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Abnormal Periods: When Should You Worry?

Posted Aug 24 2008 1:49pm
MARY WAGNER: Welcome to our webcast. I'm Mary Wagner. Abnormal uterine bleeding is an often debilitating condition that affects hundreds of thousands of American women. So what exactly is it?

Well, today, we have four of the nations leading gynecologists to help us answer that question. Let me introduce them to you.

Dr. Linda Bradley, Director of Hysteroscopic Services at the Cleveland Clinic; Dr. Steven Cohen, Director for the Center of the Women's Minimal Access Surgery at Columbia University; Dr. Keith Isaacson, Director of Reproductive Endocrinology and Infertility at Massachusetts General Hospital and Harvard Medical School, and Dr. Grace Janik, Associate Clinical Professor at the Medical College of Wisconsin and Director of Reproductive Endocrinology at St. Mary's Hospital in Milwaukee, Wisconsin.

Abnormal uterine bleeding, exactly what is it?

STEVE COHEN, MD: That's a good question because there are many definitions of abnormal uterine bleeding. Basically we need to first define what normal uterine bleeding is. And normal uterine bleeding is a menstrual cycle which occurs maybe for three to five days where you bleed, comes every three to five weeks and has a reasonable amount of flow -- maybe three tablespoons. So abnormal bleeding then becomes anything that differs from normal.

So if your periods -- you're bleeding in the middle of the month. If you're bleeding all month and just spotting. If your periods are much heavier than they should be on average, those are things that fit under the definition of abnormal uterine bleeding.

LINDA BRADLEY, MD: There is also bleeding that would interfere with your lifestyle -- athletic activities, sexual activities, sports, work. Most women who have their menstrual cycles are able to work and not miss activities because of bleeding -- because of being embarrassed, because of soiling through clothing, being humiliated because of accidents. Most women on the average will use about -- if their using tampons -- will change a tampon maybe four or five times a day. Some may change it more often for hygienic reasons, but not because they're soiling or saturating through. If you're a pad user, the same number of pads per day. So anything up and beyond that, I think you should come and see your doctor.

KEITH ISAACSON, MD: You should also understand that if a women is in menopause and she's had no period for a year and she's not on any hormone replacement therapy, then any bleeding whatsoever that's vaginal is abnormal and needs to be evaluated. Because in that patient population, you do need to rule out serious disease such as cancer.

GRACE JANIK, MD: It's also helpful for the patient to keep track of when in their cycle this bleeding is happening and have some documented information when they go to their doctor. Many of the diagnoses can be narrowed down by a bleeding calendar -- whether it's ovulatory, preovulatory, menstrual and how long.

If you are on hormone replacement therapy, when the bleeding may be happening on that replacement. All those things are clues to help figure out what is the core of the problem.

MARY WAGNER: What could be some of the causes of abnormal uterine bleeding?

GRACE JANIK, MD: One big category of cards can be hormonal abnormalities. Patients who have cycles very infrequently and have a syndrome called polycystic ovarian disease causing them to not ovulate on a regular basis, and maybe produce a little bit too much male hormone. So excess hair growth, a little bit of obesity. So that's one of the hormonal categories.

Then there's the anatomic grouping where you can have polyps which is a build up of tissues that's the endometrial lining or fibroids which is smooth muscle tumors which extrude into the cavity or a part of the wall of the uterus. Or it can be a cancer or pre-cancer condition. Those are the main groupings that are associated with abnormal bleeding.

LINDA BRADLEY, MD: I think patients -- most of our patients may have subtle things and so we want to -- if, for instance, you have easy nose bleeds, if you cut yourself and within a few minutes you don't stop bleeding -- you want to let your physician know.

If you had your tonsils out as a teenager or after having a baby, hemorrhaged a lot, you may forget about these bleeding problems in the past. Those are very, very subtle clues that can lead a doctor to order a Von Willebrand's assay. These are very expensive tests and certainly not every woman needs it. But if a woman bruises easy, nose bleeds, brushing your teeth, gums bleed very easily, paper cuts that don't stop -- those are the signals in our history taking that would say, "You know maybe this $300 test would be helpful." But I don't want women to think that every woman needs this particular assay. But certainly if you're noticing some changes, we should look for those.

And also, a lot of women are using herbal products now. Some multibillion-dollar business and I think some of the herbs are associated with problems that can lead to bleeding. Lots of women are using aspirin and if you're taking anything over the counter, you want to let your physician know because these other things can also lead to bleeding. It's not always the uterus.

What do they say? You can't see the forest for the trees or we get so focused on just the uterus, but there can be other things systemically that cause the problem.

KEITH ISAACSON, MD: The key is that most of this can be determined by a good history when you first see a patient. So if they have a regular cycle, then it's unlikely that they have hormonal problem. And therefore if it's regular cycle, these are very good candidates and the patient should be offered a diagnostic hysteroscopy in the office.

If it's irregular as, Grace, was talking about, those are patients who would do very well with hormonal treatment. Those who have bleeding problems, typically had those bleeding problems since they were adolescence, and that will be picked up on the history. So a simple history, a few questions, usually can put these patients into one of three major categories.

MARY WAGNER: Are there other tests involved such as ultrasound or --?

LINDA BRADLEY, MD: I think we want to be broadminded about our workup in terms of what technology we use. And I look at the use of ultrasound and there is another procedure that's added to that called saline infusion sonography that complements hysteroscopy. What doctors are now doing, I think in general, if the patient has a normal uterus, hysteroscopy certainly allows full evaluation of the uterine lining.

If someone has a very, very large uterus, then there may be other procedures, meaning like ultrasound that may be helpful. We have to remember that the uterus is only about the size of a lemon. When women leave their physician's office, I think they should no whether they have a normal sized uterus (one that's the size of a grapefruit or one that's the size of a watermelon) because the technology and what we can offer out patients for treatment really depends on size.

We don't want to think it's just purely one procedure or another. Your physician may need to use both for evaluation.

MARY WAGNER: Okay. What about if we talk a bit about treatment options for abnormal uterine bleeding?

KEITH ISAACSON, MD: Again, once you have the accurate diagnosis, it makes the treatment much more simple. The beauty of the hysteroscopy is that once you see that there is a polyp inside the uterus, once you see there is a fibroid inside the uterus, you don't have to take out the entire uterus to treat it -- though that's still a reasonable option. You can just treat that isolated pathology and take care of the abnormal uterine bleeding.

MARY WAGNER: Now once you've discovered the cause. Let's take a patient who has a polyp. What do you do then?

GRACE JANIK, MD: There are two options with polyps. One is to remove them in the office and it requires an operative hysteroscope -- so a little bit bigger than the diagnostic, but still very well tolerated. And it's a matter of passing a grasper through or a small scissor and detach the polyp from the wall -- grasp it and remove it.

The other option is to do it in an operating room setting. There it can be done either in IV sedation or general anesthesia, and usually IV sedation is adequate for this procedure, and the polyps can be removed.

MARY WAGNER: Now what if the patient has a fairly good sized fibroid?

KEITH ISAACSON, MD: Fibroids, if it's in the uterine cavity, most of the time will be treated in the operating room. This patient now has a few different options for removing fibroids. Again, if we start with the most extreme, she can have a hysterectomy. It will remove the fibroid and they will never come back. There is nothing wrong with that.

But you also can be offered a therapeutic hysteroscopy in which a larger hysteroscope is placed through the cervix and the fibroid is actually shaved out using electrical current or very rarely using laser energy.

Now these patients also have some other options including uterine artery embolization in which the blood vessels that supply the uterus are actually occluded with very tiny particles. When you cut off the blood supply to the uterus, it turns out the muscle of the uterus does not die, but often the fibroids will. So that is another option. It's a better option for patients who have very large fibroids, who have symptoms of pressure on their bladder or on their bowel. But it also can work for patients with abnormal uterine bleeding.

STEVEN COHEN, MD: If the major problem is bleeding, I like to think of things simply. We're really not treating -- we're not here to treat fibroids necessarily. We're here to treat the problem. The problem is that the patient is bleeding. So to me, the best way to treat bleeding -- the best way to treat this patient is to treat the bleeding. And although the patient may have a fibroid, if I can do operative hysteroscopy, remove a portion of the fibroid, or in the patient who doesn't want their fertility -- do a procedure called endometrial oblation where we actually just destroy the tissue that would regenerate every month and cause their period. That's what the patient wants. Stop me from bleeding. I don't care if I have the fibroid or not.

Like Keith said, if the patient has other symptoms from the fibroid, pressure, urinary frequency, pain, other symptoms, then the fibroid needs to be treated. But if she comes with a fibroid and just bleeding -- just abnormal bleeding -- that's usually the best approach. Treat the problem that the patient is complaining about.

GRACE JANIK, MD: The submucous fibroid -- Often this submucous fibroid is not the one that's very suitable for uterine artery embolization because that can be passed through the cervix and be extruded. So in that patient, as Steve was saying, it might be better to resect that, see how her symptoms are. If she's still having bleeding from the remaining fibroids, then proceed for other types of removal.

Myomectomy is also a choice where you remove the fibroids that are in the wall of the uterus and reconstruct the uterus. And with this, you have the ability to get pregnant and preserve fertility.

LINDA BRADLEY, MD: I think also for patients with uterine fibroids, the important thing for all of us to realize is their fibroids are rarely cancerous. And unfortunately some doctors use the language of tumors or pelvic masses, and these words are very frightening if your doctor tells you that you have a tumor.

Tumor in the way that we think within the uterus itself is rarely cancerous. One out of a thousand women has a cancer that's within a fibroid. So I think when you're looking at options, hysterectomy should be a last option for most women because of the rarity of cancer. And then, we can -- as you've mentioned -- look at other things that we can treat.

KEITH ISAACSON, MD: I think, however, there are advantages and disadvantages to all the treatment options that we've discussed. There are some advantages to a hysterectomy, for example, that we know a fibroid will never come back. The opposite extreme, there is an advantage to hysteroscopic resection in that there is no incision. It's outpatient and you're back to your normal lifestyle within 24-48 hours. The point is that I think the patient should be given all options if they are appropriate, and the patient should be well educated which is the responsibility of the health care provider. And then the patient should choose with proper guidance.

LINDA BRADLEY, MD: I think -- but I think that the message that so many women have is that hysterectomy is the only option. A webcast like this should be very informative to say that there are about three or four other things that you may be able to do that will get you through your life, staying in tact.

STEVE COHEN, MD: That's a good point. I mean you got to be aware with abnormal uterine bleeding and not having cancer, you've got to be aware of the provider or the physician who offers you only one option. Something is not quite right.

MARY WAGNER: So it's a combination of well informed patient and well informed physician. Abnormal uterine bleeding can be a thing of the past for many women.

STEVE COHEN, MD: Absolutely.

MARY WAGNER: Thanks very much for this informative discussion on abnormal uterine bleeding. And thank you for watching this webcast.

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