The evaluation of irregular bleeding should begin with a pelvic examination. All women should receive a pelvic examination yearly. At the time of this examination, a pap smear can be performed to assess the health of the cervix. There are different recommendations for different age group populations as to the needed frequency of the pap smear, but the pap smear remains an important screening test for cervical health.

 

Beyond the pap smear, the pelvic examination provides an important opportunity to establish the absence of any pelvic abnormalities.

 

Women who are identified as having abnormal bleeding are also best served by undergoing a pelvic ultrasound which allows a thorough evaluation of the uterus and the ovaries. Ultrasound is useful in identifing uterine abnormalities that may contribute to irregular bleeding and this is an important step in the diagnosis of the cause of irregular bleeding. Three dimensional ultrasound provides an excellent view of the uterine cavity in a plane (the coronal plane) that can further be used to localize any uterine abnormalities. This techonological advantage provides a more complete uterine evaluation and improves diagnostic capabilites. We perform 3 D ultrasound at the time of pelvic ultrasound specifically to evaluate this. Also using ultrasound as a tool, the shape uterine cavity (the inside of the uterus) can be evaluated using saline hysterosonography.

Potential uterine abnormalities which can contribute to irregular bleeding include uterine fibroids, endometrial polyps, and adenomyosis. These are the most common structural causes of irregular bleeding and represent benign (non-cancerous) processes. These different diagnoses can all be identified with the above mentioned ultrasound techniques. The treatment of these problems is directed toward the least invasive option possible.

 

 

When the uterine cavity is affected by these problems, an operative procedure known as hysteroscopy can be performed to restore a normal shape to the inside of the uterus. This is an outpatient procedure. In hysteroscopy a camera is advanced into the uterus through the cervix. No abdominal or skin incisions are required. Abnormal findings within  the uterus are removed using operative instruments which project from the end of the camera. This is a very effective method of dealing with fibroids and polyps which affect the uterine lining which contribute to irregular bleeding, pain, and occasionally infertility. This procedure preserves the the uterus and fertility.

 

In women who have certainly completed childbearing, there is an option of endometrial ablation. Endometrial ablation is the burning of the lining of the uterus to render it innactive or less active. This results in the improvement in heavy menses. It is only an option for women who do not desire fertility preservation. Endometrial ablation can be performed following hysteroscopy procedures, or it can be performed on an endometrial cavity which has no lesions affecting its shape when a woman is experiencing heavy bleeding not responsive to medical therapy. Endometrial ablation methods offered in our office include the Thermachoice balloon system by Gynecore and  Novasure. Endometrial ablation can be performed in the office when operative hysteroscopy is not required.

 

An endometrial biopsy is an important tool in the evaluation of irregular vaginal bleeding for women being evaluated for potential causes of the irregular bleeding and it is very informative. The endometrial biopsy helps point to the cause of the irregular bleeding and identify the best treatment options, which may be medical or surgical (as in hysteroscopy). An endometrial biopsy also excludes malignancy, or cancer. within the uterus. Endometrial biopsies are performed in the office.

 

Young women, especially women in adolescence who have just started to menstrate often experience irregular bleeding. Teenagers who have just begun their periods commonly have periods that are unpredictable. Occasionally those periods are also painful, heavy, or prolonged. These young women deserve a special evaluation of their history and their family history. Pelvic examination may deferred based on their history and a pelvic ultrasound performed by looking through the lower abdomen identifies any abnormalities of the uterus. These young women also many times require blood testing to exclude any underlying medical problems which may cause the bleeding.

 

Menopausal women who are experiencing irregular bleeding will always require an endometrial biopsy and pelvic ultrasound. Bleeding after menopause is never normal and should be always be evaluated by a gynecologist.

 

 

The treatments for irregular bleeding are medical and surgical. The least invasive surgical method is always preferable and hysterectomy is always the last option.