During
the peri-menopausal years, as many as one third of all gynecological
visits are for abnormal uterine bleeding episodes. Peri-menopause
is approximately the ten years before menopause, when a woman's
hormones begin to change. When that happens, ovulation becomes
less consistent every month. Predictable periods that come
on a regular basis usually indicates that the woman is ovulating
while periods that vary in length by more than 10 days from
one cycle to the next are likely to be secondary to the woman
not having monthly ovulations.
Besides
an absence of ovulation, most other cases of irregular menses
are due to pregnancy, uterine pathology such as polyps or
fibroids, disorders in clotting mechanisms or cancer. The
normal menstrual cycle has an interval of 24-35 days between
periods with the menstrual period usually lasting from 2-7
days. Average blood loss is approximately 30 to 40 ml per
cycle with greater than 80 ml being considered a large amount
of bleeding. Women can recognize this blood loss when they
use more than one pad of protection per hour.
Evaluation:
The evaluation of bleeding abnormalities usually begins with
a complete medical history, sorting out whether the cause
is hormonal or anatomical.
Hormonal:
The presence of symptoms such as breast tenderness, pelvic
pain and increased vaginal discharge are usually symptoms
of ovulation. The absence of these symptoms usually indicates
the woman is not ovulating and the bleeding is due to an imbalance
of estrogen and progesterone hormones. Prolonged estrogen
stimulation of the uterine lining that is not counterbalanced
by progesterone can lead to cancer. Menstrual irregularities
are also caused by systemic disease such as a thyroid disorder
and by use of certain medications.
Anatomical:
Bleeding that occurs between periods can be due to structural
lesions such as endometrial polyps, uterine fibroids and cervical
dysplasia. Pregnancy should be considered and ruled out in
all cases of abnormal vaginal bleeding. Physical examination
is important to try to determine where the bleeding is originating
from, such as the gynecological organs, the urinary organs
or the gastrointestinal tract.
Basic
testing can include a blood count to rule out anemia which
could include thyroid screening, clotting studies, a pap smear
or an office endometrial biopsy. Ultrasound examination is
now used to measure the thickness of the inside lining of
the uterus and can be used to determine if there are any anatomical
abnormalities such as polyps, uterine fibroids or cancer.
Hysteroscopy, which is a minor surgical procedure, can be
performed to visualize the inside of the uterus. The information
gained from these studies can then be used to establish a
diagnosis and begin a treatment plan.
