Uterine abnormal bleeding

You should seek an opinion from a gynaecologist if you’re troubled by heavy bleeding, or if you have bleeding after sex, bleeding in between periods, bleeding after menopause, or if you have bleeding that’s unusual for you. It is also important to have a check-up if there are no periods for over 4-6 months.

During menstruation, the lining of the womb is shed, and there is heavy bleeding; the blood may clot in the uterus or vagina. It’s a normal physiological process, but some women can pass substantial clots (e.g. bigger than a 10-pence piece), which may be a sign of abnormally heavy menstruation.

The menstrual cycle is a complex, orchestrated series of hormonal events that usually last around 28 days. The purpose of the cycle is to prepare the body for a potential pregnancy.

In the first half of the menstrual cycle, known as the follicular phase, the brain’s pituitary gland releases follicle-stimulating hormone (FSH), which stimulates the ovaries to develop and mature a follicle containing an egg. As the follicle grows, it produces increasing amounts of oestrogen. This rise in oestrogen triggers the thickening of the uterine lining (endometrium) in preparation for a fertilised egg.

The second half of the cycle, known as the luteal phase, begins after ovulation. The ruptured follicle transforms into a structure called the corpus luteum, which produces progesterone in addition to estrogen. Progesterone further prepares the endometrium for pregnancy by maintaining its thickness and promoting the secretion of nourishing substances. If fertilisation and implantation do not occur, hormone levels decrease, leading to the shedding of the uterine lining and the arrival of your period.

Some women may experience heavy bleeding when they first start their periods or when approaching menopause. If you’re experiencing heavy bleeding, it can be a sign of an underlying problem such as:

When hormonal processes go awry, abnormal uterine bleeding can occur. Irregularities in the timing or levels of oestrogen and progesterone can lead to various issues. For instance, insufficient progesterone during the luteal phase can result in a thin or unstable endometrium, causing irregular bleeding. Alternatively, excessive oestrogen levels can lead to heavy or prolonged menstrual bleeding. Some medical conditions, such as thyroid disorders and pituitary problems, can affect the normal female hormone cycles and thus affect bleeding.

Polycystic Ovary Syndrome (PCOS) is a common condition characterised by hormonal imbalances that can affect the menstrual cycle.

In PCOS, the ovaries produce excess androgens (male hormones), which can disrupt normal ovulation. Anovulation, or the absence of regular ovulation, can lead to irregular or heavy menstrual bleeding. Furthermore, women with PCOS often have high levels of oestrogen and lower levels of progesterone, contributing to hormonal imbalances that may lead to abnormal bleeding patterns.

PCOS can also cause fertility problems, increased facial hair growth and acne, fatigue, and difficulty maintaining a healthy weight. In the long term, it is linked with insulin resistance and an increase in the risk of developing diabetes and heart disease. Lifestyle changes in terms of diet and exercise can help, but some patients may require medical treatments. These can include the oral contraceptive pill (oestrogen helps to lower testosterone) and metformin. This is a diabetic medication that improves insulin sensitivity and helps to correct hormonal imbalances.

Fibroids, also known as uterine leiomyomas, are noncancerous growths of the uterus. They can vary in size and position within the uterus and are sometimes the cause of heavy or very painful periods. They can also cause fertility problems.

Fibroids can interfere with the normal functioning of the uterus and its surrounding structures. When located within the uterine wall (intramural fibroids), these growths can stretch and distort the uterine cavity, leading to changes in menstrual flow. Large fibroids on the outside of the womb (subserosal fibroids) can even push against neighbouring structures, such as the bladder or rectum, causing discomfort and potentially impacting the menstrual cycle.

Fibroids that project into the cavity of the womb (submucosal fibroids) can lead to abnormal bleeding by increasing the overall surface area of the uterine lining and can also create fertility challenges.

Endometriosis is a painful condition in which the tissue lining the uterus (called the endometrium) grows outside the uterus, most commonly on the ovaries, fallopian tubes, and other pelvic structures. This ‘ectopic’ endometrial tissue behaves just as it would normally, thickening and shedding with the monthly hormone changes. But while menstrual blood exits the body via the vagina during a period, endometriosis lesions can bleed internally at sites other than the womb, which leads to inflammation and the formation of scar tissue and cysts.

In addition to extremely painful periods, many women with endometriosis experience irregular or very heavy menstrual bleeding because of the predominance of oestrogen, which may go unrecognised by medical professionals.

Clotting, or bleeding disorders (such as von Willebrand disease and haemophilia), are a surprisingly common cause of heavy menstrual bleeding, and it’s thought that 10% of women who have heavy menstrual bleeding will have a ‘coagulopathy’. Many women put up with abnormal bleeding, and yet a proper assessment with a gynaecologist can identify if a clotting disorder is the root cause.

Women who are required to take anticoagulant medications (e.g. after a deep vein thrombosis or for atrial fibrillation) are more at risk of heavy menstrual bleeding.

Endometrial cancer is a cancer affecting the endometrium, which is the womb’s lining. It’s a common cancer in women, and it can cause spotting or bleeding in between periods and bleeding after menopause has occurred.

Endometrial cancer affects the endometrium, which is the womb’s lining. It’s a common cancer in women, and it can cause spotting or bleeding in between periods and bleeding after menopause occurs. Polyps (also known as endometrial polyps) are benign overgrowths that arise from the uterine lining, called the endometrium. They often form on slender stalks projecting into the uterine cavity.

Polyps are extremely common, with up to 10% of women developing them, and they are nearly always benign (non-cancerous) in nature. The polyps are quite fragile and can easily bleed, leading to spotting or vaginal bleeding. Some polyps arise from the cervix (neck of the womb), which can also lead to bleeding after sex.

REDS, which used to be known as the female athlete triad, is a condition which can affect sporty women who train hard. Insufficient calorie intake to meet the demands of a person’s sport can disrupt normal hormonal functioning, creating erratic or even absent periods.

Sometimes women may experience some light spotting after sex, which may occur from mechanical trauma to the cervix or with vaginal dryness (e.g. during menopause). It can, however, be caused by more serious problems, such as infection, cervical cancer, endometrial cancer, uterine polyps, or cervical inflammation (known as cervical ectropion or cervical erosion). If you’re experiencing bleeding after sex, it’s essential to get it checked out, especially if you’re post-menopausal.

When you come to the clinic, I’ll take a detailed history of your symptoms and how they are affecting you. I’ll want to listen to all of your concerns, and then I will carefully examine you.

This will likely include a vaginal speculum examination with my nurse present, and we may decide to take some swabs. I might also recommend blood tests to look for hormonal problems, an ultrasound scan (to examine the structure of the uterus and ovaries), and sometimes a test called a hysteroscopy so that the inside of the womb can be examined using a thin telescope, and samples can be taken, and sometimes a colposcopy, to look at the neck of the womb may be needed. Bringing it all together, I can then confirm what is causing your bleeding problem and make a treatment plan to suit your needs.

So, if you’re suffering from heavy, painful, or irregular periods, or if you’re bleeding in between periods or after sex, don’t suffer on.

Come and see me for a consultation.