Abnormal uterine bleeding: What physicians need to know

The majority of women will experience some kind of heavy or abnormal uterine bleeding at some point in their lives, however that does not mean physicians should treat it as normal, says Mariea Snell, DNP, APRN, FNPC, assistant director in the Doctor of Nursing Practice at Maryville University in St. Louis, Miss.

“[Abnormal bleeding] is a significant problem that affects a large percentage of women and should be taken seriously; it would be a terrible thing to miss an opportunity to help these patients get to the bottom of something that has a large impact on their quality of life,” Snell says.

Physicians should begin by taking a solid health history, she says, to determine how long ago the bleeding started, and whether it is relegated to just one month or whether it has been going on for a long period of time.

“When someone describes heavy or abnormal bleeding, you need to gauge where it’s coming from,” Snell says.

It’s common to assume that all vaginal bleeding is coming from the uterus, but she says it could be from multiple sources including: pelvic or cervical infections, the cervix (a cyst or polyp), the bladder, or even a laceration in the vaginal canal due to thinning tissue.

Physicians should, of course, determine if the patient is pregnant, as well, as bleeding could be a sign of something wrong with the pregnancy.

The age of the person experiencing the bleeding is also important. “Post menopausal, we would be more concerned about the potential for a malignancy,” she says.

Causes
The most common cause of abnormal bleeding is likely hormonal, Snell says. “An abnormality in thyroid levels, structural polyps, fibroids or adenomyosis are likely causes.”

Fibroids are one of the most common causes of heavy bleeding. These are clusters of abnormal tissue, which are generally not cancerous, that can grow within the endometrium or on the outside of the uterus, Snell explains. A polyp is exclusively an outgrowth of inner endometrial tissue that is most commonly found inside the uterus or on the cervix. Adenomyosis is a growth within the first layer of the uterus.

“They’re all essentially benign growths that disrupt the inner workings of the uterus. Their presence can cause bleeding.”

Hormonal and structural problems can also be associated with hormone disorders such as polycystic ovary syndrome.

Another consideration is if the patient has a copper IUD. “We see one of the biggest side effects is very heavy and at times painful periods.”

In rare cases, abnormal bleeding can be an indication of cancer. “If they have continued bleeding that’s not being controlled by hormonal medications, and you can’t find an obvious source and they’re post menopausal, we would consider an endometrial biopsy,” Snell says.

Since the procedure is somewhat invasive, she says it should really be saved for when all other causes have been ruled out.

Treatments
In most cases of abnormal bleeding that recur for one of the above mentioned reasons, birth control pills are typically prescribed to reduce bleeding, Snell says. Some patients opt to have surgery to remove fibroids and polyps, and in some cases, where bleeding is so excessive as to interfere with a patient’s daily activities, hysterectomy and endometrial ablation are considered.

Snell says that physicians are sometimes nervous to do these procedures because of their finality, but she has seen cases where heavy bleeding was interfering with a patient’s ability to engage in daily life activities from work to leisure.

“If their blood levels and iron and hematocrit levels are low, and it’s having a significant impact on her quality of life, it should be a no brainer. You do [a hysterectomy] and she gets her life back,” Snell says.

For physicians who are worried about recommending or performing such procedures on women still in their childbearing years, Snell says, “I would caution doctors from putting their own feelings and beliefs on a patient’s situation and listen to their patient.”

In general, she says, “We owe it to our patients to address their issues.”