Irregular bleeding can mean lifelong history of irregular periods, regular periods with spotting in-between, changes in the length of periods, or bleeding after menopause. The worst condition, which is often the focus of diagnostic studies, is cancer.
As mentioned 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.
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) [rare] xxxxxxBirth Control Methods โข Certain IUDs or hormones x |
1. Perform Pelvic exam
- Can often see Diseases of the Cervix
- Pap test can find microscopic clues to Cancers
- Feeling the uterus can suspect Fibroids (usually only if very large)
2. Order blood tests for Endocrine Conditions:
- TSH (Thyroid Stimulating Hormone) โ for Hypo- / Hyper-Thyroid
- Prolactinย —ย for High Prolactin (from brain or pituitary gland tumors)
- Testosterone, maybe other hormones, for PCOS (if excess facial / body hair, acne, obese)
- If characteristics of PCOS, maybe an early morning 17-hydroxyprogesterone blood test (with/without Cortisol stress-test) for Congenital Adrenal Hyperplasia (CAH) [rare]
3. Consider changing Birth Control Method if current one can cause irregular bleeding
4. Order an Ultrasound (for Fibroids)
5. Consider Endometrial Biopsy (EMB) if risk for Endometrial Cancer:
- All women with bleeding after menopause
- Women over 45 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 getting older, & irregular bleeding continues
- Irregular bleeding after 6 months without a period (not from birth control, breast-feeding)
- Women with one long period that won’t stop with treatment (hormones)
- Rare genetic conditions (Cowden or Lynch syndromes)
- Using estrogen without added progesterone hormone (very uncommon these days)
5a. Before Endometrial Biopsy (EMB), do Ultrasound for endometrial thickness (a.k.a. โstripeโ), or sonohysterography (ultrasound with saline infused in uterus):
- If <3-4 mm, Cancer unlikely (only valid in post-menopausal women)
- If >3-4 mm & uniform, EMB by simple suctioning
- If a single abnormal spot in uterus, 2 (or 3) options:
- dilation & curettage (D&C)
- direct biopsy by looking through hysteroscope
- simple EMB as above, but often unsuccessful for larger polyps
See Irregular Uterine Bleeding โ Full Text for more in-depth explanations and discussions.