INTRODUCTION The inside of the uterus has two layers. The thin inner layer is called the endometrium.

The thick outer layer is the myometrium (myo = muscle) (figure 1). In women who menstruate, the endometrium thickens every month in preparation for pregnancy. If the woman does not become pregnant, the endometrial lining is shed during the menstrual period. After menopause, the lining normally stops growing and shedding. Under normal circumstances, a woman's uterus sheds a limited amount of blood during each menstrual period (less than 5 tablespoons or 80 mL). Bleeding that occurs between menstrual periods or excessive menstrual bleeding is considered to be abnormal uterine bleeding. Once a woman who is not taking hormone therapy enters menopause and the menstrual cycles have ended, any uterine bleeding is considered abnormal. Abnormal uterine bleeding can be caused by many different conditions. This topic review discusses the possible causes of abnormal bleeding, how it is evaluated, and various treatment strategies that may be recommended. CAUSES OF ABNORMAL UTERINE BLEEDING Most conditions that cause abnormal uterine bleeding can occur at any age, but some are more likely to occur at a particular time in a woman's life. Abnormal uterine bleeding in young girls Bleeding before menarche (the first period in a girl's life) is always abnormal. It may be caused by trauma, a foreign body (such as toys, coins, or toilet tissue), irritation of the genital area (due to bubble bath, soaps, lotions, or infection), or urinary tract problems. Bleeding can also occur as a result of sexual abuse. Adolescents Many girls have episodes of irregular bleeding during the first few months after their first menstrual period. This usually resolves without treatment when the girl's hormonal cycle and ovulation normalizes. If bleeding persists beyond this time, or if the bleeding is heavy, further evaluation is needed. Abnormal bleeding in this age group can also be caused by any of the conditions that cause bleeding in all premenopausal women, including: pregnancy, infection, and bleeding disorder or other medical illnesses. These and other causes are discussed in the next section. Premenopausal women Many different conditions can cause abnormal bleeding in women between adolescence and menopause. Abrupt changes in hormone levels at the time of ovulation can cause vaginal spotting, or small amounts of bleeding. Breakthrough bleeding can also occur in premenopausal women who use hormonal birth control methods. Some women do not ovulate regularly and may experience intermittent light or heavy vaginal bleeding. Although anovulation is most common when periods first begin and during perimenopause, it can occur at any time during the reproductive years. (See "Patient information: Absent or irregular periods (Beyond the Basics)".) Some women who ovulate normally experience excessive blood loss during their periods or bleed between periods. The most common causes of such bleeding are uterine fibroids or polyps. These irregular growths and benign tumors are composed of uterine tissue that distort the structure of the uterus and lead to abnormal uterine bleeding. Fibroids and polyps can also occur in anovulatory women.

(See "Patient information: Uterine fibroids (Beyond the Basics)" and"Patient information: Menorrhagia (excessive menstrual bleeding) (Beyond the Basics)".) Other causes of abnormal uterine bleeding in premenopausal women include: Pregnancy Cancer or precancer of the cervix or the endometrium (lining of the uterus) (see "Patient information: Endometrial cancer diagnosis and staging (Beyond the Basics)") Infection or inflammation of the cervix or endometrium Clotting disorders such as von Willebrand disease, platelet abnormalities, or problems with clotting factors Medical illnesses such as hypothyroidism, liver disease, or chronic renal disease

Hormonal birth control Girls and women who use hormonal birth control (eg, pills, ring, shot, patch) may experience "breakthrough" bleeding between periods. If this occurs during the first few months, it may be due to changes in the lining of the uterus. If it persists for more than a few months, evaluation may be needed and/or a different birth control pill may be recommended. (See "Patient information: Hormonal methods of birth control (Beyond the Basics)".) Breakthrough bleeding can also happen if a hormonal birth control method is forgotten or taken late. In this situation, there is a risk that the woman could become pregnant if she has sex. Another form of birth control (eg, condoms) is recommended if the pill/patch/shot is not taken on time. Women in the menopausal transition Before the menstrual periods end, a woman passes through a period called the menopausal transition. During the menopausal transition, normal hormonal cycling begins to change and ovulation may be inconsistent. While estrogen secretion continues, progesterone secretion declines. These hormonal changes can cause the endometrium to grow and produce excess tissue, increasing the chances that polyps or endometrial hyperplasia (thickened lining of the uterus) will develop and potentially cause abnormal bleeding. Women in the menopausal transition are also at risk for other conditions that cause abnormal bleeding, including cancer, infection, and bodywide illnesses. Further evaluation is needed in women with persistent irregular menstrual cycles or an episode of profuse bleeding. Women in the menopausal transition still ovulate some of the time and can become pregnant; pregnancy can cause abnormal bleeding. In addition, women in perimenopause may use hormonal birth control medications, which can cause breakthrough bleeding. Menopausal women A number of conditions can cause abnormal bleeding during the menopause. Women who take hormone replacement therapy may experience cyclical bleeding. Any other bleeding that occurs during menopause is abnormal and should be investigated. Causes of abnormal bleeding during menopause include: Atrophy (excessive thinning) of the tissue lining the vagina and uterus Cancer of the uterine lining (endometrium) (see "Patient information: Endometrial cancer diagnosis and staging (Beyond the Basics)") Polyps or fibroids Endometrial hyperplasia Infection of the uterus Use of blood thinners or anticoagulants

Side effects of radiation therapy

ABNORMAL UTERINE BLEEDING EVALUATION Initial assessment While taking a woman's medical history, a clinician will review the duration and amount of bleeding; factors that seem to bring the bleeding on; symptoms that occur along with the bleeding such as pain, fever, or vaginal odor; if bleeding occurs after sexual intercourse; whether there is a personal or family history of bleeding disorders; the woman's medical history and medications she is taking; recent weight changes, stress, a new exercise program, or underlying medical problems. The clinician will perform a physical examination to evaluate the woman's overall health, and a pelvic examination to confirm that the bleeding is from the uterus and not from another site (eg, the external genitals or rectum). During the pelvic exam, the clinician will look for any obvious lesions (cuts, sores, or tumors) and will examine the size and shape of the uterus. He or she will examine the cervix to look for signs of cervical bleeding, and a Pap smear may be obtained to examine the cells of the cervix (the lower end of the uterus, where it opens to the vagina). (See "Patient information: Cervical cancer screening (Beyond the Basics)".) Lab tests In premenopausal women, a pregnancy test is performed. If there is any abnormal vaginal discharge, a cervical culture may be performed. Blood tests may also be done to determine if there are problems with blood clotting or other bodywide conditions, such as thyroid disease, liver disease, or kidney problems. Tests to determine ovulatory status Because hormonal irregularities can contribute to abnormal uterine bleeding, testing may be recommended to determine if the woman ovulates (produce an egg) during each monthly cycle. Endometrial assessment Tests that assess the endometrium (lining of the uterus) may be performed to rule out endometrial cancer and structural abnormalities such as uterine fibroids or polyps. Such tests include: Endometrial biopsy An endometrial biopsy is often performed in women over age 35 to rule out endometrial cancer or abnormal endometrial growths. A biopsy may also be performed in women younger than 35 if they have risk factors for endometrial cancer. Risks include obesity, chronic anovulation, history of breast cancer, tamoxifen use or a family history of breast cancer or colon cancer. (See "Patient information: Endometrial cancer diagnosis and staging (Beyond the Basics)".) During the biopsy, a thin instrument is inserted through the vagina into the uterus to obtain a small sample of endometrial tissue. The biopsy can be performed in a healthcare provider's office without anesthesia. Because only a small portion of the endometrium is sampled, the biopsy may miss some causes of bleeding and other tests are sometimes necessary. Transvaginal ultrasound An ultrasound uses sound waves to measure an organ's shape and structure. In a transvaginal ultrasound, a small ultrasound probe is inserted into the vagina so that it is closer to the uterus and can provide a clear image of the uterus. The lining of the uterus is evaluated and measured; postmenopausal women normally have a very thin endometrial lining (usually less than 4 or 5 mm). Ultrasound cannot distinguish between different types of abnormalities (eg, polyp versus cancer) and further testing may be necessary. Saline infusion sonography ( sonohysterography) In this test, a transvaginal ultrasound is performed after sterile saline is instilled into the uterus. This procedure gives a better picture of the inside

of the uterus, and small lesions can be more easily detected. However, because tissue samples cannot be obtained during the procedure, a final diagnosis is not always possible and additional evaluation, usually including hysteroscopy with dilation and curettage (D&C) may be necessary. Imaging tests A magnetic resonance image (MRI) is a non-invasive test that is sometimes used to determine if fibroids or other structural abnormalities of the uterus are present. Hysteroscopy During hysteroscopy, a small scope is inserted through the cervix and into the uterus. Air or fluid is injected to expand the uterus and to allow the physician to see the inside of the uterus. Tissue samples may be taken. Anesthesia is used to minimize discomfort during the procedure. In most cases, hysteroscopy is performed along with a D&C. Dilation and curettage (D&C) In a D&C, the cervix or opening of the uterus is dilated and instruments are inserted and used to remove endometrial or uterine tissue. A D&C usually requires anesthesia. It can sometimes be used as a treatment for prolonged or excessive bleeding that is due to hormonal changes and that is unresponsive to other treatments. (See "Patient information: Dilation and curettage (D and C) (Beyond the Basics)".) ABNORMAL UTERINE BLEEDING TREATMENT The treatment of abnormal bleeding is based upon the underlying cause. Birth control pills Birth control pills are often used to treat uterine bleeding that is due to hormonal changes or hormonal irregularities. Birth control pills may be used in women who do not ovulate regularly to establish regular bleeding cycles and prevent excessive growth of the endometrium. In women who do ovulate, they may be used to treat excessive menstrual bleeding. Nonsteroidal anti-inflammatory drugs (NSAIDS, eg ibuprofen, naproxen sodium) may also be helpful in reducing blood loss and cramping in these women. During the menopausal transition, birth control pills or other hormonal therapy may be used to regulate the menstrual cycle and prevent excessive growth of the endometrium. (See "Patient information: Menorrhagia (excessive menstrual bleeding) (Beyond the Basics)".) Progesterone Progesterone is a hormone made by the ovary that is effective in preventing excessive bleeding in women who do not ovulate regularly. A synthetic form of progesterone, called progestin, may be recommended to treat abnormal bleeding. Progestins are usually given as pills (eg, medroxyprogesterone acetate, norethindrone), and are taken once a day for 10 to 12 days each month or two. Progestins can be taken for longer periods if there has been overgrowth of the uterine lining. Vaginal bleeding will begin before the seventh day of progestin treatment if the uterine lining is overgrown; otherwise, it may not be seen until several days after the last progestin tablet is taken. In some cases, the progestin is given on a regular basis (eg, every few months) to prevent excessive growth of the uterine lining and heavy menstrual bleeding. If no bleeding is seen after progestin treatment, the possibility of an unintended pregnancy should be explored. Progestins may also be given in other ways, such as in an injection, an implant, or an intrauterine device. These treatments are discussed in detail in a separate topic review. (See "Patient information: Menorrhagia (excessive menstrual bleeding) (Beyond the Basics)".) Intrauterine device An intrauterine contraceptive device (IUD) that secretes progestin (eg, Mirena) may be recommended for women who do not ovulate regularly. IUDs are inserted by a healthcare provider through the vagina and cervix into the uterus. Most are made of molded plastic and include an

attached plastic string that projects through the cervix, enabling the woman to check that the device remains in place (picture 1). Progestin-releasing IUDs decrease menstrual blood loss by 40 to 50 percent and decrease pain associated with periods. Some women completely stop having menstrual bleeding as a result of the IUD, which is reversible when the IUD is removed. (See "Patient information: Long-term methods of birth control (Beyond the Basics)".) Surgery Surgery may be necessary to remove abnormal uterine structures (eg, fibroids, polyps). Women who have completed childbearing and have heavy menstrual bleeding can consider a surgical procedure such as endometrial ablation. This procedure is done while the woman is under general or regional anesthesia, and uses heat, cold, or a laser to destroy the lining of the uterus. More information about endometrial ablation is available in a separate topic review. (See "Patient information: Menorrhagia (excessive menstrual bleeding) (Beyond the Basics)".) Women with fibroids can have surgical treatment of their fibroids, either by removing the fibroid(s) (eg, myomectomy) or by reducing the blood supply of the fibroids (eg, uterine artery embolization). More information about these treatments is available separately. (See "Patient information: Uterine fibroids (Beyond the Basics)".)

What is abnormal uterine bleeding?

Abnormal uterine bleeding is any bleeding from the uterus (through your vagina) other than your normal monthly period. Having extremely heavy bleeding during your period can also be considered abnormal uterine bleeding. Very heavy bleeding during a period and/or bleeding that lasts more than 7 days is called menorrhagia (say: men-oh-raj-ee-ah). Women who have menorrhagia may, for example, bleed enough to soak through 1 or more tampons or sanitary pads every hour.

What causes abnormal uterine bleeding?

Many different things can cause abnormal uterine bleeding. Pregnancy is a common cause. Polyps or fibroids (small and large growths) in the uterus can also cause bleeding. Rarely, a thyroid problem, infection of the cervix or cancer of the uterus can cause abnormal uterine bleeding. In most women, abnormal uterine bleeding is caused by a hormone imbalance. When hormones are the problem, doctors call the problem dysfunctional uterine bleeding, or DUB. Abnormal bleeding caused by hormone imbalance is more common in teenagers or in women who are approaching menopause. These are just a few of the problems that can cause abnormal uterine bleeding. These problems can occur at any age, but the likely cause of abnormal uterine bleeding usually depends on your age.

Women in their teens, 20s and 30s

A common cause of abnormal bleeding in young women and teenagers is pregnancy. Many women have abnormal bleeding in the first few months of a normal pregnancy. Some birth control pills or the intrauterine device can also cause abnormal bleeding. Some young women who have abnormal uterine bleeding do not release an egg from their ovaries (called ovulation) during their menstrual cycle. This is common for teenagers who have just started getting their periods. This causes a hormone imbalance where the estrogen in your body makes the lining of your uterus (called the endometrium) grow until it gets too thick. When your body gets rid of this lining during your period, the bleeding will be very heavy. A hormone imbalance may also cause your body not to know when to shed the lining. This can cause irregular bleeding (spotting) between your periods.

Women in their 40s and early 50s

In the years before menopause and when menopause begins, women have months when they don't ovulate. This can cause abnormal uterine bleeding, including heavy periods and lighter, irregular bleeding. Thickening of the lining of the uterus is another cause of bleeding in women in their 40s and 50s. This thickening can be a warning of uterine cancer. If you have abnormal uterine bleeding and youre in this age group, you need to tell your doctor about it. It may be a normal part of getting older, but it's important to make sure uterine cancer isn't the cause.

Women after menopause

Hormone replacement therapy is a common cause of uterine bleeding after menopause. Other causes include endometrial and uterine cancer. These cancers are more common in older women than in younger women. But cancer is not always the cause of abnormal uterine bleeding. Many other problems can cause bleeding after menopause. For this reason, its important to talk to your doctor if you have any bleeding after menopause.

What tests can find the cause of abnormal uterine bleeding?

The tests your doctor orders may depend on your age. If you could be pregnant, your doctor may order a pregnancy test. If your bleeding is heavy, in addition to other tests, your doctor may want to check your blood count to make sure you don't have anemia (low iron) from the blood loss. An ultrasound exam of your pelvic area shows both the uterus and the ovaries. It may also show the cause of your bleeding. Your doctor may want to do an endometrial biopsy. This is a test of the uterine lining. It's done by putting a thin plastic tube (called a catheter) into your uterus. A tiny piece of the uterine lining is taken out and sent to a lab for testing. The test will show if you have cancer or a change in the cells. A biopsy can be done in the doctor's office and causes only mild pain. Another test is a hysteroscopy. A thin tube with a tiny camera in it is put into your uterus. The camera lets your doctor see the inside of your uterus. If anything abnormal shows up, your doctor can get a biopsy.

How is abnormal uterine bleeding treated?

There are several treatment options for abnormal bleeding, depending on the cause of your bleeding, your age and whether you want to get pregnant in the future. Your doctor will help you decide which treatment is right for you. Or, if your doctor decides that a hormone imbalance is causing your abnormal bleeding, you and your doctor may decide to wait and see if the bleeding improves on its own. Some treatment options include the following: Birth control pills. Birth control pills contain hormones that can stop the lining of your uterus from getting too thick. They can also help keep your menstrual cycle regular and reduce cramping. Some types of birth control pills, especially the progestin-only pill (also called the mini-pill) can actually cause abnormal bleeding for some women. Let your doctor know if the pill youre taking doesnt control your abnormal bleeding. Intrauterine device (IUD). If birth control pills dont control your bleeding, your doctor may suggest an IUD. An IUD is a small, plastic device that your doctor inserts into your uterus through your vagina to prevent pregnancy. One type of IUD releases hormones, and this type can significantly reduce abnormal bleeding. Like birth control pills, sometimes IUDs can actually cause abnormal bleeding. Tell your doctor if this happens to you. A D&C, or dilatation and curettage, is a procedure in which the opening of your cervix is stretched just enough so a surgical tool can be put into your uterus. The tool is used to scrape away the lining of your uterus. The removed lining is checked in a lab for abnormal tissue. A D&C is done under general anesthesia (while you're in a sleep-like state). If you're having heavy bleeding, a D&C may be done both to find out the problem and to treat the bleeding. The D&C itself often makes heavy bleeding stop. Your doctor will decide if this procedure is necessary. Hysterectomy. This type of surgery removes the uterus. If you have a hysterectomy, you wont have any more periods and you wont be able to get pregnant. Hysterectomy is major surgery that requires general anesthesia and a hospital stay. It may require a long recovery period. Talk to your doctor about the risks and benefits of hysterectomy. Endometrial ablation is a surgical procedure that destroys the lining of the uterus. Unlike a hysterectomy, it does not remove the uterus. Endometrial ablation may stop all menstrual bleeding in some women. However, some women still have light menstrual bleeding or spotting after endometrial ablation. A few women have regular menstrual periods after the procedure. Women who have endometrial ablation still need to use some form of birth control even though, in most cases, pregnancy is not likely after the procedure. Your doctor can do endometrial ablation in several different ways. Newer endometrial ablation techniques do not require general anesthesia or a hospital stay. The recovery time after this procedure is shorter than recovery time after a hysterectomy

Abnormal uterine bleeding: Treatment, symptoms, advice and help

About abnormal uterine bleeding
Abnormal uterine bleeding is one of the most common gynaecological problems and essentially means abnormal bleeding from the vagina.

Abnormal uterine bleeding: Incidence, age and sex

Abnormal uterine bleeding can occur at any age but it seems to be more common in adolescents and peri menopausal women.

Causes and prevention of abnormal uterine bleeding

There are several causes of abnormal uterine bleeding. It can be due to certain disorders of the genital tract, hormonal imbalances or other systemic causes. Localised gynaecological causes of abnormal uterine bleeding include abortion, benign growths in uterus called fibroids and polyps, malignancy of the uterus, the cervix or the vagina, or may be related to insertion of intra uterine devices. Ectopic pregnancy in which the product of conception is placed outside the uterus may also lead to abnormal bleeding. Other non-gynaecological causes include thyroid problems, pituitary tumours, bleeding disorders, anaemia, mental stress and certain medications like birth control pills.

Signs and symptoms of abnormal uterine bleeding: Diagnosis

Any kind of vaginal bleeding except menstrual bleeding is abnormal. It includes both increased amount as well as reduced amount of vaginal bleeding. A menstrual cycle exceeding 35 days or less than 21 days constitute abnormal uterine bleeding. Vaginal bleeding between periods or intermenstrual bleeding is abnormal. Moreover, mid cycle spotting, post menopausal bleeding or vaginal bleeding after sexual intercourse are also signs of abnormal bleeding. Absence of periods in a woman for more than 6 months without any apparent cause is a feature of abnormal uterine bleeding as well.

Abnormal uterine bleeding: Complications

There are usually no complications of abnormal uterine bleeding unless the bleeding is substantial. Long-term excessive bleeding may cause reduced haemoglobin or anaemia. Sudden excessive blood loss might result in shock which is a medical emergency. Other complications might arise due to the underlying cause of abnormal bleeding.

Abnormal uterine bleeding: Treatment

The treatment of abnormal uterine bleeding depends not only on its underlying cause but also the womans age and her family status regarding children. The treatment modalities include hormonal medication and surgery. Hormonal medication may help in maintaining hormonal balance thereby preventing abnormal bleeding from the uterus. Such medicine may be given in tablet form, injections, vaginal creams for topical applications or via intra uterine devices. Antibiotics are recommended if the bleeding is accompanied by fever and infection. Surgical treatment modality includes hysteroscopy, hysterectomy and endometrial ablation. Hysteroscopy is indicated in the treatment of uterine fibroids and polyps. Hysterectomy involves removal of uterus and its appendages. This

kind of surgery is not advisable for women of reproductive age since the patient cannot opt for pregnancy after this surgery. Endometrial ablation destroys the uterine lining, thereby controlling excess bleeding. Sometimes abnormal uterine bleeding is self limiting and returns to normal within a few months. Finally, the underlying cause of bleeding needs to be correctly diagnosed and managed effectively.