Evaluation of abnormal uterine bleeding includes ultrasound, endometrial biopsy or D&C. Typical diagnosis include: unexpected pregnancy, fibroid uterus, polyps, endometriosis, premenopausal or menopausal uterine changes, cysts and tumors.
Treatment typically includes, a trial of hormonal birth control using oral, injection or IUD delivery to reduce bleeding, cramps and pain. Other prescription medication may be prescribed to either slow bleeding down.
In some cases, surgical treatments to address abnormal uterine bleeding may be the best option. Surgical procedures include hysteroscopy, endometrial ablation, uterine artery embolization, hysterectomy, exploratory laparatomy through an abdominal incision, vaginal approach, laparoscopy or robotic assistance. Hysterectomy is considered only when a permanent treatment is required and fertility is no longer desired.
Hysteroscopy – A procedure that takes a look inside the uterus through a scope. The physician can see the lining of the uterus (endometrium) and the openings of the fallopian tubes. It allows direct view of the uterine lining and the ability to take samples of tissue. This procedure is minimally invasive and may be performed in an office or outpatient setting.
Operative Hysteroscopy – While the physician is visualizing the uterus and endometrial lining, he may remove polyps, fibroids or perform a D&C. This procedure is typically performed in a surgi-center setting.
Endometrial Ablation – A procedure using either heat or cold energy to destroy the endometrial lining of the uterus. This procedure can be performed in the office or surgi-center setting. Bleeding tends to be significantly less than before the procedure. An endometrial ablation should only be considered for women who no longer wish to become pregnant and permanent treatment is desired.
Endometrial biopsy – This procedure obtains a sample of the endometrial lining and is usually performed at your physician’s office. It involves the insertion of a plastic pipelle (a small flexible tube), thru the opening of the cervix, into the uterus. Using suction, the pipelle plucks off a sample of tissue from the uterine lining and it is removed for laboratory examination.
D & C – A procedure performed to obtain samples of the endometrium, the lining of the uterus to evaluate abnormal uterine bleeding or abnormal cells that may be from the uterus that was found during routine screening for cervical cancer. A D&C is typically performed when an endometrial biopsy is not possible or if the sample of the tissue was inadequate. This procedure typically is performed in the office or surgi-center setting.
Laparoscopy – A surgical procedure using key-hole sized incisions and a thin telescope like instrument that allows the physician to visualize operate on the uterus, fallopian tubes, ovaries and surrounding tissue. This procedure is performed in a surgi-center.
Hysterectomy – A surgical procedure performed by laparoscopy, robotic assistance, vaginally or by an open incision that removes the uterus with or without ovarian removal. This procedure typically is performed in a hospital setting and requires a period of observation.
Uterine fibroids are nodules of smooth muscle cells and fibrous connective tissue that develop within the wall of the uterus (womb). Medically they are called uterine leiomyomata. Fibroids may grow as a single nodule or in clusters and may range in size from 1 mm to more than 20 cm (8 inches) in diameter. They may grow within the wall of the uterus or they may project into the interior cavity or toward the outer surface of the uterus. In rare cases, they may grow on stalks or peduncles projecting from the surface of the uterus.
Most fibroids occur in women of reproductive age, and they are seldom seen in young women who have not begun to menstruate and they usually stabilize or shrink during menopause.
Are fibroid tumors common?
Fibroids are the most frequently diagnosed tumor of the female pelvis. It is important to know that these are benign tumors. They are not associated with cancer, they virtually never develop into cancer, and they do not increase a woman’s risk for uterine cancer.
Uterine fibroids may not require any intervention or, at most, limited treatment. For a woman with uterine fibroids that are not symptomatic the best therapy may be watchful waiting. Some women never exhibit any symptoms nor have any problems associated with fibroids, in which case no treatment is necessary. For women who experience occasional pelvic pain or discomfort, over-the counter anti-inflammatory or pain-reducing drug often will be effective. More bothersome cases may require stronger drugs available by prescription.
The name endometriosis comes from the word “endometrium,” the tissue that lines the inside of the uterus. If a woman is not pregnant this tissue builds up and is shed each month, as menstrual flow at the end of each cycle. In endometriosis, tissue that looks and acts like endometrial tissue is found outside the uterus, usually inside the abdominal cavity.
The problem is that this misplaced endometrial tissue acts like it would if it were inside the uterus. At the end of every cycle, when hormones cause the uterus to shed its endometrial lining, endometrial tissue growing outside the uterus will break apart and bleed. However, unlike menstrual fluid from the uterus, blood from the misplaced tissue has no place to go. Tissues surrounding the area of endometriosis may become inflamed or swollen. The inflammation may produce scar tissue around the area of endometriosis. This abnormal tissue may develop into what are called “lesions,” “implants,” “patches,” “nodules,” or “growths”.
The most common symptom is pain, especially excessive menstrual cramps (dysmenorrhea) which may be felt in the abdomen or lower back or pain during or after sexual activity (dyspareunia). Infertility occurs in about 30-40% of women with endometriosis. Endometrial patches may also be tender to touch or pressure and intestinal pain may also result from endometrial patches on the walls of the colon or intestine.
The amount of pain is not always related to the severity of the disease-some women with severe endometriosis have no pain; while others with just a few small growths have incapacitating pain.
Will it cause infertility?
Severe endometriosis with extensive scarring and organ damage may affect fertility. It is considered one of the three major causes of female infertility. However, unsuspected or mild endometriosis is a common finding among infertile women and how this type of endometriosis affects fertility is still not clear. However, compared to the general population, pregnancy rates for those who suffer endometriosis remain lower. Fortunately, most patients with endometriosis do not experience fertility problems.
The cause of endometriosis is still unknown. One theory is that during menstruation some of the menstrual tissue backs up through the fallopian tubes into the abdomen, where it implants and grows. Another theory suggests that endometriosis may be a genetic process or that certain families may have predisposing factors to endometriosis. In the latter view, endometriosis is seen as the tissue development process gone awry.
Diagnosis of endometriosis begins with a gynecologist evaluating the patient’s medical history. A complete physical exam, including a pelvic examination, is also necessary. However, diagnosis of endometriosis is only complete when proven by a laparoscopy. The surgeon can then check the condition of the abdominal organs and see the endometrial implants.
The laparoscopy will show the locations, extent, and size of the growths and will help the patient and her doctor make better-informed decisions about treatment.
While the treatment for endometriosis has varied over the years, doctors now agree that if the symptoms are mild, no further treatment other than medication for pain may be needed. Treatment plans are developed based on symptoms and desires for pregnancy. For those younger patients with mild endometriosis who wish to become pregnant, the best course of action is to have a trial period of unprotected intercourse for 6 months to 1 year. If pregnancy does not occur within that time, then further treatment may be needed.
For patients not seeking a pregnancy, a trial of hormone suppression treatment will be recommended. Surgical treatment to remove the endometrial implants without risking damage to healthy surrounding tissue may also be considered.
Abnormal Pap smear
Initial Pap smear results reported as abnormal indicate cell changes of the cervix. Frequently after an abnormal Pap smear, your health care provider may ask you to return to the office for a repeat Pap smear or a colposcopy to determine the significance of these cell changes. A colposcopy requires use of an instrument called a colposcope, which has a series of lenses that magnify the tissues of the cervix. It is from this instrument that the procedure gets its name.
A Colposcopy feels similar to a Pap smear collection. However, instead of taking a sample of cervical cells, your health care provider places the colposcope at the vaginal opening to more closely examine your cervical tissue in order to detect any abnormalities. In areas where cervical tissue may appear suspicious, your health care provider will use a separate instrument to obtain a small tissue sample. You may feel a slight pinch or cramp and there might be some minor bleeding from the biopsy site, or temporary pelvic pain. The tissue will then be sent to a lab for analysis.
When a biopsy is performed, your physician or clinician will contact you to discuss results and next steps. Depending upon the biopsy results, various treatments can be performed in your physician or clinician’s office. These treatments may include observation, cryosurgery or “freezing” of the cervix, laser removal or “burning,” and LEEP procedures.
LEEP, loop electro-surgical excision procedure, uses a tiny electrical wire that acts like a very sharp scalpel to remove the abnormal areas. Your cervix will be numbed with a medicine before the procedure is started. After you are treated, you may have some cramping or other side effects. Your health care provider can explain more about these effects to you.
For more advanced abnormalities revealed by colposcopy and biopsy, patients may be referred to a cancer specialist in gynecology.