What is an abnormal menstrual cycle or abnormal bleeding in women?
An abnormal menstrual cycle implies abnormal bleeding:

• that occurs in between your menses (period) or
• menstrual bleeding that is prolonged or heavy enough
  
  • to result in anemia (drop in iron count in your blood) or
  • to interfere with your normal activities

Abnormal bleeding in women also includes bleeding:

• in young girls before they begin their menstrual periods, frequently due to hormonal problems (more serious causes must be excluded)
• in postmenopausal women (bleeding after the menopause or change)

Abnormal bleeding in women may come from sites (places) other than the uterus including the:

• vagina
• bladder
• vulva (external female parts)
• rectum

After menarche (the first menstrual cycle or period), most women have a menstrual cycle every 21-35 days that lasts 3-7 days. There are certain conditions that can cause a woman to have menses much less frequent than 35 days; this should be discussed with your doctor if this applies to you. As a woman approaches the menopause, it is normal to occasionally skip a menstrual period and finally have her last menses - hence the term meno pause. Once a woman has not had a period for one year she is considered to be postmenopausal. Unless cyclic menses are being induced by hormonal replacement therapy (estrogen and progesterone), any bleeding after the menopause is abnormal bleeding.

What are some of the causes for abnormal uterine bleeding?
Abnormal uterine bleeding may be associated with any of the following conditions.

• Problems with a pregnancy such as threatened miscarriage, a tubal pregnancy, or placenta previa when the after-birth blocks the cervical canal
• Infection involving the lining of the uterus
• A primary bleeding disorder when a patient does not clot her blood properly (bleeds excessively when she gets a cut, etc.)
• An IUD (intrauterine device for birth control)
• Scar tissue or blockage within the uterus (womb) or in the canal leading from the uterus
• Benign (not cancer) growths such as fibroids, polyps, or simple overgrowth of the lining of the uterus
• Pre-cancer or cancerous conditions (tumors) of the lining of the uterus
• Hormonal treatment or even lack of hormones.

If there are so many causes for abnormal bleeding, why all the fuss?
If a woman ever gets a pre-cancerous condition of the uterus or even true uterine cancer, it can be cured in most instances if it is diagnosed early enough. The key is early diagnosis. As with any cancer, it can lead to the death of the patient if it is allowed enough time to grow and spread. Fortunately, when compared to many cancers in other parts of the body, uterine cancer with rare exception is slow growing and can usually be caught before it has time to spread.  Fortunately, most women with abnormal bleeding do not have cancer.

What if I only had a small amount of bleeding, or even just a brown discharge?
The amount or character of the bleeding is less important than the timing. A few years ago a 63 year old lady presented only having a small amount of brownish discharge for a few hours, after not having a menstrual period for over 10 years. Evaluation revealed an early uterine cancer, the patient was treated and she is doing well with no evidence of recurrent disease. Again, it is important to emphasize that the time when the bleeding occurs is much more important than the amount or color of the bleeding.

How is the source of the bleeding determined? What about the PAP smear?
The PAP smear does an excellent job of screening for pre-cancer and cancer of the cervix (mouth of the womb) but is not reliable for diagnosing causes of abnormal bleeding that originate inside the uterus. The patient’s medical history and physical examination are frequently all that are necessary to determine the cause of the bleeding. Also, specific lab tests or x-rays may be helpful in arriving at the correct diagnosis. Certain causes of abnormal bleeding however may require a closer look at the endometrium (lining of the uterus or womb).

How do we get this closer look at the endometrium?
In years past, the so-called D&C (scraping the lining) was performed in an attempt to diagnose the condition. Two problems exist with the D&C - it requires general anesthesia, and it is a "blind" procedure (it is done by feel, not by seeing, and has a good chance of missing an abnormality of the lining). More recently, hysteroscopy has been performed to more accurately diagnose abnormal uterine bleeding. Hysteroscopy utilizes a skinny telescope-like instrument to look inside of the uterus through the cervix (mouth of the womb), requires no incisions and is highly accurate; but in most instances general anesthesia is used which means going to the operating room. The newest innovation to diagnose the cause of abnormal uterine bleeding is called fluid-contrast ultrasound or sonohysteroscopy.  Along with an endometrial biopsy (both done in the office), these procedures allow accurate diagnosis without having to undergo the trouble and expense of general anesthesia that is required with D&C and hysteroscopy. It should be pointed out that hysteroscopy may be necessary if an abnormality is seen at the time of fluid-contrast ultrasound or if abnormal tissue is found on endometrial biopsy.

How is abnormal uterine bleeding treated?
The treatment depends on the specific cause of the bleeding and whether or not there are other conditions that need to be treated at the same time. If the only condition that needs to be treated is bleeding, hysterectomy is rarely indicated.