Transcription:
Abnormal Uterine Bleeding

Amanda Wilde: Uterine bleeding is perfectly normal. It's called menstruation. But women can experience uterine bleeding that's not a normal part of that monthly cycle. Dr. Janice Krystal Ascencio is here to talk about how to identify and manage abnormal uterine bleeding.

Dr. Ascensio is Vice Chair of the Obstetrics and Gynecology Department and Director of OB-GYN Ambulatory Clinics at Jamaica Hospital. And doctor, thank you for being here. Before we can have a discussion about abnormal uterine bleeding, what is considered normal uterine bleeding?

Dr. Janice Krystal Ascencio: Oh, Amanda, thank you for asking that question. A young lady starts having their period, average age is probably nine years old or so. And once you have your period, it takes about two years to establish sort of a pattern. It's over time. And so usually about two years in, you want to see that the bleeding is less than eight days in its duration. And that from month to month, you want to see that it's about 24 to 38 days apart. So that is what normal bleeding is. It's usually a part of the menstrual cycle that a young lady experiences as they pass through puberty.

Amanda Wilde: So how do we know when bleeding is abnormal?

Dr. Janice Krystal Ascencio: Well, this is a thing. As you look at your menstrual cycle and you recognize that it's supposed to occur once per month, if you're finding that you're bleeding between the times when you're supposed to have your period, then that is considered abnormal. How about menopause? You know, so once a woman goes through one year when they no longer have periods, that's considered being post-menopausal. And if you start bleeding during that time, that's also considered abnormal.

Now, there are times when a person might bleed twice in the month and it's not abnormal. And that's if it's the very tail end of the month to the very beginning of the other month, and those are nuanced. I think you just have to count the time between, and that would help to give a little more distinction.

Amanda Wilde: So then that helps us identify when it's abnormal, what causes abnormal bleeding?

Dr. Janice Krystal Ascencio: So in terms of how we look at abnormal bleeding, there is a sort of mnemonic that physicians look at to say, "Hey, a patient comes in, they're talking to me about their bleeding, how can I categorize what is going on with them?" And we say PALM as in P-A-L-M, COEIN, C-O-E-I-N. And how that works out is we look at is it structural? Is this something that's there structurally, like a polyp, fleshy tissue? Is it something like adenomyosis where tissue is between the muscle fibers that can cause that abnormal bleeding? Is it fibroids? Is it a cancerous condition? Is it that the patient's not clotting properly? Is it that they're not ovulating properly? Is it from the lining, something going on there? Or do they have like a intrauterine device or some other contraceptive device that's causing this bleeding? And in other cases, you cannot even figure out what it is, it's just unknown causes.

Amanda Wilde: Oh, okay. So there's a whole range there. Does pain come with the bleeding or sometimes can you have abnormal uterine bleeding and have no pain at all?

Dr. Janice Krystal Ascencio: Absolutely. So the pain is not what makes it abnormal. So there are patients who have abnormal uterine bleeding, and it may be associated with cramping, but that's not sort of what makes abnormal. It's really more about the timing or the frequency of the bleeding and, many times, how heavy the flow is. So you can say, "Okay. My menstruation is coming once a month. But it's coming and I'm going through more than a pad or a tampon within an hour. And this is happening for several hours on end. I'm feeling a little lightheaded. I'm a little dizzy." You're having those symptoms. "My seems a little heavy." So in those cases, that's more how the classification of the abnormal bleeding occurs separate and apart from pain. The pain patterns come with a patient who might be suffering like the endometriosis or some other thing, just painful periods that might be separate and apart from the abnormal bleeding.

Amanda Wilde: So if it's aside from a normal period, it's abnormal bleeding, and then should you in every case seek medical attention when you notice that?

Dr. Janice Krystal Ascencio: I'm so glad asked that question. So there's definitely a point within which you need to see the doctor. So, as I said before, if you're having that kind of heavy bleeding that we talked about before, that's a good reason to go and seek medical attention. If you're having the bleeding between those periods, again another good reason, because it could be very simple fix. It could just be a polyp that's there that's causing it. It could be a fibroid that's going into the lining that's causing the bleeding.

The other reason I think we should look at why a patient might want to come in for evaluation is bleeding with intercourse or after intercourse. So that's not normal. Unless you're starting a menstrual cycle and it was unknown to you, in those cases, that's a clearly difference. But if you're finding that each time you have intercourse, you're having the spotting, bleeding, that's something that you might want to also look at.

Amanda Wilde: So you were just saying that polyps and fibroids can be a generally easy fix. How do you address abnormal bleeding since there's so many ways it can happen? Are there different treatment modalities for managing the bleeding?

Dr. Janice Krystal Ascencio: Oh, absolutely. So when we go through looking at a patient who comes in and complaint of abnormal bleeding, you want to see sort of, you know, most times it is something to do with their ovulatory patterns. So if the patient is not ovulating appropriately, it may lead them to, for some times, miss a month or two and then have very heavy bleeding on the back end of that. And in those cases, they're experiencing what we call anovulation, anovulation, which leads to the heavy bleeding. There's fibroids, which are benign tumors. And sometimes depending on the location, how large they are, that can cause abnormal bleeding as well. You have the polyps that can again be in that lining and it's disrupting that lining and it could cause the flow, even the very period that they have to be heavier or bleeding between the periods.

So when we look at how we treat that, we say, "Okay, there is the medical and there is the surgical." And of course, we always try with medical management. So I think one of the things we need to talk about is the fact that what causes menstruation, right? So we have a menstrual cycle and the whole thing is run by hormones. So the first and main way in which we can manage medically is with hormonal management. That's how we can manage bleeding, irregular bleeding, is with hormones. And that can come in a number of different ways. Either we are going to give like a combination birth control pill. We're going to give progesterone-only pill. So those are some of the ways in which we manage it. Well, usually first-line is with hormones and then we can consider surgical management, either in ways where it failed or when it's not appropriate. So polyps would not respond to you using medical management, that would require surgical management. A fibroid that's sitting in the lining of the uterus causing abnormal bleeding as well would not respond to medical management, that would require removal. So there are some cases where you don't have the option of using medical management, it's just surgical.

Amanda Wilde: Now, I know surgeries have come a long way and continue to increase in, you know, how less invasive they've become over the years. What does surgery look like for some of the treatments?

Dr. Janice Krystal Ascencio: I am so thrilled that, you know, having been doing this for so many years, the evolution of how we can manage patients. First of all, we have procedures that we can do where we can actually look in the uterus with a camera and see in real time what's happening in the lining. And that can diagnose for us many times and sometimes treat in the office, the polyps or even fibroids that are in the lining. And that can really change the game because previously these were patients who would be streamlined if you couldn't control it with medicines to surgery. And so now those patients, same-day procedure, can have that polyp removed, they can have that fibroid removed and then go back to normal cycles. And that is amazing.

Now, on the other back end of that in terms of how we manage fibroids, large fibroids, there are so many things. We have radiological advances where they can basically go in, uterine artery embolization surgeries, and many times people can have the fibroid shrinking and that can decrease the symptoms, either the symptoms of it being very bulky because it's so large, causing them to want to use the bathroom too frequently or just being uncomfortable aside from the heavy bleeding that can, you know, result from the fibroids. And then, of course, we have targeted ultrasonic-guided therapies to the fibroids that can actually cause them to shrink and shrivel and die. And that would be best done laparoscopically again. We can do laparoscopic removal of these fibroids as opposed to the larger incisions that we'd usually do customarily, and those patients can, you know, again experience minimally invasive procedures; whereas previously, these were done as an open procedure. So we really have come a long way in managing our patients both medically and surgically.

Amanda Wilde: Are there any steps we can take to prevent ever having abnormal uterine bleeding?

Dr. Janice Krystal Ascencio: So that's a really great point. I'm so glad you're asking that, Amanda. You know, with abnormal uterine bleeding, sometimes it can actually result from a patient who is more overweight because, in our fat cells, we can convert some of the hormones in our fat cells to estrogen and that also influences how much we're getting in terms of on the lining of the uterus, how much estrogen effect, and that can cause the lining to be very thick and, of course, lead to the heavy bleeding. So just being healthy, eating healthy, those things can help. But, you know, you don't make a polyp because thought about it and made it. You don't create a fibroid in the lining. And so there are many things that you can't control when it comes on to abnormal bleeding.

And the other thing that I think I failed to mention is some medical conditions can actually lead to abnormal bleeding. So if a person who may have a thyroid disorder, diabetes, different chronic medical illnesses, it can actually lead to this abnormal bleeding. It can feed right into it. So you can try your best to live a healthy lifestyle. And those things always will help to pull you through and put you in a better position. But as I said before, there's some things we can't fix.

Stress also can be a real central factor around abnormal uterine bleeding. And so you want to decrease the amount of stress in your life. And that goes across the board for all parts of us keeping healthy, because the way in which our body works is usually brain to ovary. The brain sends messages to the ovary, and then the ovary sends those messages to the uterus. So if there's any disruption on that continuum, you're going to have issues. So if you're very stressed out or overexercise, different things can cause either no bleeding or heavy bleeding. And so that's I think how that goes.

Amanda Wilde: So anytime you do see abnormal bleeding, it's time to consult your doctor.

Dr. Janice Krystal Ascencio: Absolutely. Yeah. You know, you want to make sure that things are okay. And the exams that we can do first, you know, we go ahead and evaluate with the office examination. We can do a further examination with ultrasound and that can help us to see better what's going on in the pelvis, you know, what's going on in the uterus, if there's something with the ovary, a cyst or something that's also leading to the bleeding. And so you want to do a full evaluation, blood work to make sure your blood counts are not too low, dangerously low where you may need blood transfusion or iron to help you to get through that dizziness and lightheadedness that you might be feeling. So I think that's how we can look at it.

Amanda Wilde: With all these modalities, do you always achieve success in addressing abnormal uterine bleeding?

Dr. Janice Krystal Ascencio: Well, we have a pretty high rate of success in managing abnormal uterine bleeding. Now, again, when we talk about abnormal uterine bleeding, there's cases when there is acute bleeding that it requires emergent management. And those times you may have to give like IV estrogen or, you know, a combination birth control pill, progesterone, different things to try to control that. They may require surgical management by what we call a curettage at the lining of the uterus. So there's times when those things have to be done in the acute setting, in the emergent setting. But in most cases, based on the modalities we have right now, we do have success. In those limited cases where we do not have success, those patients may end up streamlined to again surgical intervention, where the uterus might need to be removed.

Amanda Wilde: Well, doctor, thank you for this enlightening conversation.

Dr. Janice Krystal Ascencio: My pleasure.

Amanda Wilde: To learn more about OB-GYN services at Jamaica Hospital or to make an appointment, please call 718-291-3276. For more information about all the services Jamaica Hospital offers, visit our website at jamaicahospital.org/podcasts. This has been Jamaica Hospital Med Talk. I'm Amanda Wilde. Stay well.