Uterine unexpected bleeding is always a concern for girls and women at any stage of life. Bleeding instead of normal menstrual period and even very heavy menstrual flow can be great cause for alarm. The medical term for excessive and/or prolonged vaginal bleeding is known as menorrhagia which is happening usually on expected period days. Metrorrhagia is the term used to refer to uterine bleeding at irregular intervals, particularly between the expected menstrual periods. Menometrorrhagia is the combination of the two – heavy uterine bleeding, both at the usual time of menstrual periods and at any other irregular intervals. Most conditions that cause abnormal uterine bleeding can occur at any age but some are more likely to occur at a particular time in a woman’s reproductive life.
Dysfunctional uterine bleeding occurs most commonly at the beginning and end of the reproductive years: 20% of cases occur in adolescent girls, and more than 50% occur in women older than 45. In about 90% of cases, the ovaries do not release an egg (ovulate) which means in most cases of bleeding the ovulation is not happening.
In normal menstrual cycle the lining of the uterus (called “endometrium”) responds to hormones produced by ovaries. The pituitary gland at the base of the brain secretes a hormone called follicle stimulating hormone (FSH) which stimulates production of estrogens by ovarian follicles. Estrogens cause the endometrium to thicken. When ovulation occurs, a second female hormone (called progesterone) is secreted by the ovary. This causes the lining of the uterus to become spongy. The corpus luteum, which produces the progesterone, lasts for fourteen days (period after ovulation). When the progesterone and estrogen levels fall, the endometrium sheds in a normal menstrual period.
Uterine Bleeding Causes
If ovulation does not occur, the ovary is continuing making estrogen and it causing the endometrium to keep thickening. This often leads to a late menstrual period followed by irregular bleeding and spotting. This can also result in endometrial polyps, or in extreme long-standing cases, cancer of the lining of the uterus.
The most common cause of teenagers’ uterine bleeding is anovulation. Many girls have episodes of irregular bleeding during the first few years. About 85% of adolescents’ menstrual cycles occur without the release of egg. As the female adolescent gets older, the percentage of cycles that are anovulatory decreases, and she is more likely to experience normal periods. By the time the female adolescent has had a menstrual cycle for six years, about 20% of cycles will occur without an egg being released from one of the ovaries.
Bleeding before menarche (First Period) is always abnormal. It may be caused by trauma, a foreign body (such as toys, coins, or toilet tissue), irritation of the genital area (due to bubble bath, soaps, lotions, or infection), or urinary tract problems. Bleeding can also occur as a result of sexual abuse.
Abnormal bleeding in this age group can also be caused by pregnancy, bleeding disorders, some medical illnesses, and infection.
Stress hormones such as cortisol are known to interfere with ovulation. Hormonal imbalances that interfere with ovulation can result in abnormal uterine bleeding. Any stress, such as traveling or a new job can interfere with ovulation. Fortunately this will usually be temporary, and rarely requires treatment.
Birth control pills
The contraceptive effect of birth control pills is mainly due to inhibition of ovulation and absence of ovulation can be a reason for endometrium thickening with following uterine bleeding. If this occurs during the first few months, it may be due to changes in the lining of the uterus. If it persists for more than a few months, a different birth control pill may be recommended.
Breakthrough bleeding can also happen if birth control is forgotten or taken late.
Approximately 30% of women have fibroid tumors. The medical term for fibroids is leiomyoma, or myoma. These growths are almost always benign, and most of the time does not cause symptoms. Fibroids typically grow larger as a woman ages, and usually decreases in size after menopause. Often a uterus will grow many fibroids.
Fibroids are noncancerous growths that invade the wall of the uterus in at least 20% of women over the age of 35. Fibroids may appear singly or in clusters, and be as small as a grape or as big as an orange. They are comprised of muscle and fibrous tissue, and may cause excessive flow during menstruation or bleeding between periods.
Polyps are another type of noncancerous growth that can invade the cervix or uterus. Polyps may be so small that they go unnoticed, or may be big enough to poke into the uterine or pelvic cavity and cause abnormal bleeding. Endometrial polyps are growths in the lining of the uterus that are very common, and usually benign. They usually hang from the lining of the uterus like figs, but at times can be rather flat. Polyps may result from long-term estrogen stimulation such as occurs from extended periods of not ovulating or from taking estrogen hormones without any progesterone.
When the lining of the uterus grows into the wall of the uterus, the condition is called adenomyosis. Normally, when the endometrium sheds during a menstrual period the blood is free to drain out through the cervix. When the lining goes into the muscle some of the blood may be trapped. When extensive, this may cause severe cramps and heavy bleeding. This can cause the walls of the uterus to thicken and the uterus to become enlarged. Often an enlarged uterus from adenomyosis is misdiagnosed as being from fibroids.
Polycystic ovary syndrome (PCOS) is a condition in which the ovaries become filled with tiny cysts and enlarge. The problem occurs when the pituitary gland produces too much of a hormone called luteinizing hormone (LH). The hormonal imbalance that results creates an overabundance of uterine lining that makes bleeding irregular. If the disorder is not treated, some of the male hormones may be converted to estrogen. Not enough progesterone is produced to balance the estrogen’s effects. If this situation continues a long time, the lining of the uterus (endometrium) may become extremely thickened (a condition called endometrial hyperplasia). Also, the risk of cancer of the lining of the uterus (endometrial cancer) may be increased.
Although usually a woman will stop having menstrual periods if she is pregnant, bleeding during pregnancy is not uncommon. If the pregnancy is abnormal, such as a tubal pregnancy or impending miscarriage, the bleeding may be interpreted as being from a menstrual period rather than a complication of pregnancy. Because pregnancy is such a common cause of abnormal bleeding, a pregnancy test should be among the first tests in anyone who is sexually active, even if she is “sure” she couldn’t be pregnant.
Older women who are approaching menopause may also experience dysfunctional bleeding due to the hormonal changes that accompany the menopausal transition.
Vaginal bleeding is a particular concern in women older than age 50 years (or after menopause). The risk of cancer increases with age. At the same time vaginal walls may be dry from lack of estrogen, which may cause bleeding during or after sexual intercourse.
Pelvic inflammatory disease (PID) is a condition in which the fallopian tubes become inflamed, usually due to a sexually transmitted infections. Inflammated endomtrium can be a cause of irregular bleeding – one of the many symptoms of PID.
Ovarian cyst bleeding is not a common symptom for all the types of such cysts. Ovarian cyst bleeding, however, is the main symptom of a particular type of cysts called haemorrhagic (associated with or resulting from blood loss) cysts. If women experience such a hemorrhage and feel a severe sensation of pain, then they must ask for medical advice as soon as possible, in order to prevent complications.
Women with ovarian cyst bleeding must not fear having cancer of the ovaries, as cancerous cysts do not cause hemorrhage.
Thyroid disorders can cause heavy bleeding, as can disorders in which the blood does not clot normally.
Certain drugs may cause bleeding, especially if a woman takes anticoagulant drugs (drugs that prevent the blood from clotting).
Some women who use the Copper-T IUD sometimes experience heavy menstrual bleeding (slight bleeding is usually normal; pay attention to heavier bleeding)
Uterine cancer is a malignant growth in the uterus. It can occur in the lining of the uterus (endometrium) or in its muscular walls (uterine sarcoma). Endometrial cancer is the most common cancer of the female reproductive system, and almost always strikes postmenopausal women between ages 50 and 70. Any vaginal bleeding that occurs after menopause should be checked out right away.
Inherited bleeding disorders
Inherited bleeding disorders (such as von Willebrand disease and hemophilia) may cause excessive or prolonged vaginal bleeding.
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