By Shyama S. Mathews, M.D.
Too many women accept abnormal periods as something they just have to live with, much like their mothers and grandmothers did.
But heavy menstruation that leaves you doubled over in pain doesn’t have to go hand-in-hand with being a woman.
Put another way, there’s nothing normal about abnormal bleeding.
If you experience abnormal uterine bleeding, it is important to see a doctor to determine the cause. Often, it can be treated with hormone therapy or minimally invasive procedures that can help restore a normal cycle and relieve uncomfortable symptoms.
Signs of Abnormal Bleeding
Menstrual cycles can range between 21 days and 35 days with bleeding that lasts two to seven days. A typical cycle is 28 days with a period that lasts four to seven days.
Moderate bleeding is expected during a period. Heavy bleeding, however, could signal something is amiss.
How heavy is heavy? That can take some figuring out, but:
• If you’re bringing extra clothes to work or school, that’s heavy.
• If you’re changing protection more than every four hours, that’s also heavy.
• If you’re using the highest absorbency products and still soaking through, that’s heavy too.
While pain and cramps often accompany menstruation, they should be easily managed with over-the-counter pain relievers. Pain so severe that it causes nausea and vomiting or results in missed work or school is cause for concern, as is menstruation accompanied by diarrhea or constipation.
Some women will experience spotting between periods. However, intermittent bleeding, bleeding or spotting after sex, unpredictable periods, or bleeding after menopause can be signs something else is going on that needs medical attention.
Hormonal or Structural
The causes behind abnormal bleeding typically fall into two categories: hormonal or structural.
Many factors can influence hormonal changes that lead to heavy bleeding or irregular and missed periods, including:
• Thyroid imbalances
• Polycystic ovarian syndrome (PCOS)
• Perimenopause
• Life stress
• Exercise
• Dietary changes
Structural conditions that can cause abnormal bleeding include:
• Uterine fibroids
• Endometrial polyps
• Ovarian cysts
• Endometriosis
• Certain types of cancer, such as cancer of the uterus
Diagnosis and Treatment
Diagnosing abnormal uterine bleeding typically begins with a physical exam and complete medical history. It is helpful if women track their cycles and any related symptoms. Today, there are several easy-to-use apps that can help analyze this information. In many cases, with a physical exam, doctors can detect fibroids or ovarian cysts.
Blood tests to measure thyroid function and hormone levels may also be recommended. Doctors may use ultrasound as well as MRI to examine the uterus, ovaries and other reproductive organs to identify structural issues.
In some cases, a saline sonogram – in which the uterus is expanded with water during an ultrasound so doctors can get a better picture of the organ – may be used to detect small, but troublesome, fibroids or polyps along the inner lining of the uterus.
If the cause of abnormal bleeding is determined to be hormonal, doctors may recommend conservative management, including lifestyle changes and a low-dose birth control pill or an intrauterine device (IUD).
If the cause is structural, surgery may be necessary. If surgery is recommended, the woman should discuss her specific concerns and goals with her doctor.
While some women may opt to do nothing, there are several safe and effective minimally invasive surgical options to deal with structural abnormalities of the uterus, including:
• Hysteroscopy, a procedure during which doctors insert a thin tube with a tiny camera into the uterus and clip off any polyps or shave away fibroids. The procedure is performed through the vagina and typically takes less than an hour.
• Endometrial ablation, which destroys the lining of the uterus to stop or reduce the total amount of bleeding. An ablation is not a form of contraception, and pregnancy is not recommended after ablation. Women who have endometrial ablation will need to use birth control until menopause.
• Myomectomy, a surgical procedure to remove fibroids that leaves the uterus in place to preserve the ability to have children. Depending on the location, number, and size of fibroids different approaches are possible. There is always a chance that new fibroids can develop over time, and this should be discussed with your doctor.
• Hysterectomy, or the surgical removal of all or part of the uterus. While most people assume all reproductive organs are removed during hysterectomy, often the ovaries can remain in place so women can avoid early menopause.
At Penn Medicine Princeton Health, both myomectomy and hysterectomy can often be performed using minimally invasive laparoscopy or a robotic surgical system with just a few small abdominal incisions. In these procedures, the abdomen is filled with gas and ports are inserted through these small incisions. A camera and instruments are inserted through the ports so the organs inside can be visualized. The surgeon is able to perform the surgical steps using this camera and the instruments, inside the abdomen and pelvis.
Robotic-assisted surgery enables surgeons to perform complex gynecological surgeries with greater precision and control, minimizing the pain and risk associated with large incisions while increasing the likelihood of a fast recovery and positive clinical outcome. In most cases, women can return home the same day and most can return to work within two weeks.
For women with a significant number of fibroids, however, open surgery may still be necessary to remove the fibroids and preserve the uterus for fertility.
Don’t Wait to Seek Treatment
Many women delay seeking treatment for abnormal uterine bleeding, tolerating it in order to focus on taking care of their families and their careers first.
Moreover, many believe they aren’t candidates for laparoscopic or robotic-assisted surgery and continue to suffer—sometimes for years.
It’s important that women talk openly with their doctor to identify a treatment approach that is right for them. Women shouldn’t be shy about asking questions, including about surgical expertise and the number of procedures their doctor performs.
And no matter what, a woman should be fully confident in her decision to proceed with surgery.
To find a physician with Penn Medicine Princeton Health call 888-742-7496 or visit www.princetonhcs.org.
Shyama S. Mathews, M.D. is a board certified gynecologist and minimally invasive gynecologic surgeon. She is a member of the medical staff at Penn Medicine Princeton Health.