertilized egg begins to grow in a place other than inside the uterus, usually in the fallopian tubes.

Endometrial Hyperplasia: A condition that occurs when the lining of the uterus (endometrium) grows too much.

Estrogen: A female hormone produced in the ovaries that stimulates the growth of the lining of the uterus.

Fallopian Tubes: Tubes through which an egg travels from the ovary to the uterus.

Fibroids: Benign (noncancerous) growths that form on the inside of the uterus, on its outer surface, or within the uterine wall itself.

Menopause: The process in a woman's life when ovaries stop functioning and menstruation stops.

Miscarriage: The spontaneous loss of a pregnancy before the fetus can survive outside the uterus.

Ovaries: Two glands, located on either side of the uterus, that contain the eggs released at ovulation and that produce hormones.

Polyps: Growths that develop from membrane tissue, such as that lining the inside of the uterus.