Irregular Periods and Abnormal Bleeding

Which bleeding counts as "abnormal"?

Guidelines group abnormal uterine bleeding under four headings:

• Heavy menstrual bleeding — excessive bleeding that adversely affects a woman's physical, emotional, social and material quality of life. The definition is made not in millilitres but by how much it restricts life. In other words, the question is not "is it a lot compared with others" but "is it disrupting your day".
• Bleeding or spotting between periods — bleeding seen between two periods.
• Bleeding after intercourse.
• Bleeding after menopause.

When should you seek help without delay?

Situations regarded as urgent

• Bleeding that is very heavy, like a flood, or that lasts a very long time.
• Suspicion of significant anaemia.
• Symptoms suggesting that the blood loss is affecting the circulation, such as weakness, palpitations and dizziness.

Situations requiring priority assessment

• Persistent heavy bleeding that does not respond to treatments taken by mouth.
• Those at high risk of cancer of the womb: those who are severely overweight, those over 40 who are overweight, and those with a particular inherited predisposition to cancer in the family (Lynch syndrome).
• Women aged 40 and over who are not using a hormonal contraceptive method and whose spotting between periods has continued for more than three months.
• Bleeding after intercourse accompanied by foul-smelling discharge.
• Every episode of bleeding after menopause.

What can the causes be?

• A polyp in the womb — overgrowth of the inner layer of the womb in a limited area.
• Fibroids — benign (non-cancerous) muscle masses developing in the wall of the womb.
• Thickening of the inner layer of the womb (endometrial hyperplasia — excessive thickening of the lining of the womb) and cancer of the womb — their most common symptoms are heavy bleeding, bleeding outside the period, or bleeding after menopause.
• Tissue changes on the cervix — can cause bleeding after intercourse; they need to be assessed by examination.
• Infections — sexually transmitted ones in particular can cause spotting between periods.
• Medicines being taken — irregular use of contraceptive pills, missed pills, or the irregularity seen in the first months of hormone treatment at menopause.
• Cycles without ovulation (anovulation — absence of ovulation) — the inner layer of the womb is exposed to oestrogen alone without the balance of progesterone, and the pattern is disturbed.

In adolescence and approaching menopause

Cycles without ovulation are common both in adolescence and in the transition to menopause (perimenopause — the transitional period before menopause). So part of the irregularity in these periods is to be expected.

But in the transition to menopause it is not left unattended, because it can trigger thickening of the inner layer of the womb. Guidelines state that once menopause is complete these areas of thickening have a high likelihood of regressing on their own. For irregularity and heavy bleeding due to absence of ovulation in adolescence, combined hormonal methods are recommended as first-line drug treatment.

Which investigations are carried out?

Pregnancy test

In a woman of childbearing age, pregnancy is ruled out first in every episode of irregular bleeding.

Ultrasound

• After menopause, ultrasound performed through the vagina is the first-choice investigation. If the inner layer of the womb measures less than 4 millimetres, the risk of cancer is regarded as very low.
• Before menopause the value of ultrasound in this respect is limited, because the inner layer of the womb already thickens and thins over the course of the cycle. In this period ultrasound is used mostly to look for structural causes such as fibroids and polyps.
• In women with polycystic ovary syndrome who have not had a period for a long time or bleed irregularly, ultrasound is done to rule out thickening.

Taking a sample from inside the womb (biopsy)

A definitive diagnosis of thickening or cancer is made only by examination of the tissue. The main situations in which it is requested:

• Those with postmenopausal bleeding whose inner layer of the womb measures more than 4 millimetres.
• Those with heavy bleeding who are at risk of cancer of the womb.
• Women on hormone treatment at menopause whose irregular spotting has continued for more than six months.

Hysteroscopy (viewing the inside of the womb with a camera)

This is looking inside the womb with a fine camera. It is done where a blind biopsy has been inadequate, has given a doubtful result, or where the bleeding has not settled — in order to take a sample under direct vision or to remove polyps.

Blood tests

Anaemia is looked for in everyone with abnormal bleeding. If a suspicious ovarian cyst is seen on ultrasound, additional blood tests may be requested to distinguish certain types of cyst that secrete oestrogen.

Treatment options

Treatment is planned according to the cause of the bleeding; there is no single standard.

A medicine that contains no hormone

A medicine aimed at reducing blood loss is the first-line choice in episodes of heavy bleeding.

Hormonal options

• The hormonal coil — the first-choice option in heavy menstrual bleeding and in thickening in which the cell structure is not disturbed. Because it acts locally inside the womb, the amount that passes into the body is small.
• Progesterone-type medicines — used to stop bleeding or to regulate it. In the treatment of thickening they need to be used continuously for at least six months; use for only a few days a month has been found ineffective for this purpose.
• Combined hormonal methods (pill, patch, vaginal ring) — effective in reducing blood loss and period pain; they are also used to regulate the cycle in polycystic ovary syndrome. Ways of using them in which the medicine-free break is removed reduce the frequency of bleeding.
• Injections that temporarily suppress the ovaries — used in resistant bleeding in women with fibroids or those who do not respond to other treatments. If they are to continue for more than three to six months, supportive treatment is added alongside to prevent bone loss.

Surgical options

• Removal of a polyp or fibroid with a camera.
• Ablation of the inner layer of the womb (rendering the inner layer non-functional) — can reduce bleeding in women who have completed their family. But it is not recommended in those whose inner layer of the womb is thickened: the adhesions that form after the procedure make future cancer screening impossible.
• Removal of the womb — the first-line treatment in thickening in which the cell structure is disturbed. In thickening in which the cell structure is not disturbed it is not the first option; it comes up in situations that do not regress despite 12 months of drug treatment or that recur after treatment. The keyhole method is preferred to open surgery because it involves less pain and a shorter recovery.

Anaemia

Depletion of iron stores is very common in women with heavy menstrual bleeding. For this reason weakness, pallor, shortness of breath and palpitations are asked about at the first consultation. In mild and moderate anaemia, treatment to reduce the bleeding is started first. If the blood loss is at a level that affects the circulation, iron support by mouth or by vein is given in hospital conditions, and a blood transfusion if necessary.