Bill Klaproth (Host): Abnormal uterine bleeding can seriously interfere with daily life and is one of the most common reasons women seek gynecological care. Here to talk with us about abnormal uterine bleeding is Dr. Monica Selander an obstetrician and gynecologist with Tidelands Health Women’s Center. Dr. Selander, thank you for your time. So, tell us, what is abnormal uterine bleeding?

Monica Selander, DO (Guest): Hi there, thank you as well. So, abnormal uterine bleeding I think to best describe what it is, we first have to talk about what is normal uterine bleeding and this refers to a woman’s menstrual cycle. We can define what is normal based on a couple of different criteria. The first is how often it occurs. We generally expect to see a cycle approximately monthly. I tell my patients don’t actually use the calendar because the calendar doesn’t listen to your body but count the days between your periods.

A normal period cycle should last anywhere from 21 to 35 days. And it doesn’t have to be something where every exactly 28 days or 30 days you have a cycle. There can be some variance. But as long as it is relatively similar within that time span, we would consider it to be occurring regularly. Another aspect that we use to define normal is how long it lasts for. Four to seven days is pretty normal. So, if you are having cycles that last for only one day or if you are having two week episodes of bleeding; that would be abnormal. That is lasting too long.

And the other thing we use to define the bleeding is a normal amount of blood loss. And this is very subjective. If you read the medical books, they say 80 cc of blood is normal which no one can account for when they look at what they are having with their bleeding. So, we can’t really use that as a guideline and really, we just use what patients say. Do they feel like their cycles are really heavy, they are losing a lot of blood. Changing more than like a pad an hour, pad or tampon an hour. Or are they having symptoms of chronic blood loss like fatigue, lightheadedness, shortness of breath. Something like that would indicate that they are losing too much blood.

So, if you are having anything go on with your cycles that are outside those parameters of normal; it’s then considered abnormal uterine bleeding.

Host: So, is this common and who is at risk for this?

Dr. Selander: It’s extremely common. We see, I would say probably around 30-40% of our office visits for abnormal bleeding. There are some risk factors that we know of for abnormal bleeding. Any type of condition that causes you to have an increased amount of estrogen can make your bleeding abnormal so this would be something like polycystic ovarian syndrome which just by nature of it has irregular cycles and hormone abnormalities. Someone who is obese. Fat tissue actually produces estrogen, so that stimulates the endometrium, the inside of the uterus and causes heavier and abnormal bleeding patterns. Someone with endocrine abnormalities like thyroid abnormalities, diabetes; they are at risk for this to occur.

However, we do see it in people who don’t have any risk factors and they just happen to have this bleeding and that’s why we do our workup to try to figure out what’s causing it.

Host: So, speaking of what’s causing this; do we have an understanding of why this happens?

Dr. Selander: We do. We have kind of a nice little pneumonic that we remember to keep us on track for what the causes are. The pneumonic is called P-A-L-M-C-O-I-N. So, the Palm side of things is really all focused on structural causes of heavy bleeding. So, the P in it stands for polyps. You can have polyps or just little outgrowths of tissue that grow abnormally, usually not a cancerous type of growth, but sometimes. And these can be present in the cervix or in the endometrium, the inside of the uterus and those can bleed heavily.

A is for adenomyosis. This is a condition where the endometrium, the inside of the uterus ends up – the tissue there ends up kind of creeping into the myometrium which is the wall of the uterus. It doesn’t belong there, and it gets into where some of those - more of the blood vessels are and causes heavier bleeding and pelvic pain.

L is for leiomyoma which is a fancy word for fibroid. I think a lot of people have heard of fibroids before. They are extremely common. They occur in 70% of Caucasian females and 80% of African American females. And these can be a very frequent source of heavy bleeding especially if they occur on the inside of the uterus. That really contributes to heavier bleeding patterns as they kind of sequester blood vessels. They are very selfish when it comes to blood. They like to steal a bunch of it and then you have a ton of bleeding with your cycles.

Then the M of that pneumonic is malignancy. So, cancer is something that we are always concerned about with bleeding but kind of on that topic; I like to talk about one bit of abnormal uterine bleeding that’s very important and that’s postmenopausal bleeding. So, that’s a woman who has gone through menopause, has stopped her periods for over a year and then is now experiencing the sudden return of spotting or bleeding. That is always abnormal. You should not have any bleeding at all after you go through menopause.

And unfortunately, one of the bigger things we are concerned about with that is endometrial cancers. Luckily, most of the time that’s not what’s causing it. But of people who have endometrial cancer, about 90% will present with some bleeding post menopause. So, that’s why we evaluate that very closely in that regard.

The other part of the pneumonic the coin side is more systemic problems that can cause the bleeding. These are things like coagulopathies, like problems with blood clotting disorders like Von Willebrand’s, ovulatory dysfunction, like I had mentioned prior with the polycystic ovarian and then there is also iatrogenic, so that is like something that maybe another doctor gave you a medicine that causes things to be a little bit abnormal. One really common one I think of is the Depo shot causes just totally irregular bleeding and it’s a normal side effect. But that’s what’s causing it.

So, this is kind of a list of some of the more common causes that we find when we are doing a workup for this bleeding.

Host: Okay so, remember PALM COIN. That’s a good way to put this into focus. So, how do you drill down on a diagnosis to figure out okay, that’s what it is, it’s abnormal uterine bleeding and not one of these other things you just mentioned?

Dr. Selander: That’s a good question. So, kind of if you think of that PALM COIN pneumonic again, we have got the palm side with the structural causes. That’s all evaluated first of all, by an ultrasound. We do a pelvic ultrasound, a transvaginal probe gives us the best pictures and that can look at all of the pelvic structures to see if there is any evidence of polyps, thickened endometrium, fibroids, masses; anything like that, it can give us an idea.

So, really the structural causes are mostly evaluated in that way. If we don’t find anything, we can further look at the organs either via a hysteroscopy which is a camera that goes on the inside of the uterus or a laparoscopy which is a camera that goes in the belly that looks at the outside of the uterus and the other pelvic structures.

In regards to the coin side of the pneumonic which is more systemic; that’s generally evaluated with blood work. So, we look at things – a TSH checks for thyroid abnormalities. We do glucose testing for diabetes. We can do panels of blood work for different blood clotting disorders to see if those seem to be the situation. And with like PCOS, we do have certain again, blood studies that we look at to see if that be what’s going on there.

Host: So, then what are the treatment options for this?

Dr. Selander: Treatment options. We have got a whole bunch. It really depends – it really is a case by case basis. Because it depends on what each patient has going on. A lot of times, there’s bleeding and pelvic pain that needs to be looked at together. So, what bothers them more? Is it bleeding, is it pelvic pain? Our treatment options might vary based on what’s important to them.

Another very important decision making factor with our treatment is what their reproductive goals are. If this is someone who doesn’t want anymore babies; then we have a lot more options and surgical options that can be done to treat these problems. Someone who wants to have babies still in the future; we will of course want to maintain the integrity of their uterus and their reproductive system so they can still have children in the future if they want.

But as a kind of general overview of our treatments, we have things – anything from oral contraceptive pills like birth control pills to longer term birth control – or I guess medications you have heard of for birth control like a Depo shot, Mirena IUDs, one of our hot things that we have that is really wonderful. It works great for bleeding and for contraception. We have other things that we can do that are more surgical so we can go in when we do that hysteroscopy, we can do polypectomies, remove polyps that might be causing bleeding. We can do myomectomies which is the term for removing the fibroids and all the way up to – and one of our best procedures we have is an ablation when we go in and burn the inside of the uterus which damages the cells that shed off every cycle for your menstrual cycle and then you don’t have bleeding anymore. And this can go all the way up to a hysterectomy when we do remove the uterus and the fallopian tubes.

So, it really just depends on what the actual situation is for the patient. If we can figure out what’s causing their bleeding and what their goals are for their future which will mold each person’s individual care plan based on what their wishes are.

Host: Right. So, it sounds like this can be managed for a lifetime until a woman reaches menopause, is that right?

Dr. Selander: Yes. Sometimes that our goal. Some people want to avoid more invasive procedures. A hysterectomy is a major surgery. It does have risks involved. So, sometimes our goal is to just kind of get them to menopause. Keep their symptoms tolerable and kind of bridge them over to menopause until the time that their body will stop bleeding and stop having problems naturally on its own and then we can just kind of let them be.

Some people just can’t really make it that long and they are having such problems and interference with their lifestyle that they do need more invasive procedures. So, it really just kind of depends on each person.

Host: Really interesting topic Dr. Selander. Thank you for your time. We appreciate it. For more information just call 1-866-TIDELANDS or visit www.tidelandshealth.org to learn more. Once again, 1-866-TIDELANDS or visit www.tidelandshealth.org to learn more. And make sure to subscribe to Better Health Radio in Apple podcasts, Google Play or wherever you listen to your podcasts. And checkback for our next episode soon. This is Better Health Radio. I’m Bill Klaproth. Thanks for listening.