Obstetrics & Gynecology

Abnormal Uterine Bleeding (AUB): Symptoms, Causes and Treatment

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 are the Symptoms?

  • You get your period more often than every 21 days or farther apart than 35 days. A normal adult menstrual cycle is 21 to 35 days long. A normal teen cycle is 21 to 45 days.
  • Your period lasts longer than seven days (normally four to six days).
  • Your bleeding is heavier than normal. If you are passing blood clots and soaking through your usual pads or tampons each hour for two or more hours, your bleeding is considered severe and you should call your doctor.
  • You have bleeding after menopause.
  • You have bleeding or spotting after sex.
  • You have bleeding or spotting between periods.

What Causes Abnormal Bleeding?

  • Problems with ovulation;
  • Fibroids or polyps (common abnormal growths in the uterus or cervix);
  • Bleeding disorders;
  • A condition in which the endometrium grows into the wall of the uterus (adenomyosis)
  • Problems linked to some birth control methods, such as an intrauterine device (IUD) or birth control pills
  • Certain types of cancer, such as cancer of the uterus
  • Abnormal pregnancy (miscarriage or ectopic pregnancy or normal pregnancy

How is Abnormal Uterine Bleeding Diagnosed?

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.

How is it Treated?

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:

  • Birth control pills— Birth control pills are often used to treat uterine bleeding 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. Abnormal bleeding from some abnormal uterine conditions can also be treated with birth control pills.
  • Nonsteroidal anti-inflammatory drugs (NSAIDS) – These drugs (e.g. 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.
  • Tranexamic acid – This medication taken during your menses reduces heavy menstrual bleeding.
  • Gonadotropin-releasing hormone (GnRH) agonists – These drugs can stop the menstrual cycle and reduce the size of fibroids by inducing a temporary menopause.
  • Progesterone— Progesterone is a hormone made naturally by the ovary that is effective in preventing or treating excessive bleeding in women who do not ovulate regularly. A synthetic form of progesterone, called progestin, may be recommended.
  • Intrauterine device— An intrauterine contraceptive device (IUD) that secretes progestin (Mirena or Skyleena) may be recommended for women who have abnormal uterine bleeding. Progestin-releasing IUDs decrease menstrual blood loss by more than 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.

What Surgical Procedures Are Available?

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.

Questions to Ask Your Doctor

  • What is the likely cause of my abnormal uterine bleeding?
  • Is my condition serious?
  • Am I at risk for any other health problems?
  • Based on the cause, what treatment options do you recommend?
  • What are the risks and benefits of surgery?
  • Will the treatment or surgery affect my chances of getting pregnant in the future?

 

  1. Michael Shaw M.D., FACOG is the Director of Gynecology for the Institute of Robotic and Minimally Invasive Surgery at Northern Westchester Hospital recognized as a Center of Excellence for Robotic Gynecologic Surgery. Dr. Shaw sees patients at CareMount Medical’s Mt. Kisco office and can be contacted directly at 914-242-1207 for appointments. www.caremountmedical.com