Scott Webb (Host): Many women wonder if the uterine bleeding they're experiencing is normal. So, it's good that my guest is here today to tell us what's normal and abnormal and what she can do to help women. I'm joined today by Dr. Lydia Garcia. She's an OB-GYN with SolutionHealth.

This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Dr. Garcia, it's so nice to have your time today. We're going to talk about irregular bleeding. And as I was mentioning to you, I've never hosted one on irregular bleeding. So, it's great to have your expertise today. Let's start here. What is considered abnormal bleeding?

Dr. Lydia Garcia: Well, I feel that answer is different for different women because what is considered normal for one woman might be different from the other. So usually, most women get periods once a month, , but once a month can vary. So, you can have one woman who has them every three weeks at 21 days and someone who's having them every five weeks. So, what we consider normal is having a period anywhere between 21 to 35 days. And most periods should usually have a little bit of bleeding, light in the beginning, then you'll have like three days or four days of heavy bleeding. Then, it will lighten up with a total amount of bleeding usually to be about seven days.

Of course, there's exceptions to this, right? So, when young girls get their first periods, usually between the ages of 9 and 14, it can take 1 to 2 years for the hormones just to kind of figure out the pathway, going from the brain, to the ovary, to the uterus. And then, you have the other extreme on the other side of life, as in older women who are starting to go into menopause, it's common for them to skip periods. So, without those two exceptions, normal periods are usually between 21 to 35 days.

So, abnormal bleeding, now that we kind of talked about normal bleeding, would be anywhere where you're going longer without a period, or more frequently with that period. So if you're having periods every two weeks, that's not normal. If you're skipping your periods every couple of months, that's not normal. Spotting in between periods is not normal. Bleeding after menopause is not normal, and then that's timing of periods, but also heaviness of a period can be considered abnormal. So if women are soaking through a tampon or a pad, more than once an hour, that's pretty heavy, and these women can lose a lot of blood and they can feel fatigued. So, it's important to talk to your doctor not just about the timing of the period, but when your periods are super heavy as well.

Host: All right. So, we've got normal, we've got abnormal, a range of things, ages and other factors, hormones and things involved. So then, what causes abnormal uterine bleeding?

Dr. Lydia Garcia: I like to explain it to patients that there's kind of like two ways to think about it. You have the structural lesions, the kind of masses inside the uterus that might cause some abnormal bleeding, things like endometrial polyps. They're kind of like skin tags and they're extra growths inside the uterus. They don't tend to be cancerous in most women, but they can cause a lot of irregular bleeding or bleeding with sex. And then, there's other masses like fibroids. Fibroids also tend to be benign masses and they're usually just big balls of muscles in the uterus, which is an actual muscle. But they can grow and depending on the size and location, they can cause heavy periods.

And then, you have the non-structural lesions, which is usually something kind of messing up with your hormones, right? So if you have a thyroid disorder, sometimes that can make you have heavier or lighter periods. There's also other issues when you're basically not having your period every single month because you're not ovulating every single month. Again, stress can do that, if you've lost a lot of weight, people with eating disorders sometimes can be skipping their periods. So, it's really important to kind of take your period as like a vital sign. So when you go to the doctor and they take your heart rate and your blood pressure and listen to your heart and lungs, for us as gynecologists, it's important to hear what your periods are doing. Are you skipping periods? Are they heavy? Are they light? Because that will help differentiate which of these causes might be happening?

Host: Yeah. I see what you mean. So, you know, obviously, we want folks who want women to reach out to their own providers and share this information, of course. And it sounds like, you know, when you've got people in the office, got women in the office, then you're really interested in sort of patient history, what's actually going on with them. As you say, see this as kind of like a vital sign, something to definitely share with a provider. I'm sure you also do workups, right? So, what can women expect from a workup for abnormal bleeding?

Dr. Lydia Garcia: Like you mentioned, talking to your doctor, I think, is the most important thing, right? And so when they're going to ask you about your periods, they're going to ask you how often do they come, how heavy are they, how many pads are you using, how many days they last, and that can be overwhelming. But now, we have all this great technology and you can use these free apps that can kind of track your periods and, you know, kind of say how many days they have. So, that's probably the most important thing to kind of talk to your doctor about.

Once you're at the doctor's office, they'll do an exam. And then for our younger girls who, you know, haven't had a pelvic exam ever, sometimes we skip that and we just talk to them and get a history to figure out what's going on. In addition, we'll send some labs. Like we talked about, the thyroid could be an issue that hormone level in the brain, if you're skipping periods, prolactin. A lot of times we want to make sure we don't have those structural lesions that we talked about, so we usually order an ultrasound. And that is, you know, no radiation. I know a lot of people are worried about mammograms and CAT scans, but there's no radiation and it's a pretty simple test with the ultrasound.

And then, depending on your age, you might have to have some more invasive procedures. And so in some women over age of 45, if you have heavy bleeding, we want to make sure that there's not that risk of cancer that could be causing your bleeding. So, women over the age of 45, we usually recommend a biopsy if they're having irregular bleeding as well.

Host: Okay. Yeah. So, you've said here it could be structural, it could be non-structural. And I want to talk about the options as we get close to wrapping up here, the options for helping women. So whether they be hormonal or surgical, let's start there. Let's start with hormonal options. What do you have for patients who are suffering?

Dr. Lydia Garcia: Yeah. A lot of women, even though they don't need contraception or they're not sexually active, regular birth control can really help their periods. So, just a pill, a patch or a ring, these are forms of contraception, but what they're doing is they're kind of taking over your body in terms of your estrogen and your progesterone. And so, your body's going to have the period when the birth control is basically telling you to. So in that case, it makes your periods lighter, it makes them more regular, you know when your period's coming. So, that's a really nice option for people who are skipping their periods or having spotting in between their periods that's not caused by a structural lesion.

In terms of surgical options, if there is a polyp there, it's a pretty simple procedure. Sometimes we can do it in the office depending on the size of the polyp or in the operating room. But we place a small, little tiny camera inside the uterus. And then, we basically pluck that polyp out either with scissors or just by pulling it out that way. And then, in terms of surgical management, you know, this is really for women who are done with childbearing. Because once we do these procedures, you can't have any more kids. So, there is a procedure called an endometrial ablation. And basically, what we're doing is we're cauterizing the inside of the uterus.

I think we need to take a step back. How do these hormones work and why do these hormones and these procedures work? I like to describe it as the grass is growing. And so, that's what It makes the grass grow and then, to cut the grass basically is progesterone. And so, we basically are mowing the lawn. And so, the progesterone is what's really important in terms of stabilizing the uterine lining and not making you have heavy periods. So when we're talking about hormonal therapies, it's mostly the progesterone that's the important part for most women to help with that. So when we're talking about endometrial ablations, instead of having that grass growing, we're cauterizing the inside of the uterus so it doesn't grow anymore. And so, people have 80% lighter periods, and a lot of women don't have periods with it at all.

Another hormonal management that is similar to the ablation but not as invasive is something like a Mirena IUD. An IUD is a small apparatus that goes in the uterus and it secretes a little bit hormone locally. So for women who don't like the idea of having systemic hormones, a Mirena is a great option because it just sits inside the uterus and it does that progesterone, that lawn mower that's cutting the grass. And so, the same way the ablation works, it decreases your bleeding by 80%. And again, in about 20% of women, you don't have a period at all, which sounds fantastic for most women, I would say.

Host: It sure does. Yeah.

Dr. Lydia Garcia: Yeah. Again, the same kind of method with the ablation and the Mirena is that it's thinning out your lining. So, you're not having that heavy bleeding. And then, if you have a fibroid, depending on where that location is, sometimes we can take out that fibroid. If it's inside the uterus where the lining is, we can just go in and kind of scoop it out in pieces. And it's usually a one-day procedure. You're back at work the next day. There are some bigger procedures if the fibroids are bigger and they're on the outside of the uterus. There's a laparoscopic, what we call myomectomy, where we take out that fibroid. That's a little bit longer of a recovery.

And then, for women who have tried all these hormonal managements or it doesn't work, there's always hysterectomy. And hysterectomy sounds pretty scary. Not for you, Scott. I realize that because you're a male. But a lot of women don't like the idea of a hysterectomy. But I will say technology has come a really long way. With our hysterectomies, we're doing them minimally invasive. So, you have really small incisions. You're going home the same day,. People are going back to work after two weeks. So, I wouldn't rule it out, I wouldn't do it as a first option, but it's definitely an option for women who have kind of failed a lot of treatment options and it's still there and it's not as scary as it used to be.

Host: Yeah. So, it's always good to hear, even though it doesn't necessarily affect me per se. It's good to know that women have options, be they hormonal, surgical, that you don't start with hysterectomies, right? You kind of work your way up to that point. I just want to give you a chance here at the end. Final thoughts, takeaways, if women are experiencing what they perceive to be irregular or abnormal bleeding, how do we get them in the office?

Dr. Lydia Garcia: I think the biggest thing is contacting your doctor. If you don't have a gynecologist, ask your primary care doctor to get you in with one. And even if you're not sure if this is normal or not, it's really important just to speak up, ask the questions, gather your data, know what your periods are doing, whether you think it's right or wrong, and just talk to someone about it.

Host: Yeah, that's perfect. As I was telling you before we got rolling, we just want to educate. We want to encourage folks to speak with their own providers, see specialists if they need to. And if they have any doubts, any worries, is this normal, is this abnormal, we have experts that we can turn to.

Dr. Lydia Garcia: Yeah, absolutely. Thank you for having me.

Host: And for more information, go to snhhealth.org and search New England. And if you enjoyed this podcast, please be sure to tell a friend and share on social media. This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Stay well, and we'll talk again next time.