Toward Optimal Health: The Experts Discuss Abnormal Uterine Bleeding

Jodi R. Godfrey, M.S., R.D.

In This Article

Is there a standard approach to the diagnosis of abnormal bleeding?

Dr. Bradley: A piece of wisdom I picked up early on -- 80%-90% of what you need to know you learn from the patient -- can go far in pinpointing the cause of this complaint. The etiology of abnormal bleeding can be uncovered in a cost-effective way if the physician knows the most common causes of bleeding in each age group and uses a logical diagnostic approach given the individual patient's history. Therefore, the best approach to abnormal uterine bleeding can be simplified and is predicated on the woman's reproductive age to narrow the etiological possibilities. Then, the clinician can focus on clinical information gathered about the patient.

Thus, when a woman experiences irregular bleeding, the physician should look at the patient's age and the length of time the problem has been present and do a thorough menstrual history (i.e., duration of period, number of pads and products, is blood flow incapacitating?) as well as a complete medical history, including such bleeding irregularities as gum disease and bruising), new medications, and sexual history. This will provide 80% of the answers.

The medical history will shed light on the emotional and social milieu and clinical issues that may be responsible for the irregular bleeding. Rather than do the million dollar laboratory workup, the physician can use the history to decide which laboratory tests and imaging may be needed to confirm a diagnosis. Transvaginal ultrasonography can be hugely effective in pinpointing the problem with minimal effort and is likely to reduce the need for drastic treatment.

Early pregnancy can produce bleeding in such conditions in nonpregnant women as tubal pregnancy, miscarriage, and retained products of conception. Pelvic pathologic conditions that can cause bleeding may include something growing in the uterus that should not be there, such as polyps, fibroids, hyperplasia, endometrial cancer, infection, sexually transmitted diseases (i.e., gonorrhea and chlamydia), and endometritis. Cancers of the uterus and cervix, ovaries, or fallopian tube carcinoma can cause irregular bleeding.

Endocrinopathies may affect the hypothalamic-pituitary axis and be associated with irregular menstruation. Common endocrinopathies include hypothyroidism or hyperthyroidism and elevated prolactin levels that manifest as abnormal bleeding. Intrauterine contraceptive devices (IUDs) and lacerations of the cervix or vagina can cause bleeding.

Medications that may induce bleeding include certain steroids, phenytoin (Dilantin Parke-Davis, Morris Plains, NJ), OC pills, medroxyprogesterone acetate (Depo-Provera, Upjohn, Kalamazoo, MI), levonorgestrel (Norplant, Planned Parenthood Federation, NY), hormone replacement therapy (HRT), and blood thinners, such as warfarin sodium (Coumadin, DuPont, Wilmington, DE) or heparin. A woman who has been treated with tamoxifen for breast cancer may be susceptible to bleeding years after the treatment has been completed, but the resultant atrophy or dryness finally causes bleeding. Tamoxifen and similar drugs also may have the opposite effect, producing a higher rate of polyps, endometrial hyperplasia, pre-cancer, or new cancer. Women who smoke and those suffering from eating disorders often have disordered menstruation.

Additional information can be gained from a physical examination, including a thorough pelvic examination. With each decade of life, the risk of cancer increases. Among older women, the proximity of the urethra to the rectum and vagina raises the possibility that bleeding is coming from the bladder rather than the vagina. A urinalysis and urine cytologic study might be useful in ruling out bladder pathology. Similarly, a rectal examination and stool hemoccult may be beneficial if there is any question of the origin of the bleeding. Fragility of the urethral opening might cause bleeding when wiping or urinating. Among women with Alzheimer's disease, close and thorough visual inspection of the vagina for foreign bodies is necessary.

In postmenopausal women, it is valuable to inquire about the use of herbal preparations, particularly those that may have an estrogenic effect, such as black cohosh, soy, red clover, and ginseng. It is becoming more common for older women who are in nonmonogamous relationships to experience STDs such as trichomoniasis, herpes, genital warts, and Chlamydia trachomatis infection, that irritate the cervix, causing it to bleed. A recent report suggests that persistent C. trachomatis infection may contribute to human papilloma virus (HPV)induced cervical neoplasia. Asking the patient if she has any concerns about her partner's having other sexual relationships may be met with an affirmative response, "I don't know," or evasiveness. Any of these possibilities suggests the need for a cultures for STDs.

Dr. Schrager: In addition to a complete evaluation based on age and risk factors, careful history taking about over-the-counter (OTC) and herbal remedies is necessary. Some herbal preparations have estrogenic properties, which may be directly responsible for the irregular bleeding. Herbal preparations, such as black cohosh, red clover, wild yam, and ginseng, are all popular products that affect each woman differently and can lead to disruption in some women's menstrual cycles.

If the history and physical examination do not reveal any clues to the reason for bleeding, the first approach usually is watchful waiting, depending on how long a woman has experienced irregular bleeding and on her age. In premenopausal women, irregular bleeding is commonly due to stress or PCOS. Stress management and weight loss often can correct the problem.

Any postmenopausal woman with irregular bleeding who is not taking HRT needs either an endometrial biopsy or a transvaginal ultrasound to exclude endometrial hyperplasia or endometrial cancer as a cause of the bleeding. Office endometrial biopsy is very sensitive in detecting abnormalities of the endometrium. Transvaginal ultrasound in postmenopausal women not taking HRT offers an improved and more definitive diagnostic capability, which will facilitate a more directed treatment plan.

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