Irregular Uterine Bleeding - The Symptoms Of Menopause: Menopause Managing The Change Of Life

Uterine bleeding: What's normal, what's not

One concern for perimenopausal and postmenopausal women is knowing whether irregular uterine bleeding is normal. Most women notice normal changes in their cycle as they approach menopause. Periods are often heavy or more frequent, and they may stop and start. But abnormal uterine bleeding may be a sign of benign gynecologic problems or even uterine cancer. Consult your physician if any of the following situations occur:

• You have a few periods that last three days longer than usual.

• You have a few menstrual cycles that are shorter than 21 days.

• You bleed after intercourse.

• You have heavy monthly bleeding (soaking a sanitary product every hour for more than a day).

• You have spotting (bleeding between periods).

• You have bleeding that occurs outside the normal pattern associated with hormone use (see "Hormone therapy").

When you report abnormal vaginal bleeding, your clinician will try to determine whether the cause is an anatomic problem or a hormonal issue. He or she also will investigate the possibility of cancer. In addition to identifying the cause, he or she will help you manage any excess bleeding, which sometimes leads to anemia.

One condition that may cause abnormal uterine bleeding is endometrial hyperplasia, a precancerous condition of the lining of the uterus (endometrium). Other possible explanations include fibroids, benign uterine tumors that may enlarge during perimenopause and decrease in size after menopause; endometrial polyps, which are benign growths in the uterine lining; and thyroid disorders, which can cause either too much or too little bleeding. Contraceptives may also cause bleeding between periods or changes in bleeding patterns. Blood clotting disorders, although rare, sometimes affect menstrual bleeding.

On rare occasions, postmenopausal women experience uterine bleeding from a "rogue ovulation," which is vaginal bleeding after a hiatus that may be preceded by premenstrual symptoms such as breast tenderness. Presumably, the ovaries are producing some hormones and maybe a final egg.

Postmenopausal women who are not taking hormones should not generally have vaginal bleeding and should seek medical care if they do. But it is normal for women who take hormone therapy in continuous doses to experience bleeding or spotting during the first several months of taking these medications. And women on cyclic hormone regimens sometimes have light monthly bleeding. Vaginal bleeding outside the usual pattern for hormone therapy in a postmenopausal woman is always a cause for concern.

Diagnosing abnormal bleeding. Your physician may use any or all of the tests below to diagnose abnormal bleeding:

• Endovaginal (transvaginal) ultrasound. This painless procedure uses a small, tampon-sized transducer, or probe, inserted in the vagina to generate ultrasound images of the uterus and measure endometrial thickness or mass to determine if further examination is necessary. If the endometrium is thickened, the next step may be an endometrial biopsy, hysteroscopy, or sonohysterogram to obtain a more complete diagnosis.

• Endometrial biopsy. Performed in a physician's office, this procedure involves inserting a thin tube through the vagina and cervical opening to remove a sample of the endometrium with a suction device. The tissue is analyzed to rule out cancer or a precancerous condition. Even though endometrial biopsy usually is performed without anesthesia, many women find it uncomfortable or painful. Taking an over-the-counter pain reliever can help before and after the procedure. In some cases, doctors use sedation or anesthesia.

• Hysteroscopy. In this procedure, the doctor uses a thin fiber-optic tube, or hysteroscope, to obtain a direct view of the uterus. After numbing the cervical area with a local anesthetic, the doctor inserts the tube through the vagina and cervix and introduces a liquid or gas to expand the uterus so it can be seen clearly through the scope. The doctor can take tissue samples or remove polyps or fibroids, usually with a regional or general anesthetic.

• Sonohysterography. The doctor performs this test like an endovaginal ultrasound, by inserting an ultrasound probe in the vagina that transmits images of the uterus and uterine lining. The difference is that a saline solution is introduced through a thin tube to expand the uterus for better viewing. Your physician can measure uterine thickness and identify polyps and other abnormalities inside the uterus.

Treating abnormal bleeding. Treatments vary depending on the underlying cause of the bleeding. The clinician may just monitor your condition periodically and recommend iron supplements if you have anemia resulting from the excess bleeding. Hormonal treatments, such as birth control pills or the intrauterine device called Mirena (see "Irregular periods"), are helpful for many women. Endometrial ablation — an outpatient surgical procedure that destroys the uterine lining using a heated balloon or a roller ball — may be appropriate for others. Finally, hysterectomy is another option (see "What about hysterectomy?").

Pregnancy during perimenopause

Fertility rates begin dropping steeply between ages 35 and 38 and fall to less than 1% by age 50. While pregnancy isn't common in 40-something women, it does occur. In fact, unintended pregnancy rates are actually higher among women in their 40s than in any other age group, including teenagers. It's one reason some women use oral contraceptives during perimenopause.

At the other end of the spectrum are women in their 40s who want to become pregnant but cannot. For them, assisted reproductive technology (ART) is an option. Just as with natural pregnancies, the success rates of these techniques (such as in vitro fertilization) decline with age. Also, the likelihood of miscarriage and genetic abnormalities in the baby are higher in older women. Using donor eggs from a younger woman increases the likelihood of a successful pregnancy.

What about hysterectomy?

Hysterectomy is less common than it used to be, although it remains the most common non-obstetrical surgery in the United States. More than 600,000 hysterectomies are performed in the United States each year, at a cost of $5 billion annually. More than a third of these surgeries are done to treat abnormal uterine bleeding or fibroids. One in three women in the United States has a hysterectomy by age 60. Removing only the uterus in a premenopausal woman can accelerate menopause by as much as two years. When the ovaries are removed with the uterus, menopause occurs immediately.

Reasons for hysterectomy. More than 90% of hysterectomies are done for noncancerous conditions, such as uncontrollable uterine bleeding, fibroids, endometriosis (in which tissue from the uterine lining adheres outside of the uterus), chronic pelvic pain, some precancerous conditions, and uterine prolapse (in which the uterus drops from its normal position into the vagina). The remainder are done to treat cancer of the uterine lining, ovaries, or cervix. Currently, no universally accepted criteria exist for when a hysterectomy is warranted for some conditions. Unless your condition is potentially life-threatening, talk to your physician about whether a hysterectomy is really necessary. It's always a good idea to get a second opinion. The fact that hysterectomy rates are far higher in the southern United States compared with the northeastern states and other countries such as the United Kingdom suggests that factors unrelated to medical necessity may be at work.

Types of hysterectomy. In an abdominal hysterectomy, the surgeon makes an incision several inches long in the abdominal wall, just above the pubic bone, and removes the uterus through the incision. In a vaginal hysterectomy, the uterus is removed through the vagina, via an incision made in the vaginal wall. In some cases, the surgeon may use a laparoscopic technique, which involves several small incisions in the abdomen and the insertion of a thin, flexible tube called a laparoscope to view the pelvic organs. The uterus is removed through one of the small incisions or through the vagina. Because of the smaller incisions, recovery time is shorter and scars are smaller. Hospitalization can be as short as one day.

Standard hysterectomy

The hysterectomy procedure. To prepare for the surgery, you will usually have general anesthesia. Your airway will be kept open with a small tube, and a catheter will be placed in your bladder. You'll probably receive an antibiotic to reduce the risk of infection. During the surgery, tissues that attach the uterus to the pelvic wall are cut, and the uterus is separated from the top of the vagina. Some or all of the cervix may be removed, depending on why you are having the surgery. If cancer isn't a concern, some women feel that keeping part of the cervix helps them maintain sexual function.

According to the Centers for Disease Control and Prevention, 78% of women ages 45–64 who have hysterectomies also have their ovaries removed at the same time, a procedure known as oophorectomy. The ovaries are routinely removed in women who have ovarian cancer or suspicious ovarian tumors. Women known to have rare, inherited types of breast or ovarian cancer sometimes have their ovaries removed to reduce their risk of these cancers. And women who have severe endometriosis often have oophorectomies, both because estrogen from the ovaries can promote the growth of any remaining endometriosis, and because endometriosis on the ovaries can spread to other organs. But oophorectomy can worsen menopausal symptoms and increase a woman's susceptibility to osteoporosis and heart disease. A 2005 study in Obstetrics and Gynecology found that for most women, these increased risks overshadow the small benefit of preventing ovarian cancer, which is very rare.

After the surgery. You will no longer have monthly menstrual periods, and you won't be able to become pregnant. As you recuperate, give yourself time to heal physically, mentally, and emotionally. Studies show a high level of satisfaction among women who choose hysterectomy. But it is a personal decision, and one that should be made after considering all the alternatives.