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Abnormal Uterine Bleeding 

Abnormal uterine bleeding is a departure from the normal and what do we consider normal? A total volume of 30 to 60 cc. This has been evaluated by doing tests on menstrual pads from a number of women to get a total volume. Once you get above 80 cc of blood - these are the patients who have menorrhagia, menometrorrhagia - and will get into anemia situations over time. A good way of estimating blood loss is with a chart that a woman can use, to circle number of pads she uses, how much bleeding there has been on the pads and so forth. You can add them up and pretty well quantify, on a visual basis, the menstrual bleeding so that you can estimate whether or not this patient really has a dysfunctional uterine bleeding, abnormal uterine bleeding, vaginal bleeding, disfunctional uterine bleeding, annovulatory bleeding, anovulatory

Abnormal patterns; we can term them into hypomenorrhea, which is a diminished total flow, oligomenorrhea which are menses occurring less than every 35 days, menorrhagia which is a profuse flow on regular intervals. So anywhere in that 21 to 35 day interval, if sheís having a profuse flow then sheís got menorrhagia. Menometrorrhagia is an excess of flow occurring on an irregular basis. So thatís excessive and irregular. Intermenstrual spotting or bleeding is light, regular, usually about mid-cycle. This is what we generally see with ovulatory spotting,

We can divide abnormal bleeding into two causes, really, or two general categories. Those that are caused by anatomic problems and those that are dysfunctional or generally hormonal in etiology. Anatomical etiologies - and I think someone probably does the presentation for you on pregnancy and complications, such as placenta previa, abruptio and so forth - cervical polyps can cause it. Leiomyomas, infection, trauma, adenomyosis and of course carcinoma. And these are anywhere in the GI tract. We can see a carcinoma of the vagina, which is fairly rare, carcinoma of the cervix. We see endocervical polyps, cervical polyps, carcinomas of the endocervix, sarcomas and carcinomas of the endometrium and myometrium. Myometrial polyps, submucous leiomyoma will cause menstrual problems and bleeding, and then ovarian dysfunctionís. So those are pretty much the anatomic sites.

Those that are dysfunctional or hormonal in etiology, we can classify into two basic parts; ovulatory, which means that the patient is releasing an egg on a monthly basis, and anovulatory problems where a patient does not ovulate on a regular basis or does not ovulate at all.

The normal physiology is the important thing that we should all keep in mind when we are evaluating the abnormal bleeding. The first phase of the menstrual cycle is what is called the follicular phase and this is dependent upon a communication between the hypothalamus sending information to the pituitary which then sends FSH and LH to the ovaries telling it to produce estrogen, which then feeds back to the hypothalamus. The estrogen also acting in concert on the ovaries with the developing follicles, produces a primary follicle that actually produces more estrogen and the estrogen also causes the endometrium to proliferate. So this is also called the proliferative phase of the

The menstrual period starts 14 days after ovulation and this is important in that the amount of tissue that you see shed at the time of menstruation is related to the duration of estrogen exposure during the proliferative or follicular phase. This means that if a woman menstruates every 28 days she will shed X amount of menstrual tissue. If her friend menstruates every 35 days - in other words, doesnít

The normal luteal phase, like I say, ovulation occurs. The corpus luteum cyst forms and produces both estrogen and progesterone and maintains the endometrium, makes it secretory, ready for a pregnancy. In discussing it with patients I will often times say, "Well, after you ovulate the endometrium becomes very thick and lush like a garden that has flowered and bloomed" and this is what we need to look for,

Pre-pubertal causes usually, I think of foreign bodies because little girls and little boys explore themselves. Explore their genitalia. They like to put things Öyou always hear about them putting things in their nose. Little girls will put things in the vagina and they may have a foreign body. Very difficult to examine little girls, and probably thereís two easy ways to do it. Number one, if sheís a very good patient, youíll have the mother lie down on the examining table and have the child lay on the motherís abdomen with her knees up under her, sort of in a knee-chest position, you can sometimes spread the labia and with a light just look up the vagina to see if thereís anything up there. If I canít get an exam done and the child is actually having bleeding and so forth, then my choice is to take them to the operating room, put them to sleep. You can do a good visual inspection and you can do a vaginoscopy with a cystoscope. Itís very simple, very easy. Sexual abuse is another thing that we think of and we look for signs of. Exogenous estrogen can be a problem. She may be picking up her motherís birth control pills and having withdrawal menses because she takes a pill and after awhile, after a few pills that her mother didnít happen to notice were gone, she stopped taking them and has some bleeding. Then of course we always worry about tumors, sarcoma botryoides, dysgerminomas and 

During the reproductive years: this is the group we see most frequently. Pregnancy and its complications is a frequent cause. Ovulatory problems only occur in maybe up to 25% of the patients. Anovulatory problems are the ones we deal with the majority of times. The patient is having either irregular anovulation or irregular ovulation, or is totally anovulatory. That can be 75% to 90% of the patients you see. And then anatomical problems in the reproductive years are usually fairly few and far between, although we do see a fair number of patients that

The reasons many patients have the anovulatory type of bleeding, the endocrine problems we see with thyroid, pituitary. Ovarian problems: they may have polycystic ovaries. Drugs such as many of the psychiatric drugs will create problems, related back to endocrine. Many of the psychiatric drugs will raise the prolactin and cause problems. Stress can cause changes in it. We all know about nutritional problems, especially in the bulimic patients that create menstrual problems such as amenorrhea, total amenorrhea and

Thyroid problems we see both in the hyper and hypo thyroid. If the patient has any other symptoms of either, such as hyperthyroid - if sheís one of those patients that can get all her housework done and have time to go shopping and all the rest of that, then I get suspicious. They may be a little hyperthyroid, and if they are not gaining weight slowly over the decades, and you should. Your metabolism changes by about 2% every five years so that the natural history is that we gain about 5 to 10 pounds every decade of life. So if she is not into that group and

Adrenal problems, hyperplasia and tumors, are things we see. Patients who have anovulatory cycling, doing laboratory testing for this is very easy. Itís a simple blood test to do and if itís normal you can pretty well count out the adrenal tumors and so forth. The test is DHEA sulfate.

Neoplasias of the hypothalamic gland; doing serum prolactins is easy. Try and draw them in the morning. Thatís when they are going to be at their highest level. Hyperprolactinemiaís are fairly frequent. You need to be careful in treating them with bromocriptine because of seizures, but Iíve only seen one patient in the 15 years Iíve been using bromocriptine that had seizures. Diabetic patients also have trouble with their

Ovarian problems, such as polycystic ovarian cysts syndromes. My treatment for that, I offer the patient a couple of choices. One is to withdraw menses every three months or so with Provera 10 mg for ten days, or put them on birth control pills to protect their hypothalamic pituitary axis and protect their endometrium from over-stimulation.

Renal blastomas, granulosa and thecal cell tumors and hilus cell tumors are difficult or may be very difficult to diagnose, but can cause bleeding. Chronic pelvic inflammatory disease - because of the vasculitis in the endometrium and also in the region of the ovaries - will cause bleeding. Endometriosis can be found almost anywhere and can interfere with the normal function of the endometrium and may cause abnormal bleeding just by having endometrial implants in the vagina. Iíve diagnosed several patients by seeing something that didnít look

Then premature menopause, which is menopause that occurs before the age of 45, can cause you to have anovulation and menstrual irregularities. Drugs that will affect your menstrual cycles: just about everything. Morphine, reserpine, phenothiazines, MAO inhibitors, anticholinergics, and then any steroid preparations you give, such as progesterones: Norplant, Depo-Provera are known to create a lot of problems with irregular spotting and bleeding. Some patients are placed on testosterones for libido. Adrenal androgens can be produced. Estrogens can be produced. The patients may be getting exogenous estrogens that you donít know about. One of the great places that they find them now are in these health food stores in the malls. They can actually get phytoestrogenís and buy estrogen-containing products and

Stress, emotional stress, excessive exercise, things like a change in habits - even as simple as flying from New York to Los Angeles, spending a couple of days in Los Angeles, back to New York - can throw off ovulation and create menstrual irregularities. The morbidly obese patient can produce too much exogenous estrone where the fat tissue is changing hormones into estrone, creates an endometrial hyperplasia and bleeding. We discussed anorexia nervosa and malabsorption syndrome. Not so much nutritional, but letís talk about exercise for a minute. Patients who excessively exercise burn up their steroid hormones and will have menstrual problems. You might see this in some

Perimenopausal bleeding: this is usually physiologic and self limited. These menstrual disturbances are usually the rule as Iíve said earlier, but we must evaluate them to rule out cancer. Usually they have ovulatory then anovulatory cycles, or several anovulatory cycles in a row, get a little endometrial hyperplasia or an endometrial polyp, or have other lesions such as submucous fibroids or something like that. So you must evaluate these and rule out cancer. I had a patient earlier this year who was only 47 that was having menstrual irregularities. And we biopsied and biopsied and didnít get anything and couldnít control them. Sheíd been tried on various hormonal therapies prior to coming to see me. We ended up doing a hysterectomy and when we opened the uterine specimen she had 50% myometrial invasion by an endometrial carcinoma. So it does happen in younger people. But itís unusual.

Postmenopausal bleeding is never physiologic. Fifteen to twenty percent of them represent cancer. The etiology is unopposed estrogens, or peripheral conversion in fatty tissue to estrone. Sometimes they are given hormone replacement or exogenous estrogen for years at a time without any progestin to counteract it. Or they have a uterine or ovarian tumor. Iíve diagnosed several ovarian cancers by postmenopausal bleeding. The evaluation of the endometrium is mandatory in these patients. You must do something to evaluate them to rule out a cancer. And thatís in the postmenopausal. How do we evaluate them? Of course, our history, physical and laboratory are your beginnings. You can do non-invasive tests and invasive tests. If I have young patients who are having menometrorrhagia and we suspect they are becoming

Their heaviest days Ö usually most of them will start out with a fairly normal bleed and then all of a sudden it gets real heavy and passes clots and then after a couple of days they will get a little bit better. Then I find out, have we had any previous infections such as things I would suspect for PID or Chlamydia which may cause bleeding and problems. Have they had any treatments recently, are they taking any

Then on physical examination I inspect the vulva, the vagina, the cervix, any lesions, polyps. Do they have condyloma, any cervicitis, then the uterus for its size, shape, and on examination the adnexa. Also I try and correlate any bleeding they are having, any intermenstrual bleeding. Occasionally Iíll get a patient sent to me for uterine bleeding whoís having hemorrhagic cystitis. So if itís only when they are emptying their

Invasive testing: endometrial biopsy. If you have any question at all, my tendency to do an endometrial biopsy is very great. I have a low tolerance for women that bleed because Iíve seen several 32-year-old patients with endometrial cancer. So if I have somebody that is not

Now, how can we treat the bleeding? We have treatment for ovulatory bleeding that may just require placing the patient on progestins where they just need to either have their progesterone levels boosted a little bit by taking a supplemental progestin and getting kind of a medical D&C performed on a monthly basis. Iíll treat those patients on days 14-23 of their cycle, with 10 mg of Provera a day. Or Iíll offer them

If they have adenomatous hyperplasia this is a little more severe and I will follow them a little closer. I will re-biopsy them in about three months to make sure we are getting improvement. If they have atypical adenomatous hyperplasia - and nowadays youíll see this described as

Hormone replacement therapy: a lot of people advocate biopsying them and then adjusting the estrogen/progestin balance as necessary if you are having trouble with spotting or breakthrough bleeding with these patients. For menopausal patients, if they are close to their menopause - within two years of cessation of their menses - I kind of tend to put them on a cyclic program for about a year to a year and a half because

Patients that are just becoming menopausal - say she quit menstruating three to six months about - and you want to know, should you biopsy her before you start her on estrogens. Does she have any endometrial growth? Itís perfectly acceptable for you to give her 10 days of Provera and see if she has a withdrawal bleed. If she doesnít, then go ahead and start her on estrogen and progestin replacement therapy

For patients on Depo-Provera , how long to I let them go without having a menstrual period if they become amenorrheic? Or when they donít want to take Depo shots any longer, how long will I let them be amenorrheic before Iíll intervene? The thing about Depo-Provera is its effects last for a long time. About 50% of patients will still be anovulatory after their last shot at a six month time frame. Some of them as long as 18 months. You have two choices. The first thing I would is, if the patient wanted to get back to menstruating, I would give her Provera. Do a Provera withdrawal test. If she does not respond to that then she has not developed enough endometrium to start menstruating from. Then you are at the point where you could interfere by giving them estrogen and progestin and then start cycling them on that. My other choice would be, if they are interested in conception, is to give them Clomid to stimulate ovulation, to 

How long will I let a smoking woman take oral contraceptives before Iíll take her off? Iíll let her go to menopause and long as she and I agree on a contract. I will discuss with her her increased risk of cardiovascular disease on the oral contraceptives, I will cut her back to like low estrin or Elise which are 20 mcg pills and