Abnormal Vaginal Bleeding

Abnormal unprovoked vaginal bleeding commonly occurs from the uterus. At the Gynae Centre we can perform an investigation by ultrasound to elucidate the cause and recommend an appropriate treatment.


Normal menstruation

The act of menstruation takes place as a result of a complex interaction between hormones called FSH and LH which are secreted by a small gland in the brain called the Pituitary Gland.  At the start of the menstrual cycle, FSH stimulates one of the follicles in the ovaries to mature by day 14 of the cycle. The maturing follicle in turn produces another hormone called Oestrogen, which makes the lining of the womb thicker in preparation of receiving the fertilized egg.  Following ovulation another hormone called Progesterone is secreted from the remainder of the follicle after ovulation, which is then known as the Corpus Luteum.   The Corpus Luteum also acts on the lining of the womb and makes it full of nutritional value for when implantation occurs, until the embryo  is able to support itself. Now the uterus is ready to receive the fertilized egg, on about day 23rd day of the cycle.  If pregnancy occurs the lining will persist and become and integral part of the pregnancy until the birth. However, most of the time pregnancy does not occur and as a result the ovary stops producing Oestrogen and Progestrone.  The reduction in the level of these hormones causes the lining of the uterus to be shed, which is what causes menstruation.  The cycle then starts again.


There are many possible causes of abnormal vaginal bleeding:


Ovulatory dysfunction

This is the most common reason for abnormal bleeding and occurs commonly after puberty and before the menopause.  As a result of non- ovulation, or improper function of the developing follicle or Corpus Luteum, one or both hormones which control the menstrual cycle i.e. Oestrogen and Progesterone, may not be secreted.  This leads to a lack of support to the endometrium and irregular shedding and bleeding.  It can also occur in reproductive years but is usually only temporary.  Occasionally this occurs due to a functional ovarian cyst.  Ultrasounds can help to identify which hormone is missing in order to rule out the possibility of a cyst and, so a course of treatment can be prescribed to correct the abnormality that cycle.


Endometrial polyps

Polyps are benign growths which occur in any body cavity due to an overgrowth of the cells of the lining. When they occur in the endometrium, they can lead to irregular bleeding. They can usually be seen by vaginal ultrasound, but sometimes it is necessary to inject sterile saline into the uterus to identify them accurately. They rarely become malignant and are commonly seen in women over the age of 30. The only way to treat them is by surgery.


Uterine fibroids

Fibroids or Myomas are benign lumps in the muscular walls of the uterus. They occur most commonly in women over the age of 30, and more notably in those without children. They can develop in the wall (intramural), project outside the uterus (subserous) or into the cavity (submucous). The subserous type rarely causes any symptoms unless it is more than 5 cm. The intramural type can cause heavy periods and the submucous may cause irregular bleeding, heavy periods and infertility. All three types are easily diagnosed by a vaginal ultrasound. Fibroids need not be treated unless they are causing symptoms and treatment is usually by surgery.


Adenmyosis

Adenomysis occurs as a result of some of the cells lining the inside of the uterus migrating into the wall of the uterus. Since these cells respond in the same way to the hormones secreted from the ovaries i.e. Oestrogen and Progestrone, it will grow, and bleed a small amount inside the muscles each month. This results in enlargement of the uterus and heavy periods. It may be diagnosed by ultrasound but MRI is more accurate. Medical treatment usually controls the bleeding.


Endometrial cancer

Cancer of the lining of the uterus is an important cause of abnormal bleeding particularly after the age of 44 years and especially after the menopause. It can usually be diagnosed by vaginal ultrasound but sometimes an outpatient endometrial biopsy is necessary to confirm the diagnosis. Treatment is usually by surgery or irradiation.


Cervical cancer

Cancer of the cervix is more commonly seen in women over the age of 30 and rarely before. It can cause irregular bleeding but usually leads to Postcoital bleeding. It is normally diagnosed by a simple examination and sometimes by a smear test. Occasionally the use of an ultrasound is needed.


Ectopic pregnancy, threatened miscarriage and abnormal pregnancies

Pregnancy related bleeding can be a reason for abnormal bleeding, even if you have not missed a period. Many women believe that if they have not missed a period then it is not possible to be pregnant; this is not true. It is possible to have had bleeding as results of complications during the pregnancy. That is why it is important to have a pregnancy test whenever you have any abnormal bleeding. Sometimes it is necessary to measure the pregnancy hormone BHCG to exclude ectopic pregnancy or abnormal growth of the placenta e.g. Hydatidiform mole.


Post coital bleeding

Bleeding after an intimate relation is described as provoked bleeding and is due to contact with the cervix. This may be due a benign polyp on the cervix, a vascular and inflamed cervix and more importantly may be due to a pre-cancerous abnormality on the cervix. It is therefore imperative that you see a doctor to examine the cervix both by the naked eye and by colposcopy.