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Abnormal Bleeding and Uterine Cavity Evaluation

Abnormal periods are the worst. They may be heavy or unpredictable. And they’re certainly common — one-third of women will experience abnormal bleeding in their reproductive lifetime. But why do they happen? To answer this many times requires uterine cavity evaluation. 

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This is a way to look in the inner womb to understand why you are having abnormal bleeding.

Why so?

Because tissue overgrowths within the uterus are a very common, and treatable, cause. 

What is the definition of abnormal bleeding anyways?

  • An irregular cycle outside of the 24-38 day range
  • Bleeding for longer than 8 days
  • A volume of more than 80 ml of blood lost
  • Bleeding in between your periods
Photo by Sydney Sims via Unsplash

How do we begin to evaluate this? 

We classify it into structural or non-structural causes. First, we rule out non-GYN causes (like hemorrhoids or liver issues, for example) or pregnancy. 

  • Structural
    • Polyps. Found in a third of women and >95% benign. 
    • Fibroids. The most common pelvic tumor. Present in three-quarters of women by menopause; 99% benign. 
    • Adenomyosis. This occurs when the inner lining gets into the muscle wall of the uterus. This lining still responds to ovarian hormones. In turn, this may cause inflammation, pain, and heavy bleeding. It’s also associated with fertility issues.
    • Abnormal pre- or cancerous cells. This is uncommon.
  • Non-structural 
    • Clotting issues where the blood is thinner than typical
    • Irregular ovulation. This leads to lining buildup and abnormal shedding
    • Endometrial (the inner lining of the uterus) changes with vessel constriction or inflammation
    • Medication-induced. Common culprits are birth control pills or some antidepressants.
    • Other causes, like arteriovenous malformations. Chronic endometritis (an inflammatory state) may be present. 

How do we figure out what the cause is?

For non-structural reasons, the history and physical exam provides much insight. Blood work will allow us to diagnose problems with ovulation or clotting. 

Saline infusion sonogram (SIS)

Structural causes & imaging. 

  • Pelvic ultrasound
    • This is the most basic and will pick up fibroids and adenomyosis fairly well. However, it’s not the best for issues within the uterine cavity, unless it is done using 3D technology.
  • Saline infusion sonogram (SIS)
    • This is a minor, short office procedure where a doctor places a thin catheter through the vagina and into the cervix. A small amount of salt water (saline) is then placed into the inner uterine cavity while watching with ultrasound guidance. 
    • It is an accurate and sensitive way to pick up overgrowths within the endometrial cavity, and can also examine the walls of the uterus plus the ovaries.
  • Hysterosalpingogram (HSG)
    • This is similar to the SIS, but done using dye and X-rays of the pelvis to look at the inner contour of the uterus plus at the fallopian tubes (to see if they’re open). 
    • It’s not as good at detecting uterine issues but is an option if you need to also evaluate the tubes.
  • Pelvic MRI
    • This isn’t as commonly done due to difficulty obtaining the images (have you ever sat in one of these tubes for an hour? It can be somewhat claustrophobic). 
    • It can help differentiate between fibroids and adenomyosis, plus give insights into the shape of the uterus and other structures in the pelvis.
  • Hysteroscopy
    • This uses a very tiny camera placed through the vagina and into the womb via the cervix. 
    • Its greatest benefit is that we can treat immediately if we do see a tissue overgrowth by using instruments that fit through the scope to remove what is seen. 
Hysteroscopy images: Fibroid inside the uterine cavity (above) and open tubal opening (below)

Other specifics of hysteroscopy:

  • It can also address uterine septum (a piece of tissue women may be born with that can affect risk of obstetric issues), scarring (an uncommon finding that can be associated with fertility and miscarriage risks), or be used to help open a proximal tube blockage with the aid of special catheters. We can identify chronic endometritis, adenomyosis, and even the tube openings. 
  • It may be done in office with minimal pain medications. In my experience of doing these multiple times weekly, the vast majority of women were completely comfortable with pre-procedure ibuprofen, a stronger medicine like norco, plus local numbing medicine. 
  • Some providers may even use a technique called vaginoscopy to place the camera, thus making it even more comfortable by avoiding the speculum when putting in the camera. 
  • The risk of complications is very low, but if you are having any concerning symptoms, make sure to reach out to your doctor (this includes during the procedure!).
  • It typically takes an hour or less.
  • Women go home the same day and may even resume normal activities the next one. 

Since abnormal bleeding is so common, you may find yourself undergoing some of these evaluation or treatment steps. Knowledge is power and allows you to identify the root cause for the crazy flow. And though some of these options may seem nerve-wracking, they are all safe and will provide insight to help heal the bleeding. 

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