ABNORMAL / HEAVY VAGINAL BLEEDING
                                                                                                                                                                                         

               During normal circumstances a woman’s uterus sheds a limited amount of blood  during each
       menstrual period. Heavy bleeding, or bleeding that occurs between menstrual periods is generally
       considered abnormal bleeding.  Heavy bleeding often requires changing pads more than every
       one or two hours, or bleeding that last longer than a full week.  Once women enter menopause and
       menstrual cycles have ended, any bleeding is considered abnormal. Menopausal women taking 
       hormonal replacement should expect a small amount of bleeding. The most common causes of
       heavy uterine bleeding are listed below:

 

                                              

                              UTERINE FIBROIDS                          HORMONAL IMBALANCE

                              ENDOMETRIAL POLYPS                  CERVICAL POLYPS

                               PELVIC INFECTIONS                        CERVICAL CANCER

                               UTERINE CANCER                             INTRAUTERINE DEVICES

                                        BLEEDING AND COAGULATION DISORDERS

                                    
                                           
    Uterine Fibroids are one of the most common causes of heavy bleeding. Fibroid tumors are solid, smooth muscle masses, usually non-cancerous, that occur in over 40% of women often during their thirties and forties. Birth control pills and estrogen medications  may cause fibroids to grow and bleed. The cause of fibroids is unclear but they are commonly seen in mothers and their daughters. Most fibroids cause no symptoms. When symptoms are present they include pain, tenderness, passing heavy clots, low blood count (anemia), abnormal enlargement of the uterus, a swollen abdomen, premature labor, miscarriages, and infertility. The size of fibroids varies immensely among women. Some are so small that a microscope is required to see them, however some women have fibroids the size of a grapefruit, and some are as large as a basketball. Large fibroids can weigh as much as 50 pounds; the largest reported fibroid ever recorded weighed in at 140 pounds. Larger fibroids may cause frequent urination, an inability to control the bladder or a complete blockage of urinary flow. Large fibroids may push on the bowels and cause constipation and pressure on the back often causes backache and back pains. Treatment of fibroids involves proper evaluation, close follow-up, and may require surgical removal of the fibroids.     

 

                                       

 

           Hormonal Imbalances are a common cause of heavy bleeding during the teenage years and around menopause. During adolescence, an immature but developing glandular system causes hormonal levels to bounce up and down, thus leading to excessive bleeding during periods. As teenage girls mature a more steady and consistent production of hormones occurs, and menstrual periods become normal and regular.  Around menopause the mature glandular system starts to produce less hormones and irregular hormone production thus leading to absence of periods for months and excessive uterine bleeding. The hormonal imbalances seen in both younger women and older women can often be treated with hormonal medications such as birth control pills or other hormones substances.     

 
        Endometrial polyps are usually non-cancerous growths that grow and protrude from the lining of the uterus as noted in the above pictures. They are often seen in childbearing and older   women and are associated with an excess of estrogen hormone as seen with hormone treatments or in some cases of cysts or masses of the ovary. Uncontrollable, heavy irregular bleeding is often associated with these types of polyps and is usually the only symptom.  Treatment involves placing a tiny camera in the uterus, called a hysteroscope, and then surgically removing the polyp.                                                                                                                                                                                       

           Cervical polyps are soft, small growths that grow from the surface of the cervix and protrude through the opening of the cervix. The cause of these polyps is unclear but they are often associated with chronic infection, congestion in blood vessels of the cervix, or elevated hormone levels. Cervical polyps are often the reason for bleeding seen after sexual intercourse. Treatment is often performed in the doctor’s office with simple removal of the polyp. Most cervical polyps are non-cancerous.           

            Pelvic infection of the uterus, called endometritis, is often associated with irregular, heavy bleeding.  Bacteria in the vagina often migrate up into the cervix, uterus and fallopian tubes causing infection of the lining of these structures.  Swelling and inflammation of the lining in the uterus often causes large amounts of tissue to fall or break off, thus causing heavy bleeding during and between menstrual periods. Sexually transmitted diseases such as trichomonas, bacterial vaginosis, and gonorrhea are often associated with irregular bleeding.The best treatment is proper diagnosis and antibiotic therapy. Failure to treat infection early can lead to severe infection in the tubes and ovaries and may lead to scarring of the pelvis and difficulties in getting pregnant.   

                                                
                                                 

                       Cervical cancer or pre-cancerous cells on the cervix are serious causes of heavy bleeding. Dysplasia of the cervix is a condition where cells on the cervix become abnormal and begin to multiply. In mild dysplasia only a few cells are abnormal, while in moderate dysplasia the abnormal cells involve about one-half of the thickness of the surface lining of the cervix. In severe dysplasia, or carcinoma in-situ the entire thickness of the cervix is disordered, but the abnormal cells have not yet spread below the surface of the cervix. Carcinoma in-situ means “ cancer in place”.  If this condition is not treated, it often will grow into invasive cervical cancer. In invasive cancer, the cells are not only disordered throughout the entire thickness of the lining, but they invade the tissue underlying the surface. Blood vessels in cervical tissue are disrupted and often heavy bleeding occurs between menstrual periods. HPV, human pappiloma virus infection accounts for over 98% of abnormal pap smears and most of all cervical cancers.  

                                                               
                                                      

Endometrial cancer is another common cause of heavy bleeding. Abnormal cells in the lining of the uterus multiply out of control and form very thick tissue called endometrial hyperplasia. Further growth of these abnormal cells forms cancer cells and is often associated with heavy bleeding. This type of cancer is often seen in women over fifty, and in women who have a long history of using estrogen hormonal replacement therapy.  Fatty tissue cells often produce high levels of estrogen, consequently, women who are mildly obese, moderately obese, or morbidly obese are at high risk of developing uterine cancer. Endometrial cancer, which originates in the inner lining of the uterus, accounts for about 90% of uterine cancers. Uterine sarcoma originates in the myometrium and accounts for less than 10% of cases.

 

Types of Uterine Cancer

Adenocarcinoma, which originates in surface cells of the endometrium, accounts for approximately 90% of cases of endometrial cancer. Adenocarcinomas are more common during perimenopause (i.e., transitional years preceding and following actual menopause) and usually are associated with an early onset of symptoms.

Another type of uterine cancer is called of uterine sarcoma. It includes carcinosarcoma (most common type), leiomyosarcoma (develop in the muscular tissue of the myometrium), and endometrial stromal sarcoma (develop in supporting connective tissue).

                   Incidence and Prevalence

                According to the National Cancer Institute (NCI), uterine cancer is the most common type of
       gynecologic cancer. In the United States, approximately 37,000 cases are diagnosed and about
       6000 women die from the disease each year.

Incidence of uterine cancer increases after menopause and approximately 75% of cases
        are diagnosed in postmenopausal patients. The average age at diagnosis is about 60 years. In
        the United States, endometrial cancer is more common in Caucasian women and uterine
        sarcoma is more common in African American women.

         Often a dilatation and curettage (D & C) is performed to diagnose the disease. This
         procedure involves dilating (widening) the cervix and inserting an instrument called a
         curette into the uterus through the vagina.

         Treatment for early endometrial cancer is very successful and is usually a hysterectomy.
         Advanced cases may require chemotherapy and radiation therapy.

 

                                                       Intrauterine Devices

           Intrauterine devices may also cause heavy bleeding during menses.  These devices
       are out of favor with most gynecologists because the IUD string often acts as a ladder for
       various bacteria to go from the vagina to the uterus and fallopian tubes causing severe
       pelvic infections, or PID, pelvic inflammatory disease. Women with heavy bleeding 
       while using the IUD should be checked for infection, probably have the IUD removed and
       choose another method of contraception.

                                            Bleeding and Coagulation Disorders

                The most common bleeding disorder in women is Von Willebrand Disaease, or
       VWD. VWD is caused by a clotting factor deficiency which makes blood difficult to clot,
       thus cuts and menstrual periods may bleed longer and heavier. It is normally
       diagnosed by special blood tests during adolescence or early adulthood. Treatment in
       extreme cases may require blood transfusions and replacement of clotting factor via
       intravenous therapy.

                   Heavy vaginal bleeding should always be promptly evaluated to help avoid
        severe  blood loss, also known as anemia, and avoid the need for future blood
        transfusions. Women who have anemia, often feel very tired; some only have a small
        loss of energy; in severe anemia women are unable to perform normal physical activities
        without early fatigue and exhaustion. All women and young girls with heavy vaginal
        bleeding should be evaluated by their gynecologists to ensure early and proper
        evaluation and management.