As noted elsewhere, bleeding conditions can originate from the vagina, which is easily noted on Pelvic Exam. Here we discuss bleeding from the Uterus, even though it may be called “Vaginal” because it exits the vagina. See also Diagram: Female Genital System.
“Irregular Bleeding” can mean several different things. It might mean periods that last different amounts of time, maybe sometimes heavy sometimes light, and come without any pattern. It might mean spotting between periods. It might mean a single, new, long period that doesn’t stop. We won’t deal with periods that begin on a different day each month, if by counting out length of time, they wind up being fairly regular periods after all, which simply occur a little more often (every 23-28 days), or a little late (up to every 38 days, 5-and-a-half weeks). Those are variations of normal.
It’s common for girls just beginning to menstruate, and for older women approaching menopause, to have irregular periods. We don’t do work-ups at those stages of life, unless the bleeding is very heavy (see Heavy Menstrual Periods). The rest of this topic deals with periods that have newly become irregular, or for young women whose periods remain very irregular into their late teens or twenties.
Causes of Irregular Uterine Bleeding
| xxxxxxxConditions of the Cervix โข Cervical Polyps โข Cervical Cancer โข Cervicitis (infection) xxxxConditions of the Endometrium โข Fibroids (leiomyomas) โข Endometrial Polyps โข Endometrial Cancer โข Chronic Uterine / Tubal Infections (rare) | xxEndocrine Conditions Affecting Ovulation โข Polycystic Ovarian Syndrome (PCOS) โข Hyperprolactinemia (High Prolactin Level) โข Hypothyroidism โข Hyperthyroidism โข Congenital Adrenal Hyperplasia (CAH) xxxxxxBirth Control Methods โข Certain IUDs or hormones x |
Diagnostic Work-Up
Our first step is a pelvic exam. Looking inside the vagina with a speculum, we can often see Diseases of the Cervix like Cervicitis (infection), and sometimes Cervical Polyps (benign growths), or a Cancer that’s large enough to bleed. We’d do a Pap smear, not only for abnorma cells of the cervix (the usual reason), but also to see if endometrial cells are being shed (which would raise concern for Endometrial Cancer if >40 years-old). A “bimanual” exam of the uterus (“using both hands,” two fingers inside the vagina, while the other feels from the outside) can suspect uterine tenderness (Uterine or Tubal Infection) or enlargement (likely Fibroids).
If we see Cervicitis, or suspect Uterine / Tubal Infection, we obtain tests for STDs and treat with antibiotics (even before results, since there may be false-negatives) and see if irregular bleeding stops.ย If we feel an enlarged uterus, we order an Ultrasound to figure out what’s there.ย Obviously, if the woman’s Birth Control Method may be associated with irregular bleeding, we consider changing it.
If the pelvic exam is normal, we consider various Endocrine Conditions (involving different hormones of the body).
- Thyroid Disease (Hyperthyroidism or Hypothyroidism): easily diagnosed by blood tests for thyroid hormones (mainly the TSH)
- Hyperprolactinemia: suspected if there’s milky discharge from breasts, easily diagnosed by blood test for prolactin hormone.ย If positive, a brain MRI is needed to detect tumors of the pituitary gland (usually benign ones), unless the woman is taking certain psychiatric medicine that can cause it
- Polycystic Ovarian Syndrome (PCOS):ย especially if the woman has excess body hair, excess facial hair, balding on the head, and/or acne, usually with obesity.ย Periods are usually light.ย Diagnosis can be made by finding high levels of testosterone; sometimes other hormones are also measured
- Congenital Adrenal Hyperplasia:ย Same body characteristics as PCOS above, but the condition is much less common.ย Diagnose by an elevated 17-Hydroxyprogesterone blood level
A main question involves whether we should worry about Endometrial Cancer, which would require an Endometrial Biopsy (EMB) (of the endometrium, the lining of the uterus). We’d want to do this in the following cases:
- All women after menopause
- Women over 45 yrs. old with bleeding between periods
- Women with certain abnormalities on Pap test (abnormal endometrial cells, any endometrial cells if patient >40 yrs. old, any abnormal cells from cervix if patient >35)
- Obese women, especially if they’re getting older, & irregular bleeding continues
- Women who have irregular bleeding after more than 6 months without a period (not related to birth control or breast-feeding)
- Women with one long period that won’t stop with treatment (hormones)
- Certainly women with rare genetic conditions with very high risk for endometrial cancer (Cowden or Lynch syndromes)
- Certainly women who happened to be taking estrogen hormones without added progesterone hormone (very uncommon these days)
For post-menopausal women, who are the majority of women diagnosed with Endometrial Cancer, we begin with an ultrasound, to measure endometrial thickness (known in medical jargon as the โstripeโ). If this is <3-4 mm thick, cancer would be most unlikely, so we might forego the biopsy (EMB). Measuring โstripeโ thickness isnโt valid before menopause.
A clearer way to evaluate the โstripeโ is by a special ultrasound called sonohysterography, during which saline is infused into the uterus. As noted, a โstripeโ >3-4 mm requires an EMB, which is uncomfortable, but easily done in an office or clinic by suctioning.
However, if a specific abnormal area is noted on either type of ultrasound, we refer to Gynecology for one of two options:
- Dilation & Curettage (D&C), scraping the endometrium under anesthesia
- Hysteroscopy — inserting an endoscope into the uterus to pinpoint the place and obtain the biopsy.
- A standard EMB is also possible, but local abnormalities may be too large to sample by suctioning.
We’d also want to do an EMB for women with irregular bleeding after childbirth or procedures on the uterus, especially if the uterus is tender, since it could be a sign of rare chronic infection.
If the EMB is normal (no cancer), we reassure the woman. Treatments for irregular bleeding exist, but aren’t necessary; the main point is that there isn’t Cancer. However, if the woman is way beyond menopause, Gynecologists may want to perform a D&C to be sure.
See also Irregular Uterine Bleeding for the clinicianโs condensed thought-process when face-to-face with a patient.