Patient information: Abnormal uterine bleeding (Beyond the Basics)

AuthorHoward A Zacur, MD, PhD Section EditorRobert L Barbieri, MD

INTRODUCTION The inside of the uterus has two layers. The thin inner layer is called the endometrium. The thick outer layer is the myometrium (myo = muscle) (figure 1). In women who menstruate, the endometrium thickens every month in preparation for pregnancy. If the woman does not become pregnant, the endometrial lining is shed during the menstrual period. After menopause, the lining normally stops growing and shedding. Under normal circumstances, a woman's uterus sheds a limited amount of blood during each menstrual period (less than 5 tablespoons or 80 mL). Bleeding that occurs between menstrual periods or excessive menstrual bleeding is considered to be abnormal uterine bleeding. Once a woman who is not taking hormone therapy enters menopause and the menstrual cycles have ended, any uterine bleeding is considered abnormal. Abnormal uterine bleeding can be caused by many different conditions. This topic review discusses the possible causes of abnormal bleeding, how it is evaluated, and various treatment strategies that may be recommended.

What Is PMS?
Premenstrual syndrome (PMS) is the term for the physical and emotional symptoms that many girls and women get right before their periods begin each month. If you have PMS, you might experience: acne bloating fatigue backaches sore breasts headaches constipation diarrhea

food cravings depression or feeling blue irritability mood swings difficulty concentrating difficulty handling stress feeling tense trouble sleeping PMS is usually at its worst during the 1 to 2 weeks before a girl's period starts, and it usually disappears when her period begins.

Why Do Some

Girls Get PMS?

Doctors have not pinpointed the exact cause of PMS, but many believe it is linked to changing hormone levels. Following a girl's period, the amounts of estrogen and progesterone (female hormones) in her body increase. Then about 1 week before her period starts, levels of both of these hormones begin to fall. The thinking is that these changing hormone levels can lead to PMS symptoms. It isn't clear why some girls develop PMS and others don't. It's possible that those who develop PMS are simply more sensitive to the changes in hormone levels. There are other theories as well. For example, some believe that what you eat can affect how you feel, especially during the couple of weeks before your period. Luckily, you can do a few things to ease PMS symptoms. Eating a balanced diet with lots of fresh fruits and vegetables and cutting back on processed foods like chips and crackers can help. You might also want to reduce your salt intake (salt can make you retain water and become more bloated) and, believe it or not, drink more water. Say no to caffeine (it can make you jumpy and anxious) and yes to plenty of sleep. Getting enough calcium and taking a daily multivitamin can be helpful. Also, daily exercise and stressrelief techniques like meditation can help some girls. When it comes to medicine, over-the-counter pain medicines like ibuprofen can relieve achy heads and backs. But for really serious PMS pain, see your doctor, who might be able to prescribe a different medicine or birth control pills to help.

Also let your doctor know right away if you feel very depressed or have had any thoughts of hurting yourself.

Why Do Some Girls Get Cramps?

Lots of girls have abdominal cramps during the first few days of their periods. Cramps are most likely caused by prostaglandins (pronounced: pross-tuh-glan-dinz), chemicals your body produces that make the muscles of the uterus contract. The good news is that cramps usually only last a few days. But if you're in pain, medicine like ibuprofen might help. Exercise also can make you feel better, possibly because it releases endorphins, chemicals in the body that literally make you feel good. Soaking in a warm bath or putting a warm compress on your stomach won't make your cramps disappear but may help your muscles relax a little. If you have severe cramps that keep you home from school or from doing stuff with your friends, or if over the counter medications aren't working, visit your doctor for advice.

Why Isn't My Period Regular?

It can take a few years from the time a girl starts menstruating for her body to develop a regular cycle. Even then, what's regular varies girls' cycles can range from 21 to 45 days. Changing hormone levels might make your period short one month (such as 2 or 3 days) and more drawn out (such as 7 days) the next. You might skip a month, get two periods almost right after each other, have a really heavy period, or one so light you almost don't notice it. (If you're sexually active and you skip a period, though, you should visit your doctor or a women's clinic to make sure you're not pregnant.) All this irregularity can make planning for your period a real hassle. Try to keep track of when your last period started, and guess that about 4 weeks from that day you could be due for another. If you're worried about wearing that cute dress and suddenly starting your period at school, just make sure you pack protection. Carry a pad or tampon in your backpack, and wear a pantiliner to handle the first wave. When it comes to periods, every girl's body has a unique (and unpredictable) timeline for getting on track. If your period still has not settled into a relatively predictable pattern after 3 years, or if you were having regular periods and then become irregular or have no period for a couple of months, make an appointment with your doctor to check for possible problems.

Why Haven't I Started My Period Yet?

Everybody goes through puberty at different speeds. Some girls begin menstruating as early as age 8 or 9; others don't get going until they're 15 or 16. It all depends on your hormones and your family. Want to guess when you'll get your period? Ask when your mom and grandmothers (from both sides of your family) started theirs. When you start puberty is partly linked to genetics. So although there's no guarantee that you'll follow in their footsteps, your relatives could give you a clue about your own period. One thing that can delay puberty and your period is excessive exercising, usually distance running, ballet, or gymnastics, combined with a poor diet. For exercise to be excessive, it means more than just playing soccer a few times a week or working out once in a while with an exercise video. To exercise so much that you delay your period, you would have to train vigorously for several hours a day, most days of the week, and not get enough calories, vitamins, and minerals. Unless compulsive exercise has postponed your period, there's nothing you can do on your own to hurry things along. If you haven't started to menstruate by the time you're 16, consult your doctor. He or she will examine you, and may do a pelvic exam and take a blood test to determine the hormone levels in your body. Different treatments are available depending on what is causing the delay in your period.

Menstrual Problems
Even if it seems strange to you, most of the stuff that goes along with a girl's period is completely normal. But a few conditions can be more serious. If you suspect you have any of these problems, see your doctor for advice.

No Periods
Amenorrhea is the term doctors use for absence of periods. Girls who haven't started their periods by the time they are 16 may have primary amenorrhea, usually caused by a hormone imbalance or developmental problem. There's also a condition called secondary amenorrhea, when a girl who had normal periods stops menstruating for at least 3 months. Low levels of gonadotropin-releasing (pronounced: go-nad-uh-troe-pin) hormone (GnRH), which controls ovulation and the menstrual cycle, frequently bring on amenorrhea. Stress, anorexia, weight loss or gain, stopping birth control pills, thyroid conditions, and ovarian cysts are examples of things that can throw your hormones out of whack. To get everything back on course, your doctor may use hormone therapy.

If a medical condition is affecting your monthly cycles, then treatment of the condition will help to resolve the problem. As mentioned earlier, lots of strenuous exercise combined with a poor diet can also cause amenorrhea. Cutting back on exercise and eating a balanced diet with more calories will help correct the problem, but be sure to talk with your doctor too.

Heavy Periods
Menorrhagia (pronounced: men-uh-ray-jee-uh) is the term doctors use for extremely heavy, prolonged periods. Menorrhagia is more than just 1 or 2 days of a heavier-than-average flow. Girls who have menorrhagia soak through at least a pad or tampon an hour for several hours in a row or have periods that are more than 7 days long. The most frequent cause of menorrhagia is an imbalance between the amounts of estrogen and progesterone in the body. Because of this imbalance, the endometrium (pronounced: en-dohmee-tree-um), which is the lining of the uterus, keeps building up. Then when the body gets rid of the endometrium during a period, the bleeding is very heavy. Many girls have hormone imbalances during puberty, so it's not uncommon to experience menorrhagia during the teen years. Other possible causes of heavy bleeding include thyroid conditions, blood diseases, or inflammation or infections in the vagina or cervix. To help figure out the cause of abnormal bleeding, a doctor may do a pelvic exam, a Pap smear, and blood tests. If you do have menorrhagia, it can be treated with hormones, other medications, or removal of any extra tissue in the uterus that may be the cause of excessive bleeding.

Extremely Painful Periods

Dysmenorrhea (pronounced: dis-men-uh-ree-uh) is the medical term for very painful periods. Primary dysmenorrhea painful periods that are not caused by a disease or other condition is more common in teens than secondary dysmenorrhea (painful periods caused by a disease or condition). The culprit in primary dysmenorrhea is prostaglandin, the same naturally occurring chemical that causes cramps. Sometimes, prostaglandin can cause nausea, vomiting, headaches, backaches, diarrhea, and severe cramps when you have your period. Fortunately, these symptoms usually only last for a day or two. Doctors usually prescribe antiinflammatory medicines to treat primary dysmenorrhea. As with cramps, exercise, hot water bottles, and birth control pills might also bring some relief.

Some of the more common conditions that can cause secondary dysmenorrhea include: endometriosis, a condition in which tissue normally found only in the uterus starts to grow outside the uterus pelvic inflammatory disease (PID), a type of bacterial infection usually caused by a sexually transmitted disease fibroids or growths on the outside, inside, or in the wall of the uterus All of these conditions require that a doctor diagnose the problem and then treat you appropriately.

CAUSES OF ABNORMAL UTERINE BLEEDING

Most conditions that cause abnormal uterine bleeding can occur at any age, but some are more likely to occur at a particular time in a woman's life. Abnormal uterine bleeding in young girls Bleeding before menarche (the first period in a girl's life) is always abnormal. It may be caused by trauma, a foreign body (such as toys, coins, or toilet tissue), irritation of the genital area (due to bubble bath, soaps, lotions, or infection), or urinary tract problems. Bleeding can also occur as a result of sexual abuse. Adolescents Many girls have episodes of irregular bleeding during the first few months after their first menstrual period. This usually resolves without treatment when the girl's hormonal cycle and ovulation normalizes. If bleeding persists beyond this time, or if the bleeding is heavy, further evaluation is needed. Abnormal bleeding in this age group can also be caused by any of the conditions that cause bleeding in all premenopausal women, including: pregnancy, infection, and bleeding disorder or other medical illnesses. These and other causes are discussed in the next section. Premenopausal women Many different conditions can cause abnormal bleeding in women between adolescence and menopause. Abrupt changes in hormone levels at the time of ovulation can cause vaginal spotting, or small amounts of bleeding. Breakthrough bleeding can also occur in premenopausal women who use hormonal birth control methods. Some women do not ovulate regularly, causing irregular hormone levels and intermittent light or heavy bleeding. Although anovulation is most common when periods first begin and during perimenopause, it can occur at any time during the reproductive years. (See "Patient information: Absent or irregular periods (Beyond the Basics)".)

Some women who ovulate normally experience excessive blood loss during their periods or bleed between periods. The most common causes of such bleeding are uterine fibroids or polyps. These irregular growths and benign tumors are composed of uterine tissue that distort the structure of the uterus and lead to abnormal uterine bleeding. Fibroids and polyps can also occur in anovulatory women. (See "Patient information: Uterine fibroids (Beyond the Basics)" and "Patient information: Menorrhagia (excessive menstrual bleeding) (Beyond the Basics)".) Other causes of abnormal uterine bleeding in premenopausal women include:

Pregnancy Cancer or precancer of the cervix or the endometrium (lining of the uterus) (see "Patient information: Endometrial cancer diagnosis and staging (Beyond the Basics)") Infection or inflammation of the cervix or endometrium Clotting disorders such as von Willebrand disease, platelet abnormalities, or problems with clotting factors Medical illnesses such as hypothyroidism, liver disease, or chronic renal disease

Birth control pills Girls and women who use hormonal birth control (eg, pills, shot, patch) may experience "breakthrough" bleeding between periods. If this occurs during the first few months, it may be due to changes in the lining of the uterus. If it persists for more than a few months, evaluation may be needed and/or a different birth control pill may be recommended. (See "Patient information: Hormonal methods of birth control (Beyond the Basics)".) Breakthrough bleeding can also happen if birth control is forgotten or taken late. In this situation, there is a risk that the woman could become pregnant if she has sex. Another form of birth control (eg, condoms) is recommended if the pill/patch/shot is not taken on time. Women in the menopausal transition Before the menstrual periods end, a woman passes through a period called the menopausal transition. During the menopausal transition, normal hormonal cycling begins to change and ovulation may be inconsistent. While estrogen secretion continues, progesterone secretion declines. These hormonal changes can cause the endometrium to grow and produce excess tissue, increasing the chances that polyps or endometrial hyperplasia (thickened lining of the uterus) will develop and potentially cause abnormal bleeding.

Women in the menopausal transition are also at risk for other conditions that cause abnormal bleeding, including cancer, infection, and bodywide illnesses. Further evaluation is needed in women with persistent irregular menstrual cycles or an episode of profuse bleeding. Women in the menopausal transition still ovulate some of the time and can become pregnant; pregnancy can cause abnormal bleeding. In addition, women in perimenopause may use hormonal birth control medications, which can cause breakthrough bleeding. Menopausal women A number of conditions can cause abnormal bleeding during the menopause. Women who take hormone replacement therapy may experience cyclical bleeding. Any other bleeding that occurs during menopause is abnormal and should be investigated. Causes of abnormal bleeding during menopause include:

Atrophy (excessive thinning) of the tissue lining the vagina and uterus Cancer of the uterine lining (endometrium) (see "Patient information: Endometrial cancer diagnosis and staging (Beyond the Basics)") Polyps or fibroids Endometrial hyperplasia Infection of the uterus Use of blood thinners or anticoagulants Side effects of radiation therapy

ABNORMAL UTERINE BLEEDING EVALUATION

Initial assessment While taking a woman's medical history, a clinician will review the duration and amount of bleeding; factors that seem to bring the bleeding on; symptoms that occur along with the bleeding such as pain, fever, or vaginal odor; if bleeding occurs after sexual intercourse; whether there is a personal or family history of bleeding disorders; the woman's medical history and medications she is taking; recent weight changes, stress, a new exercise program, or underlying medical problems. The clinician will perform a physical examination to evaluate the woman's overall health, and a pelvic examination to confirm that the bleeding is from the uterus and not from another site (eg, the external genitals or rectum). During the pelvic exam, the clinician will look for any obvious lesions (cuts, sores, or tumors) and will examine the size and shape of the uterus. He or she will

examine the cervix to look for signs of cervical bleeding, and a Pap smear may be obtained to examine the cells of the cervix (the lower end of the uterus, where it opens to the vagina). (See "Patient information: Cervical cancer screening (Beyond the Basics)".) Lab tests In premenopausal women, a pregnancy test is performed. If there is any abnormal vaginal discharge, a cervical culture may be performed. Blood tests may also be done to determine if there are problems with blood clotting or other bodywide conditions, such as thyroid disease, liver disease, or kidney problems. Tests to determine ovulatory status Because hormonal irregularities can contribute to abnormal uterine bleeding, testing may be recommended to determine if the woman ovulates (produce an egg) during each monthly cycle. Endometrial assessment Tests that assess the endometrium (lining of the uterus) may be performed to rule out endometrial cancer and structural abnormalities such as uterine fibroids or polyps. Such tests include: Endometrial biopsy An endometrial biopsy is often performed in women over age 35 to rule out endometrial cancer or abnormal endometrial growths. A biopsy may also be performed in women younger than 35 if they have risk factors for endometrial cancer. Risks include obesity, chronic anovulation, history of breast cancer, tamoxifen use or a family history of breast cancer or colon cancer. (See "Patient information: Endometrial cancer diagnosis and staging (Beyond the Basics)".) During the biopsy, a thin instrument is inserted through the vagina into the uterus to obtain a small sample of endometrial tissue. The biopsy can be performed in a healthcare provider's office without anesthesia. Because only a small portion of the endometrium is sampled, the biopsy may miss some causes of bleeding and other tests are sometimes necessary. Transvaginal ultrasound An ultrasound uses sound waves to measure an organ's shape and structure. In a transvaginal ultrasound, a small ultrasound probe is inserted into the vagina so that it is closer to the uterus and can provide a clear image of the uterus. The lining of the uterus is evaluated and measured; postmenopausal women normally have a very thin endometrial lining (usually less than 4 or 5 mm). Ultrasound cannot distinguish between different types of abnormalities (eg, polyp versus cancer) and further testing may be necessary. Saline infusion sonography ( sonohysterography) In this test, a transvaginal ultrasound is performed after sterile saline is instilled into the uterus. This procedure gives a better picture of the inside of the uterus, and small lesions can be more easily detected. However, because tissue samples cannot be obtained during the procedure, a final diagnosis is not always possible and additional evaluation, usually including hysteroscopy with dilation and curettage (D&C) may be necessary.

Imaging tests A magnetic resonance image (MRI) is a non-invasive test that is sometimes used to determine if fibroids or other structural abnormalities of the uterus are present. Hysteroscopy During hysteroscopy, a small scope is inserted through the cervix and into the uterus. Air or fluid is injected to expand the uterus and to allow the physician to see the inside of the uterus. Tissue samples may be taken. Anesthesia is used to minimize discomfort during the procedure. In most cases, hysteroscopy is performed along with a D&C. Dilation and curettage (D&C) In a D&C, the cervix or opening of the uterus is dilated and instruments are inserted and used to remove endometrial or uterine tissue. A D&C usually requires anesthesia. It can sometimes be used as a treatment for prolonged or excessive bleeding that is due to hormonal changes and that is unresponsive to other treatments. (See "Patient information: Dilation and curettage (D and C) (Beyond the Basics)".)

ABNORMAL UTERINE BLEEDING TREATMENT

The treatment of abnormal bleeding is based upon the underlying cause. Birth control pills Birth control pills are often used to treat uterine bleeding that is due to hormonal changes or hormonal irregularities. Birth control pills may be used in women who do not ovulate regularly to establish regular bleeding cycles and prevent excessive growth of the endometrium. In women who do ovulate, they may be used to treat excessive menstrual bleeding. Nonsteroidal anti-inflammatory drugs (NSAIDS, eg ibuprofen, naproxen sodium) may also be helpful in reducing blood loss and cramping in these women. During the menopausal transition, birth control pills or other hormonal therapy may be used to regulate the menstrual cycle and prevent excessive growth of the endometrium. (See "Patient information: Menorrhagia (excessive menstrual bleeding) (Beyond the Basics)".) Progesterone Progesterone is a hormone made by the ovary that is effective in preventing excessive bleeding in women who do not ovulate regularly. A synthetic form of progesterone, called progestin, may be recommended to treat abnormal bleeding. Progestins are usually given as pills (eg, medroxyprogesterone acetate, norethindrone), and are taken once a day for 10 to 12 days each month or two. Progestins can be taken for longer periods if there has been overgrowth of the uterine lining. Vaginal bleeding will begin before the seventh day of progestin treatment if the uterine lining is overgrown; otherwise, it may not be seen until several days after the last progestin tablet is taken. In some cases, the progestin is given on a regular basis (eg, every few months) to prevent excessive growth of the uterine lining and heavy menstrual bleeding. If no bleeding is seen after progestin treatment, the possibility of an unintended pregnancy should be explored.

Progestins may also be given in other ways, such as in an injection, an implant, or an intrauterine device. These treatments are discussed in detail in a separate topic review. (See "Patient information: Menorrhagia (excessive menstrual bleeding) (Beyond the Basics)".) Intrauterine device An intrauterine contraceptive device (IUD) that secretes progestin (eg, Mirena) may be recommended for women who do not ovulate regularly. IUDs are inserted by a healthcare provider through the vagina and cervix into the uterus. Most are made of molded plastic and include an attached plastic string that projects through the cervix, enabling the woman to check that the device remains in place (picture 1). Progestin-releasing IUDs decrease menstrual blood loss by 40 to 50 percent and decrease pain associated with periods. Some women completely stop having menstrual bleeding as a result of the IUD, which is reversible when the IUD is removed. (See "Patient information: Long-term methods of birth control (Beyond the Basics)".) Surgery Surgery may be necessary to remove abnormal uterine structures (eg, fibroids, polyps). Women who have completed childbearing and have heavy menstrual bleeding can consider a surgical procedure such as endometrial ablation. This procedure is done while the woman is under general or regional anesthesia, and uses heat, cold, or a laser to destroy the lining of the uterus. More information about endometrial ablation is available in a separate topic review. (See "Patient information: Menorrhagia (excessive menstrual bleeding) (Beyond the Basics)".) Women with fibroids can have surgical treatment of their fibroids, either by removing the fibroid(s) (eg, myomectomy) or by reducing the blood supply of the fibroids (eg, uterine artery embolization). More information about these treatments is available separately. (See "Patient information: Uterine fibroids (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below. Patient level information UpToDate offers two types of patient education materials. The Basics The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Uterine cancer (The Basics) Patient information: Dilation and curettage (D and C) (The Basics) Beyond the Basics Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon. Patient information: Hormonal methods of birth control (Beyond the Basics) Patient information: Absent or irregular periods (Beyond the Basics) Patient information: Uterine fibroids (Beyond the Basics) Patient information: Menorrhagia (excessive menstrual bleeding) (Beyond the Basics) Patient information: Endometrial cancer diagnosis and staging (Beyond the Basics) Patient information: Chlamydia (Beyond the Basics) Patient information: Gonorrhea (Beyond the Basics) Patient information: Cervical cancer screening (Beyond the Basics) Patient information: Dilation and curettage (D and C) (Beyond the Basics) Patient information: Long-term methods of birth control (Beyond the Basics) Professional level information Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading. An overview of endometrial ablation Chronic menorrhagia or anovulatory uterine bleeding Clinical features and diagnosis of polycystic ovary syndrome in adolescents Dilation and curettage Evaluation of the endometrium for malignant or premalignant disease Initial approach to the premenopausal woman with abnormal uterine bleeding Overview of causes of genital tract bleeding in women Terminology and evaluation of abnormal uterine bleeding in premenopausal women The evaluation and management of uterine bleeding in postmenopausal women The following organizations also provide reliable health information.

National Library of Medicine (www.nlm.nih.gov/medlineplus/healthtopics.html)

The American College of Obstetricians and Gynecologists (http://www.acog.org/)

The Nemours Foundation (www.kidshealth.org, search for menstrual)

The Hormone Foundation (www.hormone.org)

References 1. Fraser IS, Critchley HO, Munro MG, et al. A process designed to lead to international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding. Fertil Steril 2007; 87:466. 2. Mohan S, Page LM, Higham JM. Diagnosis of abnormal uterine bleeding. Best Pract Res Clin Obstet Gynaecol 2007; 21:891. 3. van Dongen H, de Kroon CD, Jacobi CE, et al. Diagnostic hysteroscopy in abnormal uterine bleeding: a systematic review and meta-analysis. BJOG 2007; 114:664. 4. Gray SH, Emans SJ. Abnormal vaginal bleeding in adolescents. Pediatr Rev 2007; 28:175.

These are the internal organs that make up a woman's reproductive system.

Mirena IUD
This device is implanted into the uterus. While there it delivers hormones into the body that help prevent pregnancy.Reproduced with permission from: Berlex Laboratories. Copyright Berlex
Laboratories.