1. Physical Disorder
Physical
Injury
Exercise
Premature menopause
Physical
Injury
Bleeding may be caused by an injury to the vulva or vagina,
sexual abuse, inflammation of the vagina (for example, from an inserted
object), an infection in the uterus, or blood disorders that cause
abnormal clotting, such as leukemia or a low platelet count. Other causes
include cancer and noncancerous tumors, such as fibroids and cysts in the
reproductive tract, as well as adenomyosis (noncancerous invasion of the
muscular wall of the uterus by the uterine lining). Tumors of the ovaries
occasionally cause bleeding from the vagina, but usually only if they
produce hormones. Prolapse of the urethra (a condition in which the
channel that transports urine from the bladder to the outside of the body
bulges out) may also result in bleeding.
Age is an important factor in determining the likely cause
of uterine bleeding. A newborn girl may have some spotting of blood for a
few days after birth because of estrogens absorbed before birth from her
mother--which is not a cause for concern. Bleeding in childhood may result
from puberty that starts very early (precocious puberty).
Pubic hair and breasts are obvious signs that puberty has begun.
Precocious puberty may be caused by certain drugs, brain abnormalities,
low thyroid hormone levels, or hormone-producing tumors of the adrenal
glands or ovaries. In most cases, however, the cause is unknown.
Bleeding in childhood may also be caused by the overgrowth
of glandular tissue in the vagina (vaginal adenosis), which most often
results from exposure to diethylstilbestrol (DES) taken by the mother
before the child's birth. Girls with vaginal adenosis have an increased risk of developing
cancer of the vagina and cervix later in life.
During the reproductive years, abnormal bleeding may be
caused by birth control methods--such as oral contraceptives,
progesterone, or an intrauterine device (IUD)--or by complications of
pregnancy--such as placenta previa (an abnormally placed placenta) or an
ectopic pregnancy (a pregnancy that develops outside the uterus). Other
causes of bleeding include a hydatidiform mole (a tumor of the placenta)
and endometriosis. Cancer may cause bleeding in this age group, but not
commonly.
The most serious cause of bleeding from the vagina after
menopause is cancer, such as cancer of the uterine lining, the cervix, or
the vagina. The most common noncancerous causes of bleeding are thinning
of the vaginal wall (atrophic vaginitis), thinning or thickening of the
uterine lining, and growths on the uterine lining (uterine polyps).
Diagnosis and Treatment
The symptoms and a physical examination help a doctor
determine what other procedures are needed for diagnosis. Treatment
varies, depending on the cause. If a doctor suspects vaginal adenosis or cancer in a girl, a
sample of cells is removed from the vagina and examined under a
microscope. Usually, a girl who has vaginal adenosis doesn't need to be
treated--unless cancer is found--but she is reexamined at regular
intervals for signs of cancer. A woman who has abnormal bleeding from the vagina,
particularly after menopause, is examined to determine whether she has
cancer.
Exercise
Strenuous exercise can cause periods to stop. Apparently,
exercise causes the pituitary to decrease its secretion of the hormones
that stimulate the ovaries, so the ovaries produce less estrogen. The
absence of periods can also be caused by disorders of the uterus, such as
a tumor of the placenta ( hydatidiform mole) and scarring of the uterine lining resulting from an infection or
surgery (Asherman's syndrome).
Some women don't undergo puberty; consequently, their
periods don't start. Causes include a birth defect in which the uterus or
fallopian tubes don't develop normally and chromosomal disorders--for
example, Turner's syndrome, in which the cells contain only one X
chromosome instead of the usual two. A very rare cause is
male pseudohermaphroditism, in which a person who is genetically male
develops as a female. A girl who shows no evidence of
puberty by age 13, who hasn't had a period by age 16, or who hasn't had a
period within 5 years of starting puberty should be examined for possible
medical problems.
Symptoms
Vary, depending on the cause of the absence of
periods. For instance, if the cause is failure to undergo puberty, the
normal signs of puberty, such as breast development, pubic and underarm
hair, and changes in body shape, are absent or only partially present. If
the cause is pregnancy, symptoms may include morning sickness and
enlargement of the abdomen. If thyroid hormone levels are high, symptoms
include a rapid heartbeat, anxiety, and warm, moist skin. Cushing's
syndrome produces a moon (round) face, a fat abdomen, and thin arms and
legs. Some causes, such as Asherman's syndrome, produce no symptoms other
than no periods. Polycystic ovary syndrome produces some masculine
characteristics, such as facial hair, and causes periods to be irregular
or to stop.
Diagnosis and Treatment
Diagnosis is based on the woman's symptoms and age. During a
physical examination, a doctor can determine whether puberty has occurred
normally and look for evidence of other causes of amenorrhea. A variety of
tests may be performed, depending on the likely cause. For instance, the
levels of pituitary hormones, estrogen, thyroid hormones, or cortisol may
be measured in a sample of blood. X-rays of the skull may be taken to
determine whether the space occupied by the pituitary gland is enlarged
because of a pituitary tumor. Computed tomography (CT) or ultrasound
scanning may be used to look for a tumor in the ovaries or adrenal
glands.
Specific causes are treated whenever possible. For instance,
a hormone-producing tumor is removed. However, some causes, such as
Turner's syndrome and other genetic abnormalities, can't be cured.
If a girl's periods have never started and all test results
are normal, an examination is performed every 3 to 6 months to monitor the
progression of puberty. Progesterone and possibly estrogen may be given to
start her periods. Estrogen is given to induce the changes of puberty in
girls who haven't developed breasts or pubic and underarm hair and who
can't develop them spontaneously.
Premature (early) menopause is a condition in which the
ovaries stop functioning and menstrual periods cease before age
40.
In premature menopause, estrogen levels are low. However,
levels of the pituitary hormones that stimulate the ovaries
(gonadotropins), especially follicle-stimulating hormone, are high in a
vain attempt to stimulate the ovaries. Causes of premature menopause
include genetic, usually chromosomal, abnormalities and autoimmune
disorders, in which antibodies damage the ovaries. Smoking may cause
menopause to begin several months early.
In addition to no longer having periods, a woman with
premature menopause often has other symptoms of menopause, such as hot
flashes and mood swings.
Diagnosis and Treatment
Determining the cause of premature menopause is particularly
important for women who want to become pregnant. A physical examination
may be helpful. Blood tests may be performed to look for antibodies
responsible for damaging the endocrine glands--an example of an autoimmune
disease.
For women under age 30, a chromosome analysis is usually
performed. If a Y chromosome is present (that is, the person is
genetically male), any testicular tissue is surgically removed from the
abdomen because the risk of cancer developing in this tissue is 25
percent. Chromosome analysis is probably not needed for women over age
35.
Estrogen replacement therapy can prevent or reverse the
symptoms of menopause. However, a woman with premature menopause has less
than a 10 percent chance of being able to conceive. She has up to a 50
percent chance of being able to become pregnant by having another woman's
eggs (donor eggs) implanted in her uterus after they have been fertilized
in the laboratory. Before implantation, artificial menstrual cycles are
created by giving the woman estrogen and progesterone, to rejuvenate the
lining of the uterus and increase the chances of a successful
pregnancy.
Dysfunctional uterine bleeding is abnormal bleeding
resulting from hormonal changes, rather than from an injury, inflammation,
pregnancy, or a tumor.
Dysfunctional uterine bleeding occurs most commonly at the
beginning and end of the reproductive years: 20 percent of cases occur in
adolescent girls, and more than 50 percent occur in women over age 45.
Most abnormal uterine bleeding is the dysfunctional type, but this
diagnosis is made only when all other possibilities have been
excluded.
Causes and Symptoms
Dysfunctional uterine bleeding commonly results from
sustained levels of estrogen, which cause the uterine lining to thicken.
The lining is then shed incompletely and irregularly, causing bleeding.
For example, in polycystic ovary syndrome, the overproduction of
luteinizing hormone may cause the ovaries to produce large amounts of
androgens--some of which are converted to estrogen--rather than to release
an egg. Over time, estrogen without sufficient progesterone to counteract
its effects can result in abnormal uterine bleeding.
Bleeding is irregular, prolonged, and sometimes heavy. A
blood sample is taken and analyzed to determine the extent of the blood
loss.
Diagnosis and Treatment
The diagnosis of dysfunctional uterine bleeding is made when
no other cause can be found. A biopsy (removal of a tissue sample for
examination under a microscope) of the uterine lining is performed before
drug treatment is started if a woman is age 35 or older, has polycystic
ovary syndrome, or is substantially overweight and hasn't had children. A
biopsy is performed because such women have an increased risk of
developing cancer of the uterine lining.
Treatment depends on the woman's age, the condition of the
uterine lining, and the woman's plans regarding pregnancy.
When the uterine lining is thickened and contains abnormal
cells (particularly if a woman is over 35 and doesn't want to become
pregnant), often the uterus is removed surgically (hysterectomy), because
the abnormal cells may be precancerous.
When the uterine lining is thickened but contains normal
cells, heavy bleeding may be treated with high doses of an oral
contraceptive containing estrogen and a progestin or with estrogen alone,
usually given intravenously, then followed by a progestin given by mouth.
Bleeding generally stops in 12 to 24 hours. Low doses of the oral
contraceptive may then be given in the usual manner for at least 3 months.
Women who have lighter bleeding may be given low doses from the start.
When treatment with oral contraceptives or estrogen is
inappropriate, a progestin alone may be given by mouth for 10 to 14
days each month.
If a woman doesn't respond to treatment with these hormones,
dilatation and curettage (D and C), in which tissue from the uterine
lining is removed by scraping, is usually needed. If she wants to become
pregnant, clomiphene may be given by mouth to induce egg release.
Uterine
Growths:
Common:
a) Fibroids b)
Uterine polyps
Less
Common: a). Hyperplasia
b).
Adenomyosis and c). Endometrial Cancer
Uterine Growths:
These growths,
usually fibroids or polyps, are almost always (benign) non cancerous
. In addition to bleeding, symptoms may include pain or
pressure.
Fibroids
Round "knots" of
uterine muscle tissue, fibroids (myomas) often grow slowly and without symptoms.
But they can cause heavy bleeding or abnormal discomfort. Fibroids often
can be felt during a pelvic exam.
Treatment Options
The treatment choice
depends on the size and position of your fibroids, their rate of growth, and
your symptoms. One option is simply to monitor the fibroid's growth with
periodic pelvic exams or ultrasound. A variety of surgical options is also
available.
Uterine polyps
Made of soft uterine lining
tissue, polyps usually dangle from stalks into the uterus where they are easily
seen with a hysteroscope. They usually don't cause pain, but can cause
abnormal bleeding, even when small.
Treatment Options
In most cases, polyps can
be removed using hysteroscopy or D & C. With hysteroscopy, your doctor
can check to see that all the polyps are removed.
Less
Common Uterine growth
a). Hyperplasia b).
Adenomyosis and c). Endometrial Cancer
Hyperplasia
An overgrowth of the
uterine lining, hyperplasia is stimulated by a hormonal imbalance. A postmenopausal woman who has irregular bleeding while taking
estrogen may have more regular menstrual periods if a progestin is also
taken for about 10 days of each cycle. If a woman doesn't take a progestin
with estrogen, she has an increased risk of developing cancer of the
uterine lining. If the uterine lining is thickened and contains abnormal
cells, which may be precancerous. It can be diagnosed by biopsy or D
& C.
Treatment Options
If not precancerous,
hypeplasia can be treated with progesterone to restore hormonal balance. If the
hyperplasia is precancerous, the uterus, may need to be removed surgically (hysterectomy).
Adenomyosis
Uterine lining cells grow
into the muscle wall. This results in a soft, spongy, enlarged uterus,
which can sometimes be detected during the pelvic exam or ultra-sound.
Bleeding and painful cramps are common.
Treatment Options
Bleeding may be helped with
birth control pills or other medications. Surgery to remove the uterus may
be needed.
Endometrial Cancer
Endometrial Cancer is not
common. Still, it is a concern for women with bleeding problems,
especially women who have passed menopause. The cure rate is high when it
is detected early with biopsy.
Treatment Options
Removal of uterus may be
recommended. Radiation therapy may be used as well.
Surgical
Options
Sometimes surgery is the
best option to stop abnormal uterine bleeding. Surgery usually involves
removing a growth or removing the entire uterus. With new technology
available, you and your doctor can choose from a wide variety of surgical
procedures. If your doctor recommends surgery, ask about the advantages
and disadvantages of your options. Your doctor can describe the
procedures, their effect on your ability to have children, and the chances
that bleeding will return after surgery.
Removing a Growth or
Removing the Lining
Removing a growth or lining
saves the uterus, but any growths or heavy bleeding may return. Small
fibroids or polyps on the inside of the uterus may be removed using hysteroscopy
or D & C -- simple, same day surgeries. For large, fast-growing, or
hard-to-reach fibroids, a more involved type of surgery (abdominal myomectomy)
may be needed. It may require a hospital stay of two to four days. Endometrial
ablation (removal of lining) is an outpatient procedure. After
ablation, you can usually expect a fairly rapid recovery.
Hysterectomy
(Removing the Uterus)
For many women with heavy
bleeding, hysterectomy is the best solution, especially if you have other
related problems. Having this surgery means that pregnancy will no longer
possible, but it also guarantees that you will never have uterine bleeding
problems again. Your uterus and cervix are removed either through an abdominal
incision (Abdominal Hysterectomy) or through the vagina
(Vaginal Hysterectomy). The ovaries may
be kept in place to allow the continued production of hormones. Recovery
usually includes two to four days in the hospital.