What Is Abnormal Uterine Bleeding

Abnormal uterine bleeding is described by the International Federation of Gynecologists and Obstetricians (FIGO) as

  • Heavy menstrual bleeding
  • Irregularmenstrual bleeding
  • Intermenstrual bleeding
  • Disordered cycle length

What Is Heavy Mentrual Bleeding

  • 20-50% of women experience heavy menstrual bleeding
  • Heavy menstrual bleeding is any bleeding whose volume interferes with the woman’s quality of life
  • Heavy menstrual bleeding causes anemia in 30% of 15-49 year old women worldwide
  • 90% of women with underlying bleeding disorders experience heavy menstrual bleeding
  • 70% of women on anticoagulation therapy experience heavy menstrual bleeding

What Is Irregular Menstrual Bleeding

  • Irregular menstrual bleeding is bleeding that lasts longer than eight days
  • Heavier, prolonged bleeding is associated with elevated FSH

Risk factors for irregular menstrual bleeding include

  • Age, race, genetics
  • Diet, exercise, stress, BMI, weight fluctuations
  • Smoking, caffeine, alcohol
  • Gynecologic disorders lik fibroids, adenomyosis, polyps, cancer, and ovarian dysfunction
  • Non-gynecologic disorders like thyroid, prolactin, genital tuberculosis, and coagulation disorders

What Is Intermenstrual Bleeding

Intermenstrual bleeding is any bleeding between your periods.

Ovulation spotting is the most common, and occurs in 5-30% of women.

Ovulation spotting is caused either by an LH surge or estradiol drop.

Intermenstrual bleeding can also be caused by

  • A Polyp
  • Malignancy of endometrium, cervix, or vagina
  • Endometrial Hyperplasia
  • Infection of reproductive tract

Intermenstrual bleeding in the follicular phase could also be caused by a cesarean scar defect (especially if it is dark colored blood).

What Is an Irregular Cycle Length

If you are between 18-25 years old or 42-45 years old your menstrual cycle length should never vary by more than 7 days.

If you are between 26-41 years old your menstrual cycle length should never vary by more than 9 days.

Changes in the length of the cycle are related to

  • Levels of estrogen and progesterone
    • PCOS
    • Birth control pills
    • IUD
    • Brain-based
  • Metabolic Issues
    • Metabolic syndrome
    • Type 2 diabetes
    • Obesity
  • Hyperthyroid/Hypothyroid
  • Coronary heart disease
  • Rheumatoid arthritis
  • Anemia
  • Osteoporosis
  • Over-exercise
  • Psychological problems
  • Impaired quality of life
  • Stress
  • Early or late menarche

Causes of Abnormal Uterine Bleeding

The International Federation of Gynecologist and Obstetricians identifies two categories of cause

  • Structural
    • Polyp (endometrial or cervical)
    • Adenomyosis
    • Leiomyosis (uterine fibroid)
    • Malignancy or endometrial hyperplasia
  • Non-Structural
    • Coagulopathy
    • Ovulatory dysfunction
    • Endometrium
    • Iatrogenic
    • Not yet classified

Polyps Can Cause Abnormal Uterine Bleeding

  • 20-30% of women with abnormal uterine bleeding have polyps
  • Polyps can cause bleeding at any time in the menstrual cycle
  • Cervical polyps can be caused by cervix inflammation, yeast or bacterial infections, or sexually transmitted infections
  • Uterine polyps are diagnosed by ultrasound, Cervical polyps can be diagnosed by speculum exam
  • Polyps are typically removed

Adenomyosis Can Cause Abnormal Uterine Bleeding

Adenomyosis is endometriosis of the uterus. It occurs when the endometrium grows into the muscle of the uterus.

Adenomyosis is characterized by upregulation of estrogen receptors and downregulation of progesterone receptors.

This results in local progesterone resistance and estrogen dominance

20-35% of women with abnormal uterine bleeding have adenomyosis.

Adenomyosis is typically diagnosed by transvaginal ultrasound.

Adenomyosis is typrically treated by biomedicine with gonadotrophin releasing hormone agonists, contraceptive hormones, or surgery (including hysterectomy).

Leiomyoma (Uterine Fibroids) Can Cause Abnormal Uterine Bleeding

Uterine fibroids are benign tumors of the uterine smooth muscle.

Only submucosal leiomyomas can cause abnormal uterine bleeding.

Over 80% of all women have fibroids by the time they are 50 years old.

Fibroids are diagnosed by transvaginal ultrasound.

Leiomyomas are treated with hormonal contraception, gonadotrophin releasing hormone agonists, or a variety of surgical procedures including hysterectomy.

Malignancy and Endometrial Hyperplasia Can Cause Abnormal Uterine Bleeding

  • These are uncommon conditions
  • Cervical cancer often presents as bleeding after sex and bleeding between your periods
  • Endometrial biopsy and hyperplasia is diagnosed with endometrial biopsy
  • Cervical cancer is diagnosed with pap smear/colposcopy/biopsy
  • šPMID: 35136207 PMID: 37538019

Coagulopathy Can Cause Abnormal Uterine Bleeding

  • 13% of women with heavy menstrual bleeding have a problem clotting
  • If you have a coagulopathy you have persistently heavy periods ever since you started your periods
  • You also need to have at least one of the following
    • Hemorrage after having a baby
    • Bruising 1-2 times monthly
    • Bleeding with surgery, dental work, or flossing
    • Nosebleeds 1-2 times monthly
    • šPMID: 35136207 PMID: 37538019

Ovulatory Dysfunction Can Cause Abnormal uterine Bleeding

There are four types of ovulatory dysfunction. These types of ovulatory issues are more common in teens and perimenopause

  • Type 1 = Hypothalamic
  • Type 2 = Pituitary
  • Type 3 = Ovarian
  • Type 4 = PCOS
  • šPMID: 35136207 PMID: 37538019

Thyroid Function Can Influence Abnormal Uterine Bleeding

Hypothyroid

Can cause heavier, longer bleeding

Hyperthyroid

Can cause lighter, shorter bleeding and infrequent cycles

šPMID: 39070464

Perimenopause Can Cause Abnormal Uterine Bleeding

Perimenopausal abnormal bleeding is common and typically self-limiting.

Common reasons for abnormal uterine bleeding during perimenopause include

  • Unstable ovarian function (low progesterone)
  • Benign endometrial polyps and fibroids
  • Sexually transmitted infections
  • šPMID: 38412750

How To Diagnose Abnormal Uterine Bleeding

Lab Testing

  • Complete blood count with differential
  • Pregnancy test
  • Coagulation testing
  • Testing for von Willebrand’s disease
  • Iron panel
  • Thyroid testing
  • Liver function testing
  • Chlamydia trachomatis testing
  • šhttps://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2013/04/management-of-acute-abnormal-uterine-bleeding-in-nonpregnant-reproductive-aged-women

Exam for Bleeding After Sex

  • Speculum exam
  • Pap smear
  • šPMID: 38412750

Ovulatory Dysfunction Work-Up

  • Estradiol
  • Progesterone
  • Testosterone/DHEA
  • FSH/LH
  • TSH
  • Prolactin
  • Anti-Mullerian Hormone
  • šPMID: 38764520

Postmenopausal Bleeding or Bleeding Between Periods in Women over 45

  • Hysteroscopy with endometrial biopsy
  • šPMID: 38764520

Diagnostic Imaging

  • Transvaginal Ultrasound
  • MRI if cannot tolerate or declines transvaginal ultrasound
  • šPMID: 35136207

Biomedical Management of Abnormal Uterine Bleeding

  • Oral contraception or suppression of menstruation
  • Gonadotropin releasing hormone agonists/antagonists
  • ING-IUS (levonorgestrel-releasing intrauterine system)
  • Surgical treatment for structural issues such as polyps, fibroids, adenomyosis, malignancy
  • šPMID: 35136207 PMID: 38412750

Contraindications for Use of Oral Contraception for Management of Abnormal Uterine Bleeding

  • Previous thromboembolic event or stroke
  • History of estrogen-dependent tumor
  • Active liver disease
  • Pregnancy
  • Hypertriglyceridemia
  • Older than 35 and smokes >15 cigarettes daily
  • Older than 40, prefer progestin only
  • https://www.jabfm.org/content/19/6/590/tab-figures-data

Natural Treatment of Abnormal Uterine Bleeding

  • Supplement with heme iron for any excess bleeding
  • Natural medicine is only auxilliary for polyp, fibroid, malignancy, sexually transmitted infections, congenital variants, coagulopathy
  • Adenomyosis & Fibroids treated with hormonal adaptogens, liver/gut detox support, castor oil packs
  • Ovarian dysfunction treated with hormonal adaptogens, brain and ovarian nutrition, address inflammation/obesity, liver/gut detox, craniosacral therapy for brain/glymphatics
  • Visceral manipulation of uterus/ovaries for abnormal uterine bleeding

In Conclusion

The underlying reason for abnormal uterine bleeding needs to be identified to be treated properly.

Natural medicine can treat or support biomedical treatment of most types of abnormal uterine bleeding.