Diagnosis
A physician will perform a pelvic examination to check for pregnancy-related conditions and for signs of fibroids or other abnormalities, such as ovarian cysts.
Medical and Personal History
The physician needs to have a complete history of any medical or personal conditions that might be causing heavy bleeding. He or she may need the following information:
- Any family history of menstrual problems or bleeding disorders (which should be suspected in teenage girls with heavy bleeding). It should be noted that, in some cases, young women with heavy bleeding from inherited conditions may not even report it if they grew up in a family where such bleeding was considered normal.
- The presence or history of any medical conditions that might be causing heavy bleeding. Women who visit their gynecologist with menstrual complaints, particularly heavy bleeding, pelvic pain, or both may actually have an underlying medical disorder, which must be ruled out.
- The pattern of the menstrual bleeding. (If it occurs during regular menstruation, nonhormonal treatments are tried first. If it is irregular, occurs between periods, occurs after sex, is associated with pelvic pain, or if it occurs with premenstrual pain, the physician should look for specific conditions that may cause these problems.)
- Regular use of any medications (including vitamins and over-the-counter agents).
- Diet history, including caffeine and alcohol intake.
- Past or present contraceptive use.
- Any recent stressful events.
- Sexual history. (It is very important that the patient trust the physician enough to describe any sexual activity that might be risky.)
Ruling out Other Conditions that Cause Heavy Bleeding (Menorrhagia)
Almost all women, at some time in their reproductive life, experience heavy bleeding during a period (medically called menorrhagia). Being taller, being older, and having a higher number of pregnancies increases the chances for heavier than average bleeding. In some cases the cause of heavy bleeding is unknown, but a number of conditions can cause menorrhagia or contribute to the risk, including the following:
- Miscarriage. An isolated instance of heavy bleeding usually after the period due date may be due to a miscarriage. If the bleeding occurs at the usual time of menstruation, however, miscarriage is less likely to be a cause.
- Having late periods or approaching menopause. These events may cause occasional menorrhagia.
- Uterine polyps. (These are small benign growths in the uterus.)
- Certain contraceptives. (Oral contraceptives or an intrauterine device, an IUD.)
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| The intrauterine device shown uses copper as the active contraceptive, others use progesterone in a plastic device. IUDs are very effective at preventing pregnancy (less than 2% chance per year for the progesterone IUD, less than 1% chance per year for the copper IUD). IUDs come with increased risk of ectopic pregnancy and perforation of the uterus and do not protect against sexually transmitted disease. IUDs are prescribed and placed by health care providers. |
- An isolated instance of heavy bleeding may be due to a miscarriage. If the bleeding occurs at the usual time of menstruation, however, miscarriage is less likely to be a cause.
- Bleeding disorders. Bleeding disorders that impair blood clotting can cause heavy menstrual bleeding and, according to different studies, have been associated with between 10% and 17% of menorrhagia cases. Von Willebrand disease, a genetic condition, is the most common of these bleeding disorders. Most, but not all studies, report this problem to be more common in African American than Caucasian women. Other rare disorders that impair blood platelets and clotting factors can also account for some cases of menorrhagia. Most bleeding disorders have a genetic basis and should be suspected in adolescent girls who experience heavy bleeding.
- Uterine cancer.
- Pelvic infections.
- Endometriosis. (These are small implants of uterine tissue. They are more likely to cause pain than bleeding.)
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Click the icon to see an image of endometriosis. |
- Adenomyosis. This condition occurs when glands from the uterine lining become embedded in the uterine muscle. Its symptoms are nearly identical to fibroids (heavy bleeding and pain), and in one study fibroids were also present in 62% of cases. It is most likely to develop in middle-aged women who have had many children.
- A number of medical conditions: E.g., thyroid problems, systemic lupus erythematosus, diabetes, certain cancers and chemotherapies, and some uncommon blood disorder.
- Certain drugs, including anticoagulants and anti-inflammatory medications.
- In many cases the cause of heavy bleeding is unknown, and basic physiologic factors may be responsible, although their mechanisms are not fully clear.
Hysteroscopy
Hysteroscopy is a procedure that may be used to detect the presence of fibroids, polyps, or other causes of bleeding. Although less invasive procedures can also detect causes of abnormal uterine bleeding, hysteroscopy has the added advantage of serving as a surgical procedure for the removal of submucous fibroids. It is also quite useful in ruling out cancer. If cancer is suspected, more invasive procedures, such as D&C or endometrial biopsy, are warranted.
It is done in the office setting and requires no incisions. The procedure uses a long flexible or rigid tube called a hysteroscope, which is inserted into the vagina and through the cervix to reach the uterus. A fiber optic light source and a tiny camera in the tube allow the physician to view the cavity. The uterus is filled with saline or carbon dioxide to inflate the cavity and provide better viewing. This can cause cramping.
Hysteroscopy is non-invasive, but 30% of women report severe pain with the procedure. The use of an anesthetic spray, such as lidocaine, may be highly effective in preventing pain during this procedure. Other complications include excessive fluid absorption, infection, and uterine perforation.
Imaging Techniques
Ultrasound and Sonohysterography. Ultrasound is the standard imaging technique for evaluating the uterus and ovaries, detecting fibroids, ovarian cysts and tumors, and also obstructions in the urinary tract. It uses sound waves to produce an image of the organs and entails no risk and very little discomfort.
Transvaginal sonohysterography uses ultrasound along with saline infused into the uterus, which enhances the visualization of the uterus. This technique is proving to be more accurate than standard ultrasound in identifying potential problems. Some experts believe it should become a first line diagnostic tool for diagnosing heavy bleeding.
Magnetic Resonance Imaging. Magnetic Resonance Imaging (MRI) gives a better image of any fibroids that might be causing bleeding, but it is expensive and not usually necessary.
Endometrial Biopsy with or without Dilation and Curettage (D&C)
When heavy or abnormal bleeding occurs, an endometrial (uterine) biopsy can be performed in the office along with an ultrasound. It is usually used with a procedure called dilation and curettage (D&C), which is particularly important to rule out uterine (endometrial) cancer. A D&C is a somewhat invasive procedure:
- A D&C is usually done in an outpatient setting so that the patient can return home the same day, but it sometimes requires a general anesthetic. It may need to be performed in the operating room to rule out serious conditions or treat some minor ones that may be causing the bleeding.
- The cervix (the neck of the uterus) is dilated (opened).
- The surgeon scrapes the inside lining of the uterus and cervix.
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Click the icon to see an image of a D&C. |
The procedure is used to take samples of the tissue and to relieve heavy bleeding in some instances. D&C can also be effective in scraping off small endometrial polyps, but it is not very useful for most fibroids, which tend to be larger and more firmly attached.
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