By: F. Michael Shaw, MD, FACOG
Director of Gynecology for the Institute of Robotic and Minimally Invasive Surgery at Northern Westchester Hospital
Abnormal uterine bleeding (AUB), a term that refers to menstrual bleeding of abnormal quantity, duration, or schedule, is a common gynecologic problem, occurring in approximately 10 to 35 percent of women. Chronic, heavy, prolonged, or irregular uterine bleeding can result in anemia, interfere with daily activities, and raise concerns about uterine cancer.
If you have heavy bleeding during your period or in between periods this is an example of abnormal uterine bleeding. Bleeding during pregnancy is a different problem. If you are pregnant and have any amount of bleeding from the vagina, be sure to call your doctor immediately.
What Causes Abnormal Bleeding?
The doctor will need to diagnose the cause of any abnormal bleeding: is it related to hormonal dysfunction, pregnancy or the uterus. Your doctor will ask how often, how long, and how much you have been bleeding. Your doctor may also conduct a pelvic exam, have you undergo a urine test for pregnancy, blood tests for hormone levels and possibly a pelvic ultrasound to evaluate the uterus and ovaries. These tests will help your doctor understand the cause of your abnormal bleeding. He or she may also take a tiny sample (biopsy) of tissue from your uterus for testing.
Once the doctor and you are able to discover the cause of your abnormal bleeding, treatments can be discussed. Typically, medications are the first course of action in treating AUB. Often, the medications that are prescribed include:
Medical therapy may not be effective in all patients, or patients may desire a procedure that has long-term efficacy or is a definitive therapy (hysterectomy, removing the uterus surgically). In addition, women may desire surgery to avoid continued frequent dosing or adverse effects associated with medication.
Heavy menstrual bleeding due to structural lesions (leiomyomas, uterine polyps or adenomyosis) is typically the main indication for surgery. The choice of surgical therapy depends upon the patient’s characteristics and therapeutic goals. In patients over the age of 35, biopsy of the uterine lining or hysteroscopy and D&C to rule out cancerous or precancerous uterine conditions is often needed.
Uterine polyps are easily treated with minor surgery to the uterus. Hysteroscopy is a procedure where a small telescope was inserted through the cervix to the uterus and the polyps are removed and tested. This is also usually done with a dilation and curettage or D&C which allows for accurate sampling of the endometrium (uterine lining) to ensure that no precancerous or cancerous conditions are present.
The choice of whether to proceed with surgery and the type of procedure depends upon plans for fertility. For women who desire future childbearing, surgical options include removal of uterine polyps or fibroids. Fibroids can be removed by performing a myomectomy and often with minimally invasive robotic surgery.
For women who do not desire to preserve fertility, other minimally invasive options may be appropriate. Procedures include endometrial ablation or uterine artery embolization. Endometrial ablation is an outpatient procedure which cauterizes the endometrium and will reduce or eliminate bleeding. Uterine artery embolization is performed by an interventional radiologist and can decrease the size of uterine fibroids. Hysterectomy is appropriate for women who have failed other medical or surgical treatments or who desire definitive treatment. Most hysterectomies can now be done with minimally invasive robotic laparoscopic techniques which have less complications and more rapid return to full activities than older open techniques.