Abnormal uterine bleeding can encompass a wide range of problems that can occur throughout the reproductive years and beyond. Vaginal bleeding is considered to be abnormal in the following circumstances:

· Bleeding before puberty in young children.

· Menstrual periods are too long. Normal periods occur about every 4 weeks and lasts 3-5 days on average. If you bleed 7 or more days, there may be a problem.

· Menstrual periods are too heavy. Women typically lose about 30 ml of blood during a normal period. Most women will change tampons or pads 2-3 times a day during the heavy part of the menstrual cycle. If you are changing more often or pass blood clots, this means your periods are too heavy.

· Bleeding between menstrual periods. The amount of bleeding may vary from spotting to heavy. Either way, this is not normal and should be investigated.

· Cyclic interval (number of days from the first day of one period to the first day of next period) is normally about 4 weeks. There is a problem if your periods are occurring more frequently than every 3 weeks or less frequently than 5 weeks,

· Irregular periods. Some women have periods that have no regularity and they seem to occur at totally random intervals. If your periods are occurring in unpredictable manner, there is a problem and you should undergo evaluation.

· No periods for 3 months or longer. This is called amenorrhea. Unless there is a known reason why you are not having periods, it requires evaluation.

· Bleeding after menopause. Any bleeding that occurs after menopause is not normal and must be investigated. In most instances, cancer must be ruled out.

· Bleeding associated with pregnancy. Any bleeding during pregnancy is not normal and must be evaluated promptly. Sometimes, women do not even know they are pregnant and think they are having an abnormal period.

What Causes Abnormal Uterine Bleeding?

There are numerous causes of abnormal bleeding. Some of the most common causes include:

· Medications- some medications are associated with bleeding

· Hormonal agents such as birth control pills, contraceptive implants, and injections

· An IUD or intrauterine device

· Infection of the cervix, vagina, uterus, fallopian tubes or ovaries.

· Pelvic Inflammatory Disease

· Uterine fibroids

· Endometriosis (particularly involving the uterine wall)

· Ovulation

· PCOS, or polycystic ovary syndrome

· Cancer of the uterus or ovary

· Thyroid dysfunction

· Endometrial polyp- mass in the uterine cavity

· Hormonal imbalance

· Bleeding disorder (such as von Willebrand disease)

· In some instances, extreme emotional stress and too much physical activity can cause atypical bleeding.

How is Abnormal Uterine Bleeding Evaluated?

First, a detailed history of abnormal bleeding will be taken followed by physical examination. Often, some laboratory studies will be needed which may include blood count, thyroid and pituitary function tests, hormone levels, coagulation profile, etc. Regular and/or specialized ultrasound examination may need to be performed. Occasionally, tissue biopsy (endometrial biopsy) will be recommended. Once the reason for bleeding has been identified, the provider will be able to address the issue and ensure that it is successfully managed.

How is abnormal bleeding diagnosed?

Your healthcare provider will ask about your personal and family health history as well as your menstrual cycle. It may be helpful to keep track of your menstrual cycle before your visit. Note the dates, length, and type (light, medium, heavy, or spotting) of your bleeding on a calendar.
You will have a physical exam. You also may have blood tests. These tests check your blood count and hormone levels and rule out some diseases of the blood. You also may have a test to see if you are pregnant.

What tests may be needed to diagnose abnormal uterine bleeding?

Based on your symptoms, other tests may be needed. Some of these tests can be done in your health care provider’s office. Others may be done at a hospital or surgical center:

• Sonohysterography – Fluid is placed in the uterus through a thin tube, while ultrasound images are made of the uterus.
• Ultrasound – Sound waves are used to make a picture of the pelvic organs.
• Magnetic resonance imaging – In this imaging test, powerful magnets are used to create images of internal organs.
• Hysteroscopy – A thin device is inserted through the vagina and the opening of the cervix. It lets the health care provider view the inside of the uterus.
• Endometrial biopsy – Using a small or thin catheter (tube), the tissue is taken from the lining of the uterus (endometrium). It is looked at under a microscope.

What factors are considered when deciding on a type of treatment?

The type of treatment depends on many factors, including the cause of the bleeding, your age, and whether you want to have children. Most women can be treated with medications. Others may need surgery.

What medications are used to help control abnormal uterine bleeding?

Hormonal medications often are used to control abnormal uterine bleeding. The type of hormone you take will depend on whether you want to get pregnant as well as your age. Birth control pills can help make your periods more regular. Hormones also can be given as an injection, as a vaginal cream, or through an IUD that releases hormones. An IUD is a birth control device that is inserted in the uterus. The hormones in the IUD are released slowly and may control abnormal bleeding.

Other medications given for abnormal uterine bleeding include nonsteroidal anti-inflammatory drugs (such as ibuprofen), tranexamic acid, and antibiotics. Nonsteroidal anti-inflammatory drugs can control bleeding and reduce menstrual cramps. Tranexamic acid is a drug used to treat heavy menstrual bleeding. Infections are treated with antibiotics.

What types of surgery are performed to treat abnormal uterine bleeding?

Some women may need to have surgery to remove growths (such as polyps or fibroids) that cause bleeding. Some fibroids can be removed with hysteroscopy. Sometimes other techniques are used.
Endometrial ablation may be used to control bleeding. It is intended to stop or reduce bleeding permanently. An endometrial biopsy is needed before ablation is considered.

Hysterectomy may be done when other forms of treatment have failed or they are not an option. Hysterectomy is major surgery. Afterward, a woman no longer has periods. She also cannot get pregnant.