Uterine Fibroids (Benign Tumors Of The Uterus)

Uterine Fibroids
(Benign Tumors Of The Uterus)

Uterine fibroids facts

• Uterine fibroids are benign tumorsthat originate in the uterus(womb).
• It is not known exactly why women develop uterine fibroids.
• Most women with uterine fibroids have no symptoms. However, fibroids can cause a number of symptoms depending on their size, location within the uterus, and how close they are to adjacent pelvic organs. These are most commonly abnormal bleeding, pain and pressure.
• Uterine fibroids are diagnosed bypelvic exam and by ultrasound.
• If treatment for uterine fibroids is required, both surgical and medical treatment options are available.

What are uterine fibroids?

Uterine fibroids are benign tumors that originate in the uterus (womb). Although they are composed of the same smooth muscle fibers as the uterine wall (myometrium), they are much denser than normal myometrium. Uterine fibroids are usually round.

Uterine fibroids are often described based upon their location within the uterus. Subserosal fibroids are located beneath the serosa (the lining membrane on the outside of the uterus). These often appear localized on the outside surface of the uterus or may be attached to the outside surface by a pedicle. Submucosal (submucous) fibroids are located inside the uterine cavity beneath the inner lining of the uterus. Intramural fibroids are located within the muscular wall of the uterus

What causes uterine fibroids and how common are they?

We do not know exactly why women develop these tumors. Genetic abnormalities, alterations in growth factor (proteins formed in the body that direct the rate and extent of cell proliferation) expression, abnormalities in the vascular (blood vessel) system, and tissue response to injury have all been suggested to play a role in the development of fibroids.

Family history is a key factor, since there is often a history of fibroids developing in women of the same family. Race also appears to play a role. Women of African descent are two to three times more likely to develop fibroids than women of other races. Women of African ancestry also develop fibroids at a younger age and may have symptoms from fibroids in their 20s, in contrast to Caucasian women with fibroids, in whom symptoms typically occur during the 30s and 40s. Early pregnancy decreases the likelihood that fibroids will develop. Fibroids have not been observed in girls who have not reached puberty, but adolescent girls may rarely develop fibroids. Other factors that researchers have associated with an increased risk of developing fibroids include having the first menstrual period (menarche) prior to age 10, consumption of alcohol (particularly beer), uterine infections, and elevated blood pressure (hypertension).

Estrogen tends to stimulate the growth of fibroids in many cases. During the first trimester of pregnancy, about a third of fibroids will enlarge and then shrink after the birth. In general, fibroids tend to shrink after menopause, but postmenopausal hormone therapy may cause symptoms to persist.

Overall, these tumors are fairly common and occur in about 70% to 80% of all women by the time they reach age 50. Most of the time, uterine fibroids do not cause symptoms or problems, and a woman with a fibroid is usually unaware of its presence.

What are the symptoms of uterine fibroids?

Most women with uterine fibroids have no symptoms.

However, abnormal uterine bleeding is the most common symptom of a fibroid. If the tumors are near the uterine lining, or interfere with the blood flow to the lining, they can cause heavy periods, painful periods, prolonged periods or spotting between menses. Women with excessive bleeding due to fibroids may develop iron deficiencyanemia. Uterine fibroids that are degenerating can sometimes cause severe, localized pain.

Fibroids can also cause a number of symptoms depending on their size, location within the uterus, and how close they are to adjacent pelvic organs. Large fibroids can cause:

• pressure,
• pelvic pain,
• pressure on the bladder with frequent or even obstructed urination, and
• pressure on the rectum with painful or difficult defecation.

While fibroids do not interfere with ovulation, some studies suggest that they may impair fertility and lead to poorer pregnancy outcomes. In particular, submucosal fibroids that deform the inner uterine cavity are most strongly associated with decreases in fertility. Occasionally, fibroids are the cause of recurrent miscarriages. If they are not removed in these cases, the woman may not be able to sustain a pregnancy.

Do untreated uterine fibroids pose a risk?

For the most part, uterine fibroids that do not cause a problem for the woman can be left untreated. In some cases, even fibroids that are not causing symptoms require removal or at least close observation. Rapid growth is a reason to watch more carefully, since a rare cancerous form of fibroid (referred to as a leiomyosarcoma) can be a fast-growing tumor, and it cannot be differentiated from a benign fibroid by ultrasound, MRI , or other imaging studies. However, this type of tumor occurs in less than 1% of uterine fibroids.

Another risk of leaving these tumors alone is that they sometimes grow to a size that eventually cause significant symptoms, thus requiring removal. If fibroids grow large enough, the surgery to remove them can become more difficult and risky.

What are the usual ways of diagnosing uterine fibroids?

Uterine fibroids are diagnosed by pelvic exam and even more commonly by ultrasound. Often, a pelvic mass cannot be determined to be a fibroid on pelvic exam alone, and ultrasound is very helpful in differentiating it from other conditions such as ovarian tumors. MRI and CT scans can also play a role in diagnosing fibroids, but ultrasound is the simplest, cheapest, and best technique for imaging the pelvis. Occasionally, when trying to determine if a fibroid is present in the uterine cavity (endometrial cavity), a hysterosonogram (HSG) is done. In this procedure, an ultrasound exam is done while contrast fluid is injected into the uterus through the cervix. The fluid within the endometrial cavity can help outline any masses that are inside, such as submucosal fibroids.

What is the treatment for uterine fibroids?

There are several options for the treatment of uterine fibroids that include surgery (hysterectomy, myomectomy, cryosurgery, MRI-guided high-intensity focused ultrasound (MRgFUS), and uterine artery embolization (UAE). Medical treatments include medications such as mifepristone (RU-486, danazol (Danocrine), raloxifene (Evista), GnRH analogs (Lupron and others), and low-dose formulations of oral contraceptives.

Surgery for fibroids?

There are many ways of managing uterine fibroids. Surgical methods are the mainstay of treatment when treatment is necessary. Possible surgical interventions include hysterectomy, or removal of the uterus (and the fibroids with it). Myomectomy is the selective removal of just the fibroids within the uterus. Myomectomy can be done through a hysteroscope, laparoscope or with the standard open incision on the abdominal wall. Some treatments have involved boring holes into the fibroid with laser fibers, freezing probes (cryosurgery), and other destructive techniques that do not actually remove the tissue but try to destroy it in place. Surgery is necessary if there is suspicion of malignancy in any case of a leiomyoma or uterine mass.

Another technique for treating fibroids is known as uterine artery embolization (UAE). This technique uses small beads of a compound called polyvinyl alcohol, which are injected through a catheter into the arteries that feed the fibroid. These beads obstruct the blood supply to the fibroid and starve it of blood and oxygen. While this technique has not been in use long enough to evaluate long-term effects of UAE versus surgery, it is known that women undergoing UAE for fibroids have a shorter hospital stay than those having surgery but a greater risk of complications and readmissions to the hospital. Studies are underway to evaluate the long-term outcomes of UAE as opposed to surgical treatment. Uterine artery occlusion (UAO), which involves clamping the involved uterine arteries as opposed to injecting the polyvinyl alcohol beads, is currently under investigation as a potential alternative to UAE. 

Medical treatment for fibroids?

Non-surgical techniques are usually hormonal in nature and include the use of drugs that turn off the production of estrogen from the ovaries (GnRH analogs). These medications are given for three to six months and induce a hypoestrogenic (low estrogen) state. When successful, they can shrink the fibroids by as much as 50%. Side effects of these drugs are similar to the symptoms of menopause and can include hot flashes,sleep disturbance, vaginal dryness, and mood changes. Bone loss leading to osteoporosis after long-term (6 to 12+ months) use is one complication. This is generally reversed after the treatment ends. These drugs may also be used as preoperative treatment for large leiomyoma to shrink them in order to make the operation less difficult and reduce surgical risk.

Mifepristone (RU-486) is an antiprogestin drug that can shrink fibroids to an extent comparable to treatment with the GnRH analogs. This drug is also used to terminate early pregnancy. Treatment with mifepristone also reduced the bleeding associated with fibroids, but this treatment can be associated with adverse side effects such as overgrowth (hyperplasia) of the endometrium (uterine lining). Mifepristone is not approved by the US Food and Drug Administration (FDA) for the treatment of uterine leiomyomas, and the required dosages (different from those used for termination of early pregnancy) have not been determined.

Danazol (Danocrine) is an androgenic steroid hormone that has been used to reduce bleeding in women with fibroids, since this drug causes menstruation to cease. However, danazol does not appear to shrink the size of fibroids. Danazol is also associated with significant side effects, including weight gain,muscle cramps, decreased breast size, acne, hirsutism (inappropriate hair growth), oily skin, mood changes, depression, decreased high density lipoprotein (HDL or 'good cholesterol') levels, and increased liver enzyme levels.

The administration of raloxifene (Evista), a drug used to prevent and treat osteoporosis in postmenopausal women, has been shown to decrease the size of fibroids in postmenopausal women, but results with this therapy in premenopausal women have been conflicting.

Low dose formulations of oral contraceptives are also sometimes given to treat the abnormal bleeding associated with fibroids, but these do not shrink the fibroids themselves. 

What are the risks of uterine fibroids during pregnancy?

Some studies have shown an increased risk of pregnancy complications in the presence of fibroids, such as first trimester bleeding, breech presentation, placental abruption, and problems during labor. Fibroids have also been associated with an increased risk of cesarean delivery. The size of the fibroid and its precise location within the uterus are important factors in determining whether a fibroid causes obstetric complications.

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FAMILY PLANNING

FAMILY PLANNING

Birth control facts

• Birth control methods can be broadly classified into barrier methods (that prevent sperm cells from reaching the egg), methods that prevent ovulation such as the pill, and methods that allow fertilization of the egg but prevent implantation of the fertilized egg inside the uterus (womb).
• Condoms and diaphragms are examples of barrier birth control methods.
• Birth control pills are an example of a birth control methods that prevents ovulation.
• The decision about what kind of birth control option to use is extremely personal, and there is no single choice that is safest or best for all women or couples.
• A woman should carefully weigh the risks and benefits, along with the effectiveness of each method before choosing a birth control method. A thorough and open discussion with a health care-professional can help in this decision process.
• Different forms of birth control have different side effects and risk profiles.
• The choice of birth control method depends on many factors, such as the desire for reversible birth control (preserving future fertility) or permanent birth control methods (surgical sterilization). Some birth control methods, such as barrier methods, may offer some protection against sexually-transmitted diseases (STDs), while most methods do not.
• No method of birth control is 100% effective in preventing STDs.
• Some birth control methods have higher success rates than others, but no method of birth control is 100% effective in every case.

Types of birth control

Types of birth control methods include options that prevent sperm from reaching an egg, known as barrier methods; methods that prevent ovulation, and methods that prevent implantation of a fertilized egg into the uterus.

Types of birth control include:

• Hormonal birth control methods, including birth control pills and patches
• Barrier birth control methods
  • Diaphragms
  • Condoms
  • Cervical caps
• Natural birth control methods
• Intrauterine devices
• Emergency contraception
• Surgical sterilization

Hormonal birth control options (including oral contraceptives pills)

Hormonal options of birth control involve the use of hormones to prevent ovulation in a woman. Althoughoral contraceptive pills are the most widely used hormonal method, other options are available including the vaginal ring, hormone patches applied to the skin, and injections of progestin.

Common side effects of birth control pills can include

• nausea,
• vomiting,
• weight gain,
• skin discoloration,
•  acne,
• bleeding between periods or spotting,
• mood swings,
• change in menstrual flow, and
• breasts swelling or tenderness.

Heart attacks, blood clots, and strokes are more serious complications of oral contraceptives. Cigarette smoking increases the risk of these complications. This risk is greatest in women over 35 who are heavy smokers (>15 cigarettes/day). 

Barrier birth control options (including condoms)

Barrier options prevent fertilization of the egg by a sperm cell. These either prevent contact between egg and sperm via a physical block or kill sperm cells before they are able to fertilize an egg. Examples of physical barrier contraceptives include the diaphragm,condoms, and the cervical cap or shield. Contraceptive sponges contain a spermicide cream to kill sperm cells, and other forms of spermicides are available as well. Spermicides may be used in combination with barrier methods for greater effectiveness.

Side effects of barrier methods of birth control can include an increased risk for developing urinary tract infections (UTIs) if using a diaphragm and spermicide. Leaving a diaphragm or cervical cap in for longer than 24 hours increases your risk for toxic shock syndrome. Finally, some people may have allergies to the chemicals used in spermicide creams or other spermicide products. They may develop irritation of the vagina or penis.

Natural birth control options

Natural methods involve tracking a woman's menstrual cycle to try to determine when ovulation is most likely to occur, and avoiding sexual intercourse (or using barrier contraceptives) during that time. There are different ways to detect ovulation, including the basal body temperature method and the use of home ovulation test kits. Checking and recording the consistency of cervical mucus is another way to help determine when ovulation occurs.

Surgical sterilization (tubal ligation or vasectomy) birth control

Surgical sterilization is a form of permanent birth control that is available for both women (tubal ligation) and men (vasectomy). Sterilization implants are a more recent type of permanent birth control that is available for women that allows women to avoid the surgical procedure associated with tubal ligation.

Although women who have had tubal ligation do not have side effects after recovering from the procedure, any surgery itself carries a small risk of infection or bleeding as well as complications from the anesthetic agents.

Likewise, the vasectomy procedure is associated with small risks from the procedure as well as some swelling and pain in the days following the procedure.  

Emergency contraception birth control

Emergency contraception is a medication or device used to prevent pregnancy after unprotected intercourse has occurred. Emergency hormonal contraceptives are sometimes known as "morning after" pills. These drugs prevent pregnancy if taken within 72 hours after intercourse. This is also known as emergency contraception. Insertion of a copper intrauterine device (IUD) is also an effective method of emergency contraception.

Side effects of emergency contraception or "morning after" pills can include

• nausea,
• vomiting,
• headache,
• tiredness,
• dizziness,
• breast tenderness, and
• lower abdominal pain.

IUDs (intrauterine devices) birth control

IUDs or intrauterine devices are implantable devices that create an environment in the lining tissues of the womb that is unfavorable for implantation of a fertilized egg.

Side effects of IUDs depend on the type of IUD being used.

• Copper-containing IUDs may worsen menstrual bleeding and cramps.
• Puncture or perforation of the uterus is a rare complication of all IUDs.
• IUDs that contain hormones may cause similar side effects to hormonal contraceptives, like headaches, breast tenderness, acne, or headaches.

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Vaginal Bleeding

Vaginal Bleeding

Vaginal bleeding facts

• Normal vaginal bleeding is the periodic blood flow from the uterus.
• Normal vaginal bleeding is also called menorrhea. The process by which menorrhea occurs is calledmenstruation.
• In order to determine whether bleeding is abnormal, and its cause, the doctor must answer 3 questions: Is the woman pregnant? What is the pattern of the bleeding? Is she ovulating?
• Abnormal vaginal bleeding in women who are ovulating regularly most commonly involves excessive, frequent, irregular, or decreased bleeding.
• There are many causes of abnormal vaginal bleeding that are associated with irregular ovulation.
• A woman who has irregular menstrual periods requires a physical examination with a special emphasis on the thyroid, breast, and pelvic organs.
• Treatment for irregular vaginal bleeding depends on the underlying cause. After the cause is determined, the doctor decides if treatment is actually necessary.

What is normal vaginal bleeding?

Normal vaginal bleeding is the periodic blood that flows as a discharge from the woman's uterus. Normal vaginal bleeding is also called menorrhea. The process by which menorrhea occurs is called menstruation.

Normal vaginal bleeding occurs as a result of cyclic hormonal changes. The ovaries are the main source of female hormones, which control the development of female body characteristics such as the breasts, body shape, and body hair. The hormones also regulate the menstrual cycle. The ovary, or female gonad, is one of a pair of reproductive glands in women. They are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries produce eggs (ova) and female hormones. During each monthly menstrual cycle, an egg is released from one ovary. The egg travels from the ovary through a Fallopian tube to the uterus.

Unless pregnancy occurs, the cycle ends with the shedding of part of the inner lining of uterus, which results in menstruation. Although it is actually the end of the physical cycle, the first day of menstrual bleeding is designated as "day 1" of the menstrual cycle in medical jargon.

The time of the cycle during which menstruation occurs is referred to as menses. The menses occurs at approximately four week intervals, representing the menstrual cycle.

Menarche is the time in a girl's life when menstruation first begins.Menopause is the time in a woman's life when the function of the ovaries ceases and menstrual periods stop. Menopause is defined as the absence of menstrual periods for 12 consecutive months. The average age of menopause is 51 years old.

What is abnormal vaginal bleeding?

Abnormal vaginal bleeding is a flow of blood from the vagina that occurs either at the wrong time during the month or in inappropriate amounts. In order to determine whether bleeding is abnormal, and its cause, the doctor must consider three questions:

• Is the woman pregnant?
• What is the pattern of the bleeding?
• Is she ovulating?

Every woman who thinks she has an irregular menstrual bleeding pattern should think carefully about the specific characteristics of her vaginal bleeding in order to help her doctor evaluate her particular situation. Her doctor will require the details of her menstrual history. Each category of menstrual disturbance has a particular list of causes, necessary testing, and treatment. Each type of abnormality is discussed individually below.

1. Is the woman having abnormal vaginal bleeding during pregnancy?

Much of the abnormal vaginal bleeding during pregnancy occurs so early in the pregnancy that the woman doesn't realize she is pregnant. Therefore, irregular bleeding that is new may be a sign of very early pregnancy, even before a woman is aware of her condition. Vaginal bleeding during pregnancy can also be associated with complications of pregnancy, such as miscarriage or ectopic pregnancy.

2. What is the pattern of the abnormal vaginal bleeding?

The duration, interval, and amount of vaginal bleeding may suggest what type of abnormality is responsible for the bleeding.

An abnormal duration of menstrual bleeding can be either bleeding for too long of a period (hypermenorrhea), or too short of a period (hypomenorrhea).

The interval of the bleeding can be abnormal in several ways. A woman's menstrual periods can occur too frequently (polymenorrhea) or too seldom (oligomenorrhea). Additionally, the duration can vary excessively from cycle to cycle (metrorrhagia).

The amount (volume) of bleeding can also be abnormal. A woman can either have too much bleeding (menorrhagia) or too little volume (hypomenorrhea). The combination of excessive bleeding combined with bleeding outside of the expected time of menstruation is referred to asmenometrorrhagia.

3. Is the woman ovulating?

Usually, the ovary releases an egg every month in a process called ovulation. Normal ovulation is necessary for regular menstrual periods. There are certain clues that a woman is ovulating normally including regular menstrual intervals, vaginal mucus discharge halfway between menstrual cycles, and monthly symptoms including breast tenderness, fluid retention, menstrual cramps, back pain, and mood changes. If necessary, doctors will order hormone blood tests (progesterone level), daily home body temperature testing, or rarely, a sampling of the lining of the uterus (endometrial biopsy) to determine whether or not a woman is ovulating normally.

On the other hand, signs that a woman is not ovulating regularly include prolonged bleeding at irregular intervals after not having a menstrual period for several months, excessively low blood progesterone levels in the second half of the menstrual cycle, and lack of the normal body temperature fluctuation during the time of expected ovulation. Sometimes, a doctor determines that a woman is not ovulating by using endometrial sampling with biopsy.

What conditions cause abnormal vaginal bleeding in women who are ovulating regularly?

Abnormal vaginal bleeding in women who are ovulating regularly, most commonly involve excessive, frequent, irregular, or decreased bleeding. Some of the common conditions that produce each of these symptoms are discussed below.

Excessively heavy menstrual bleeding (menorrhagia)

Excessively heavy menstrual bleeding, called menorrhagia, is menstrual bleeding of greater than about eight tablespoons per month (normal menstrual bleeding produces between two and eight tablespoons per cycle). The most common pattern of menorrhagia is excessive bleeding that occurs in regular menstrual cycles and with normal ovulation.

There are several important reasons that menorrhagia should be evaluated by a doctor. First, menorrhagia can cause a woman substantial emotional distress and physical symptoms, such as severe cramping. Second, the blood loss can be so severe that it causes a dangerously lowered blood count (anemia), which can lead to medical complications and symptoms such as dizziness and fainting. Third, there can be dangerous causes of menorrhagia that require more urgent treatment.

Benign (noncancerous) causes of menorrhagia include:

• uterine fibroids (benign tumors of smooth muscle tissue),
• endometrial polyps (tiny benign growths that protrude into the womb),
• adenomyosis (the presence of uterine lining tissue within the muscular wall of the uterus),
• intrauterine devices (IUD's),
• underactive thyroid function (hypothyroidism),
• an autoimmune disorder systemic lupus erythematosus,
• blood clotting disorders such as inherited bleeding disorders, and
• certain medications, especially those that interfere with blood clotting.

Though not common, menorrhagia can be a sign of endometrial cancer. A potentially precancerous condition known as endometrial hyperplasia can also result in abnormal vaginal bleeding. This situation is more frequent in women who are over the age of 40.

Although there are many causes of menorrhagia, in most women, the specific cause of menorrhagia is not found even after a full medical evaluation. These women are said to have dysfunctional uterine bleeding. Although no specific cause of the abnormal vaginal bleeding is found in women with dysfunctional uterine bleeding, there are treatments available to reduce the severity of the condition.

Irregular vaginal bleeding; menstrual periods that are too frequent (polymenorrhea)

Menstrual periods that are abnormally frequent (polymenorrhea) can be caused by certain sexually transmitted diseases (STDs) (such as Chlamydiaor gonorrhea) that cause inflammation in the uterus. This condition is called pelvic inflammatory disease. Endometriosis is a condition of unknown cause that results in the presence of uterine lining tissue in other locations outside of the uterus. This can lead to pelvic pain and polymenorrhea. Sometimes, the cause of polymenorrhea is unclear, in which case the woman is said to have dysfunctional uterine bleeding.

Menstrual periods at irregular intervals (metrorrhagia)

Irregular menstrual periods (metrorrhagia) can be due to benign growths in the cervix, such as cervical polyps. The cause of these growths is usually not known. Metrorrhagia can also be caused by infections of the uterus (endometritis) and use of birth control pills (oral contraceptives). Sometimes after an evaluation, a woman's doctor might determine that her metrorrhagia does not have an identifiable cause and that further evaluation is not necessary at that time.

Perimenopause is the time period approaching the menopausal transition. It is often characterized by irregular menstrual cycles, including menstrual periods at irregular intervals and variations in the amount of blood flow. Menstrual irregularities may precede the onset of true menopause (defined as the absence of periods for one year) by several years.

Decreased amount or duration of menstrual flow (hypomenorrhea)

An overactive thyroid function (hyperthyroidism) or certain kidney diseases can both cause hypomenorrhea. Oral contraceptive pills can also cause hypomenorrhea. It is important for women to know that lighter, shorter, or even absent menstrual periods as a result of taking oral contraceptive pills does not indicate that the contraceptive effect of the oral contraceptive pills is inadequate. In fact, many women appreciate this "side effect" of oral contraceptives.

Bleeding between menstrual periods (intermenstrual bleeding)

Women who are ovulating normally can experience light bleeding (sometimes referred to as "spotting") between menstrual periods. Hormonal birth control methods (oral contraceptive pills or patches) as well as IUD use for contraception may sometimes lead to light bleeding between periods. Psychological stress, certain medications such as anticoagulant drugs, and fluctuations in hormone levels may all be causes of light bleeding between periods. Other conditions that cause abnormal menstrual bleeding, or bleeding in women who are not ovulating regularly (see below) can also be the cause of intermenstrual bleeding.

What conditions cause vaginal bleeding after menopause or abnormal vaginal bleeding in women who are not ovulating regularly?

Many conditions can interfere with the proper function of female hormones that are necessary for ovulation. For example, many conditions or circumstances may cause oligomenorrhea (reduction in the number of menstrual periods and/or amount of flow than usual) such as:

• If a woman has chronic medical illnesses or is under significant medical or emotional stress, she can begin to have a loss of her menstrual periods.
• Malfunction of a particular part of the brain, called the hypothalamus, can cause oligomenorrhea.
• Anorexia nervosa is an eating disorder associated with excessive thinness that causes many serious medical consequences as well as oligomenorrhea or amenorrhea (the absence of menstrual periods).
• Polycystic ovarian syndrome (PCO or POS) is a hormonal problem that causes women to have a variety of symptoms that include irregular or no menstrual periods, acne, obesity, infertility, and excessive hair growth; that are detectable with blood tests.

The complete loss of ovulation is referred to as anovulation. Since ovulation allows the body to maintain an adequate supply of progesterone, anovulation is a condition in which a woman's hormonal balance is tipped toward too much estrogen and not enough progesterone. The excess estrogen stimulates the growth of the lining of the uterus. The result is that the lining of the uterus becomes too thick, which eventually leads to an increased risk of uterine pre-cancer or uterine cancer over many years. In order to replace progesterone and establish a proper hormonal balance, doctors will prescribe either progesterone to be taken at regular intervals, or an oral contraceptive that contains progesterone. Such treatment dramatically decreases the risk of uterine cancer in women who do not ovulate. Because uterine cancer results from many years of anovulation, any woman with prolonged anovulation needs to be treated to avoid developing uterine cancer.

Women who are postmenopausal (those who have not had a menstrual period for 12 consecutive months or more) should not experience vaginal bleeding. Any vaginal bleeding is considered abnormal in postmenopausal women. Women who are taking combined estrogen and progesteronehormone therapy (HRT or HT) may experience some light, irregular vaginal bleeding during the first six months of treatment. Likewise, postmenopausal women who are taking a cyclic hormone regimen (oral estrogen and a progestin for 10-12 days per month) may experience some vaginal bleeding that is similar to a menstrual period for a few days each month.

Postmenopausal women who experience heavy or prolonged vaginal bleeding while on hormone therapy should always see a doctor to rule out more serious causes of vaginal bleeding. Less frequent but serious causes of vaginal bleeding in postmenopausal women include endometrial cancer or hyperplasia (overgrowth of the lining tissues of the uterus, which can be precancerous in some cases).

What causes vaginal bleeding during or after sexual intercourse?

Vaginal bleeding may occur during or after sexual intercourse for a number of reasons including:

• Injuries to the vaginal wall or introitus (opening to the vagina) during intercourse
• Infections (for example, gonorrhea, Chlamydia, yeast infections) can be a cause of vaginal bleeding after intercourse.
• Lowered estrogen levels in peri-menopausal or postmenopausal women may cause the lining of the vagina to become thinned and easily inflamed or infected, and these changes can be associated with vaginal bleeding after intercourse.
• Anatomical lesions, such as tumors or polyps on the cervix or vaginal wall may lead to vaginal bleeding during or after intercourse.

Women who experience vaginal bleeding during or following sexual intercourse should always visit their doctor to determine the cause of the bleeding.

What causes abnormal vaginal bleeding during pregnancy?

Many women have some amount of vaginal bleeding during pregnancy. Some studies show that up to 30% of pregnant women will experience some degree of vaginal bleeding while they are pregnant. Vaginal bleeding during pregnancy is more common with twins and other multiple gestations than with singleton pregnancies (pregnancy with one fetus).

Sometimes women experience a very scant amount of bleeding in the first two weeks of pregnancy, usually around the time of the expected menstrual period. This slight bleeding is sometimes referred to as "implantation bleeding." Doctors do not know for certain what causes this bleeding, but it may occur as a result of the fertilized egg implanting in the uterine wall.

The amount of the bleeding, the stage of pregnancy, and any associated symptoms can all help determine the cause of vaginal bleeding in pregnancy. While vaginal bleeding in pregnancy does not always signify a problem with the pregnancy, women who experience bleeding during pregnancy should be evaluated by a doctor.

Causes of vaginal bleeding in pregnancy include miscarriage, an abnormal location of the placenta, ectopic pregnancy, cervical infection or polyp, and premature labor. Chronic medical conditions and medication use can also be related to vaginal bleeding during pregnancy.

What diagnostic tests are used to evaluate abnormal vaginal bleeding?

• A woman who has irregular menstrual periods requires a physical examination with a special emphasis on the thyroid,breast, and pelvic area. During the pelvic examination, the physician attempts to detect cervical polyps or any unusual masses in the uterus or ovaries.
• A Pap smear is also done to rule out cervical cancer. While the Pap smear is being obtained, samples might be taken from the cervix to test for the presence of infections such as chlamydia or gonorrhea.
• A pregnancy test is routine if the woman is premenopausal.
• A blood count may be done to rule out a low blood count (anemia) resulting from excessive blood loss.
• If something in the patient's (or her family's) medical background or physical examination raises a doctor's suspicion, tests to rule out certain blood clotting disorders may be done.
• Sometimes, a blood sample will be tested to evaluate thyroid function, liverfunction, or kidney function abnormalities.
• A blood test for progesterone levels or daily body temperature charting may be recommended to verify that the woman ovulates.
• If the doctor suspects that the ovaries are failing, such as with menopause, blood levels of follicle-stimulating hormone (FSH) may be tested.
• Additional blood hormone tests are done if the doctor suspects polycystic ovary, or if excessive hair growth is present.
• A pelvic ultrasound is often performed based on the woman's medical history and pelvic examination.
• If a woman does not adequately respond to medical treatment, if she is over age 40, or if she has persistent vaginal bleeding between her periods, a sampling of the lining of her uterus (termed endometrial sampling or endometrial biopsy) is often analyzed. Endometrial sampling helps to rule out cancer or precancer in the uterus, or it can confirm a suspicion that a woman is not ovulating.

How is irregular vaginal bleeding treated?

Treatment for irregular vaginal bleeding depends on the underlying cause. After the cause is determined, the doctor decides if treatment is actually necessary. Sometimes, all that is needed is for dangerous causes to be ruled out and to determine that the irregular vaginal bleeding does not bother the woman enough to warrant medication or treatment. If thyroid, liver, kidney, or blood clotting problems are discovered, treatment is directed toward these conditions.

Medications for treatment of irregular vaginal bleeding depend on the cause. Examples are described below:

• If the cause of the bleeding is lack of ovulation (anovulation), doctors may prescribe either progesterone to be taken at regular intervals, or an oral contraceptive, which contains progesterone, to achieve a proper hormonal balance. Such treatment dramatically decreases the risk of uterine cancer in women who do not ovulate.
• If the cause of irregular vaginal bleeding is a precancerous change in the lining of the uterus, progesterone medications may be prescribed to reduce the buildup of precancerous uterine lining tissues in an attempt to avoid surgery.
• When a woman has been without menses for less than six months and is bleeding irregularly, the cause may be menopausal transition. During this transition, a woman is sometimes offered an oral contraceptive to establish a more regular bleeding pattern, to provide contraception until she completes menopause, and to relieve hot flashes. A woman who is found to be menopausal as the cause of her irregular bleeding may also receive menopause counseling if she has troubling symptoms.
• If the cause of irregular vaginal bleeding is polyps or other benign growths, these are sometimes removed surgically to control bleeding because they cannot be treated with medication.
• If the cause of bleeding is infection, antibiotics are necessary. Bleeding during pregnancy requires prompt evaluation by an obstetrician. Endometriosis can be treated with medications and/or surgery (such aslaparoscopy).
• Sometimes, the cause of excessive bleeding is not apparent after completion of testing (dysfunctional uterine bleeding). In these cases, oral contraceptives can improve cycle control and lessen bleeding.
• If bleeding is excessive and cannot be controlled by medication, a surgical procedure called dilation and curettage (D&C) may be necessary. In addition to alleviating the excessive bleeding, the D&C provides tissue that can be analyzed for additional information that can rule out abnormalities of the lining of the uterus.
• Occasionally, a hysterectomy is necessary when hormonal medications cannot control excessive bleeding. However, unless the cause is pre-cancerous or cancerous, this surgery should only be an option after other solutions have been tried.

Many new procedures are being developed to treat certain types of irregular vaginal bleeding. For example, studies are underway to evaluate techniques that selectively block the blood vessels involved in the bleeding. These newer methods may be less complicated options for some patients and as they are further evaluated they will likely become more widely available.

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