Transcription:
Abnormal Uterine Bleeding: Causes and What to do Next

Melanie Cole (Host): Welcome to Say Yes to Good Health with Memorial Hospital. I'm Melanie Cole and today, we're talking about abnormal uterine bleeding, causes and what do you do if this is happening to you? We're talking with Dr. Chris Jones, Obstetrician Gynecologist with Memorial Hospital. Dr. Jones, it's a pleasure to have you back with us. So abnormal, uterine bleeding, what type of bleeding is considered normal and what is considered abnormal?

Chris Jones, MD, OB/GYN, FACOG (Guest): Melanie, a lot of it's very subjective, obviously. We treat a patient who comes in and says, I'm bleeding abnormally as a patient with abnormal uterine bleeding, but, generally abnormal uterine bleeding can be defined as either or either or irregular bleeding. So not on a predictable cyclic basis or heavy, so, heavier than, than what a patient is used to having in terms of the volume of menstrual blood. Just in, in general. Classic traditional normal menstrual cycle is about 28 days between the first day of each period and in general, periods that are normal are going to last anywhere between and seven days. So anything that deviates from that can be considered abnormal uterine bleeding.

Host: So we're going to talk about the differences between age, right? Because when I was pre-menopausal and in my normal years, had heavy periods. If somebody does have that sort of situation Dr.Jones, how do they know if it's abnormal if they are heavy bleeders anyway?

Dr. Jones: Again, to a certain extent somewhat subjective, you know, Melanie and to a large ,extent, one of the things that we do when we have a patient who comes in complaining of abnormal bleeding, we want to, first of all, evaluate their risk for something more significant, like a cancer.

But in general, what I like to do is, describe abnormal uterine bleeding, that is any bleeding that is affecting the patient's quality of life. So that's enough for me, if a patient comes in and they say that my periods are heavy and it's really getting in the way of my ability to function and enjoy my life the way I want to.

Well then I consider that abnormal uterine bleeding. Now granted, it may be within the amount of bleeding that, that patient may be having may fall within the range of normal, and when you look at it on a population basis. But that doesn't necessarily mean that we don't try to help that patient because it's, for the most part, a lot of these abnormal uterine bleeding patients, we're trying to help them with their quality of life, as they're usually not dealing with something that's going to threaten their life like a cancer or anything of that nature.

But, there are some objective measures that we can use to see if a patient is having a heavy, heavier than normal menstrual bleeding. And one of those things we can do is we can check hemoglobin. So, I'm sure your listeners are aware of anemia. So anemia is less hemoglobin than a patient is supposed to have. A hemoglobin is the molecule that's on the red blood cells that carry oxygen.

And if you don't have as much hemoglobin as you're supposed to, you don't have as much ability to carry oxygen. So those patients can be affected from the lack of hemoglobin molecules in their blood. And they may be experiencing fatigue or tiredness or, poor exercise capacity.

And again, you know, a lot of this is just subjective, but if they're going through a pad an hour for over two or three days, and that's kind of an objective measure of some pretty heavy bleeding that we might want to address and figure out the cause and potentially figure out how to best manage that patient.

Host: Dr. Jones, tell us a little bit about what types of cancer that might cause abnormal bleeding. I know women, we worry a lot, but this is not something that is usually, or always the case, when we have abnormal bleeding, right?

Dr. Jones: So that's exactly right. In the vast majority of cases, when a patient comes in and they've decided that their bleeding is abnormal, in the vast majority of those cases, they don't need to freak out and some patients do, you're right. But for the predominant number of patients that come in, they do not have cancer, but, in those cases and again it's a small minority of cases. In those patients that do have cancer, that is the etiology or the cause of their abnormal uterine bleeding, most commonly that's going to be endometrial cancer.

I believe we've done a program about that. Endometrial cancer is a cancer of the lining of the uterus. And then less commonly, it would be due to something like cervical cancer or even vaginal and vulvar cancer, where you can have bleeding from anywhere in the genital tract that could cause abnormal uterine bleeding.

But again, most of the time, for the vast majority of patients, it's not going to be cancer. But that doesn't mean it's not important. Most patients feel like when they go to the gynecologist, that's on par with going to the dentist. So they don't really enjoy going to the gynecologist, but they're there because they're concerned and they want some relief from some of their symptoms. So it's obviously very important that they're there and that we evaluate it. So even if it's not cancer, it's obviously important to myself and the patient.

Host: That's definitely true, I mean, I don't mind going because as women it's good that we're good health advocates for ourself, and you're obviously such a kind and passionate man. Now tell us a little bit about what treatments, you might offer a woman that is really, as you say, it's affected the quality of her life.

It's something that makes it difficult for her to go out and wear certain clothes. What kinds of treatments are available?

Chris Jones, MD, OB/GYN, FACOG (Guest): Yeah. So, when I'm talking to my patient, that's in front of me so I've got a patient abnormal uterine bleeding, I say, well, this does not appear to be cancer. So then that opens up a wide variety of treatment modalities. And a lot of it, Melanie, depends on what we think the etiology of the abnormal uterine bleeding is.

So we try to tailor our treatments to the, to the etiology or the cause of the bleeding. The majority of patients that come in with abnormal uterine bleeding, I would say probably 75 to 80% of the time, the abnormal uterine bleeding is due to ovulatory dysfunction. Now the way I try to describe that to my patients is the only reason that you have nice normal regular periods every 28 days is that your ovaries are functioning absolutely correctly and telling your uterus what to do. So, menstrual bleeding is a, is a direct consequence of our reproductive function.

So the ovaries try to get the uterus prepared for a potential pregnancy. And then the ovaries ovulate and then they produce a second hormone called progesterone. And in this, in the second half of the cycle, I don't want to get too into the weeds here, but then in the second part of the menstrual cycle progesterone is produced. In the first part of the cycle estrogen is produced. Then the ovary ovulates, and then progesterone is produced. And then the ovaries say, hey, have we achieved a pregnancy yet?

And then if you have not achieved a pregnancy, then the ovaries say, okay, let's stop. And they stop producing those hormones. And then the uterus bleeds and that's the period. So if the ovaries aren't doing exactly what they're supposed to be doing in that fashion, then the patient will experience abnormal uterine bleeding.

So in 80% of the time, when patients come in with abnormal uterine bleeding, it's because that described cycle is not happening. And usually that means that the ovaries are not achieving ovulation. So that's why we call it ovulatory dysfunction. And that could be caused by a myriad of different things. Commonly young adolescents when they are just starting their reproductive life are going to have what we call an immature ovarian axis, A-X-I-S and the ovaries and the hypothalamus, which is a portion of the brain are just kind of learning how to do things. And so, young women, adolescents that are just starting their menstrual life often have irregular bleeding and that's due to ovulatory dysfunction.

And then at the other extreme, as women trend towards menopause, that axis also stops kind of functioning perfectly. And then the ovaries don't ovulate every month, like they're supposed to during the reproductive cycle. So those women often have abnormal uterine bleeding. I'm sure a lot of your listeners have experienced perimenopausal bleeding and that's usually the cause of abnormal uterine bleeding in that period of life as well. That it is that the ovaries aren't doing exactly what they're supposed to be doing, meaning they're not ovulating every month.

So Melanie, I think we would want to take some time and talk about the treatments at the next segment. But generally if a patient is experiencing abnormal uterine bleeding, I'd really like to encourage our listeners to give their provider a call and schedule an appointment so that they can come in and discuss with the provider what's going on and start to develop a diagnostic algorithm and see, try to figure out what's going on and then move towards some sort of treatment modality.

Host: And we will get into some of those. This is so helpful for women. Sometimes we think there's not really that help out there and it's just something we have to live with, but that's not true and you're telling us that today. We were just getting into some of the treatment options for women that as you say, it really affects their quality of life, when they have abnormal bleeding, really heavy periods, painful periods. Tell little us a bit about some of the things that can be done to alleviate.

Chris Jones, MD, OB/GYN, FACOG (Guest): Yeah, sure, Melanie. So I mentioned prior to the break that we try to tailor our treatments towards the cause of the bleeding and I mentioned that the majority of cases are going to be due to ovulatory dysfunction. And in those cases, we we generally can't tell the ovary what to do, meaning we can't get it to ovulate unless the ovulatory dysfunction is due to something like PCOS, polycystic ovarian syndrome and in those cases we can discuss lifestyle modifications and a couple of different medications that can help with ovulatory dysfunction.

But in general, the kind of the first line treatment will be giving exogenous hormones to try to mimic that normal cycle that the ovaries go through and tell the uterus what to do. And in general, that's going to be birth control pills. So combination oral contraceptives or there's different types of combination contraceptives at this point with a transdermal. So something, a patch placed on the skin or even a vaginal ring that could be placed in the vagina that can mimic the normal ovarian cycle. So generally that's one of our first line treatments is, is hormonal treatment. In addition, NSAIDS, so things like ibuprofen and Aleve can not only help with the painful periods, they can also diminish the amount of bleeding that a patient's having. So that's kind of the, the first line sort of, treatment for ovulatory dysfunction would be hormonal therapy plus anti-inflammatory medications.

Host: Wow. So, I mean, you're really telling us that there are a lot of treatment options out there.

Dr. Jones: Well, well, there then I don't want to go without talking about some of the other types of causes. It's not always ovulatory dysfunction. Your listeners and my patients have all heard of things like a uterine fibroids. So fibroids can cause abnormal uterine bleeding or polyps that are within, in the uterus. Just like the colon can have polyps. The uterus can have polyps. And when the uterus has polyps, sometimes that can cause abnormal uterine bleeding. And then in those cases generally we still usually start with some sort of medical management. Cause if we think it's not cancer, then we don't necessarily have to subject the patient to any sort of invasive procedure.

So generally we will, we'll start with some form of medical management, but if that's not successful, then we move on towards the more invasive type things like let's just talk about fibroids at this point. If the fibroids are ideally located, those can be removed hysteroscopically, so that's an instrument that's placed inside the uterus, just like we're doing kind of a pap smear type exam. An instrument can be placed inside the uterus and the fibroid can be removed that way. And the advantage of that is that usually is an outpatient procedure. It's got minimal risk. And the sometimes fibroids can't be addressed that way and they can be addressed other ways up to, and including a hysterectomy.

Host: Dr. Jones. I'm so glad that you brought up fibroids. So many women have this, I myself have them and I've had ultrasounds cause they're a little bit scary sometimes. You're not sure if they’re growing. Speak about fibroids. I'd like you to expand as you get into some of the treatments, tell us what they really are and do they really lead to cancer?

Dr. Jones: Yeah. So, fibroids are benign tumors of the uterine wall is made up of smooth muscle fibers. So, some of your organs in your body are lined by smooth muscle. Specifically, you can think about there's some smooth muscle in your intestinal tract to, to move the GI contents through the intestinal tract, but smooth muscle is different from skeletal muscle that are like your biceps and your triceps, but generally fibroids are benign smooth muscle tumors of the uterus. And when I say generally, I say, I mean, the vast majority of fibroids are benign. I would say upwards of 99.7% of clinically diagnosed fibroids are going to be benign.

Host: Well, that's encouraging to hear. Are fibroids painful? sometimes just not even know we have them?

Dr. Jones: Absolutely. If we look close enough and let's just take your average 50 year old woman, if we enough look close enough probably half of those women are going to have some evidence of fibroids. And those and the interesting thing is, is there's a wide spectrum of the size of those fibroids.

They can be anywhere from a couple of millimeters so much less than an inch to we've just had fibroids described as being as large as the entire abdominal cavity. So there's a wide spectrum of how large they can be but they're extremely common.

Host: Is treatment for fibroids always necessary, Dr. Jones? Sometimes do you just kind of watch and wait, they are affecting the woman's quality of life?

Dr. Jones: Yeah, exactly. So generally, if a fibroid is asymptomatic, you're not going to want to subject that patient to any sort of treatment. So I often tell my patients, I can't improve upon asymptomatic. And so and since, generally fibroids are not cancer, we would not want to incur risks with any treatment for said fibroids, if they're truly asymptomatic. Sometimes if we diagnose a fibroid and it's assymptomatic, we may want to repeat some sort of imaging modality in three to six months, just to assure ourselves that this isn't one of those rare cases of a cancerous fibroid. And then as long as the fibroid appears to be stable, really there's nothing else left to do unless the patient starts to have symptoms from the fibroid.

And so that tells you that not all fibroids are symptomatic, not all cause pain or abnormal uterine bleeding. And so, you surely wouldn't want to do an invasive procedure for a tumor, a benign tumor in the uterus that a patient will live with all her life and not even know it's there. So that's generally our principle is not to make the treatment worse than the problem.

Host: And that is certainly a great principle to follow. Are there other, you mentioned lifestyle behaviors in our first segment, but are there things that we can do and not only behaviors, but things that we can do, like pelvic floor physical therapy is something that women have heard about now. It's, It's a relatively new field.

What else can you do for women if those fibroids are a little bit painful or they kind of cause heavy bleeding, they cause bloating. I don't know. They cause things sometimes.

Dr. Jones: Yeah, well, pelvic floor physical therapy is certainly a, an underutilized modality for a lot of different gynecologic problems. I can't really say that pelvic floor physical therapy has too much space to help with uterine fibroids, but there's a large variety of other conditions that it can be helpful with.

But you asked the question is what can we do for these fibroids if they're painful, or if they're causing any other symptoms such as abnormal uterine bleeding, and again, in general, if I have a patient come to me with a fibroid and we're sure it's not anything that's going to threaten the patient's life, then usually start with some sort of medical management. And again, this goes back to hormonal therapy and anti-inflammatories and we'll give that a good trial and see if that doesn't help the patient and her quality of life. Then if it doesn't, then we can move on to some different types of treatments for fibroids.

Host: Wow. There's so many things that we women really go through and you're so well-versed on so many of them. Tell us a little bit about anything else that you would like to expand on for women as if they're suffering from abnormal uterine bleeding or fibroids, any of these things, and when you feel Dr. Jones, that it's important that a woman visit her gynecologist, maybe not just for her annual wellness exam, if any of these things bother her.

Dr. Jones: Yeah. So as we've talked about in other segments, it's always important to try to address a problem earlier rather than later. So if they ha- if a patient has symptoms that are bothering her and usually those symptoms are going to be related to the size of the fibroids and the location of the fibroids, and those symptoms can be uncomfortable periods, crampy periods, pelvic fullness, or pelvic pressure or abnormal uterine bleeding, and any sort of fibroid is better addressed earlier rather than later. So I would just encourage our listeners to go in to their provider and discuss the various treatment modalities for fibroids and then come up with a plan that best suits the patient's priorities and preferences.

Host: It's really great information, you’re just a wealth of knowledge, Dr. Jones and such a great guest and a really good educator as well. Thank you so much for joining us today. I mean, it's really great for women to have this information right at their fingertips. Listen to these podcasts ladies, and then share them with other women that, you know, because you know, we're all kind of going through some of these things.

And to get this information straight from the experts at Memorial Hospital can really help us to be our own best health advocates. Dr. Jones, thank you again for joining us and listeners can call 217-357-2173 to schedule an appointment with Dr. Jones. And that concludes this episode of say Yes to Good Health with Memorial hospital.

For more health tips, please visit our website. M H T L c.org to learn more about Memorial hospital's obstetric services. We'd like to thank our audience and invite you to download subscribe, rate, and review on apple podcast, Spotify and Google podcast. I'm Melanie Cole as always. Thanks so much for listening

Disclaimer: The medical health information provided during this program is for general information and educational purposes only, and is not a substitute for professional advice. None of the given information is for the purpose of diagnosis or treatment. Neither does this program serve as approval for any health product or brand. This program aims to enhance your personal health and wellness through the adoption of healthy lifestyles and your prompt presentation to the health professional whenever you suspect that you are ill. For treatment and professional advice, ensure you consult your physician.