Abnormal Uterine Bleeding - What it means and how to manage it
A variety of issues can cause abnormal uterine bleeding. It can be a sign of endometrial cancer, but a variety of other benign and treatable problems can also cause abnormal bleeding.
For example, bleeding can be caused by polyps or fibroids in the uterus, hormonal imbalances (such as PCOS), hormone replacement therapy, menopause, taking birth control pills or using an intrauterine device (IUD).
There are different categories of abnormal bleeding:
- Bleeding that occurs between periods (spotting)
- Regular periods that are heavy or longer
- Erratic periods.
Menstrual cycles more often than every 21 days or farther apart than 35 days are abnormal; normal bleeding lasts five to seven days. Abnormal bleeding can be related to your menstrual period as previously described, or non-menstrual related (postcoital bleeding). In postmenopausal women any bleeding is abnormal.
Abnormal Bleeding and Endometrial Cancer
As many as 90% of endometrial cancer cases are preceded by abnormal uterine bleeding as an early sign, and women are advised to present to a doctor as soon as they have concerns. It is important to have a clear line of investigation in women presenting with these symptoms, first excluding them for other benign conditions to not subject them to avoidable invasive tests.
What diagnostic tests are performed for abnormal bleeding?
A full medical history should be taken by your GP, including menstruation history, the nature of the current bleeding, the patient’s quality of life and any other related symptoms.
A pelvic examination is performed, including an examination with a speculum to inspect the cervix, vagina and vulva.
A full blood count test should be undertaken, including tests for sexually transmitted diseases (if relevant), and thyroid function tests. Pregnancy should also be excluded for premenopausal women.
Women need to be up to date with their cervical cancer screening (to exclude cervical cancer). A transvaginal ultrasound is then conducted, and should include the thickness of the lining of the uterus (endometrial thickness); higher endometrial thickness may indicate an abnormality.
Advice on the next steps differ in the medical community.
New research advises that all women of 60+ years should be given an endometrial biopsy (with or without hysteroscopy), regardless of their endometrial thickness on ultrasound. A hysteroscopy is a thin tube with a tiny camera that enables the surgeon to look inside your uterus to assess the endometrium (inner lining of the uterus).
This recommendation was based on research from 593 postmenopausal women and 570 premenopausal women who developed abnormal vaginal bleeding. The researchers evaluated their risk to calculate the best diagnostic approach to assess abnormal bleeding. The risk of endometrial cancer was 8% in postmenopausal women and 1.2% in premenopausal women.
The researchers advise that women aged under 60 years require an endometrial biopsy only if their endometrial thickness on ultrasound is more than 4 mm. The likelihood of cancer in these women is very low. GP surveillance continues and an endometrial biopsy (with or without hysteroscopy) is only then performed if the bleeding continues.
These clinical recommendations currently do not align with existing clinical practice. Current practice suggests that an endometrial biopsy is only indicated if the endometrial thickness is 4 mm or higher on ultrasound, regardless of menopausal status.
I suggest that clinical management guidelines should be updated to differentiate between pre-and postmenopausal women.
- Premenopausal women should have an endometrial assessment if the endometrial thickness is 4 mm or higher.
- Postmenopausal women should have an endometrial assessment regardless of the endometrial thickness.
For more information on the symptoms and causes of Endometrial Cancer, the Endometrial Cancer Page might be useful reading. If you would like to make an appointment to discuss abnormal uterine bleeding, please contact me.