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Abnormal Menstrual Bleeding
(not on hormonal contraceptives)
Frederick R. Jelovsek MD
   
Period twice in one month
If one of the bleeding episodes is extra bleeding rather than a
menses. It may be due to ovulation. Also if something happens to
the corpus luteum gland on the ovary in the second half of the
cycle, this may induce extra bleeding. Usually if the extra
bleeding does not occur more than two months in a row, You don't
need to have it investigated.
Bleeding 5 weeks after delivery with pain
This is not uncommon. As long as you do not have a fever and
as long as the bleeding is not greater than a normal menses, the
doctor will probably just have you wait to see what happens
further.
Probably not although sometimes strenuous activity can start
off some spotting.
It probably is not a menses but it could represent your first
ovulation if you are not breast feeding.
Sexual relations can sometimes start up some bleeding
postpartum for the first one or two times. If it happened more
than that you might need to see the doctor for a checkup.
Could be but probably not. What tissue does come out sometime
later is the decidua which is the tissue between the lining of
the uterus and the placenta. It takes awhile to totally slough
out.
Continuous bleeding in spite of BC pill therapy
Has it been only one month that there has been bleeding other
than at normal menstrual time or is it many months? We need to know
the full history on the bleeding.
It sounds as if the cramps have been going on quite awhile.
Have you asked to be referred to a gynecologist?
Anovulatory bleeding that is irregular often does take 3
months to straighten out on its own, but we don't wait 3 months
to treat if it is continuous bleeding. If this is really
continuous for 5-6 weeks you should get some hormonal treatment
to try to stop it, cause a withdrawal bleed and hopefully get it
straightened out. If a family doctor can't do that, insist on
seeing a gynecologist soon.
You have had reasonable trials of hormonal therapy. It is now
time for a hysteroscopy and D&C to make sure there is no
mechanical cause of bleeding inside the uterus such as polyps or
fibroids.
Endometrial ablation for heavy 8 day menses
Yes, ablation is targeted at women with heavy menstrual blood
loss in the ABSENCE of organic pathology such as fibroids that
have failed other medical or surgical management and who no
longer wish to become pregnant. However, don't forget the numbers
about success. In large studies, after ablation 25-60% had no
subsequent periods, with most of the remainder having a decrease
in the amount of menstrual flow. About 10% fail to improve and
require another ablation or hysterectomy (about 2%).
Can prolonged menses be due to stress?
Tension and stress can affect ovulation which in turn affects
menses. Your current bleeding however, if it is due to stress, is
not due to the stress at this moment. Rather it is likely that the
bleeding now represents stress in the month before this period
started. The stress somehow causes a dysfunctional ovulation and
then the menstrual bleeding after that is what is disturbed.
When ovulation goes dysfunctional, there is often a follicular
cyst or corpus luteum cyst on the ovary that can produce pain. There
are other possibilities though such as infection, endometriosis,
etc, so it would be a good idea to be checked if this pain
persists.
Light brown discharge 9-14 days into cycle
You can get ovulatory bleeding in the middle of the cycle and if
it is very light, it just comes out as brown tinged as you
describe. Usually it doesn't happen every month though.
Do you know that the Pap was normal or just that it was not
abnormal? The reason I ask is sometimes inflammation shows up on
the Pap but if you are not symptomatic with abnormal bleeding (in
this case you are), then physicians usually don't notify you that
the Pap shows this.
That doesn't sound worrisome. If you start having bleeding more
often or bleeding after sexual relations then you should return
to see the doctor.
Endometrial ablation for bleeding and PMS
I don't know the answer to this. In one respect, all
the factors associated with PMS -- ovulation, progesterone, pelvic
blood vessel engorgement will still be present even though you
have the ablation. The fact that the cramps and flow will
decrease or be absent should play a role in decreasing some of
the PMS symptoms. Basically I'm not sure whether ablation will
decrease your PMS symptoms, but it is an out patient procedure
which would not put you out of work or activity for more than
3-7 days.
Will spotting with straining interfere with conception?
No. The spotting should not interfere with conception.
Recent period 1 week early then another 2 weeks later
Sometimes ovulation or menses gets out of synch for a cycle or
two and we never know why. It can be due to medications, colds,
things eaten, stress, etc. Usually the rule of thumb is that if
the abnormal bleeding persists 3 cycles in a row, you need to see
the doctor because it may not get better on its own. Your doctor
ordered a pregnancy test because you are not on contraception and
having bleeding could indicate an ectopic pregnancy or early
miscarriage. With those ruled out by the negative test, it is
generally safe to wait and see if the bleeding cyclicity will
straighten out on its own.
Bleeding after intercourse and anovulatory problems
The bleeding (spotting) after intercourse is probably due to
either direct irritation of the cervix or from starting up
endometrial bleeding that is due to your basic problem of
anovulation. Since you have had many blood studies done, your
doctors must have some idea of what type of anovulation you have,
i.e., hypothalamic amenorrhea, polycystic ovarian disease,
hyperprolactinemia, etc. ClomidŽ may be used to induce ovulation
in any of those so that is not helpful.
One of the main problems now it seems, is that the therapy is
focusing on two goals, regulating the bleeding and inducing
ovulation so as to get pregnant, that usually require almost the
opposite therapy. One solution might be to just focus on the
abnormal bleeding and get that straightened out, and then resume
the fertility induction.
With so much abnormal bleeding, it is not safe to assume it
only is dysfunctional, anovulatory bleeding even though you are
young. Mechanical causes (polyps, fibroids) need to be ruled out
with a hysteroscopy and D&C if that hasn't already been done.
Also bleeding due to other unusual diseases such as coagulation
problems (Von Willebrand's disease), thyroid problems (I'm sure
this has already been checked), other medical diseases and
medications need to be ruled out. When all of these have been
done, the next step might be to regulate your periods with
something like Premphase which is used in the
perimenopausal/postmenopausal period to regulate bleeding and
still produce a monthly menses.
Presuming the Premphase would regulate you so that there was
no more abnormal bleeding for about 3 or 4 months, then you might
consider retrying the ClomidŽ therapy to induce ovulation or
whatever your doctor feels is needed.
At this point I would suggest making another visit to your
doctor to discuss the bleeding after intercourse and let him
examine you to make sure there are not local cervical factors,
irritation etc., causing the bleeding. Then discuss the above
plan as you and he think it applies. Agree on any plan or
modification of the above so that you can have a systematic
approach to getting over all of these problems. He will probably
benefit from some regrouping in plan as much as you will.
Can heavy bleeding wash out sperm or prevent implantation?
If you are bleeding heavily such that it can "wash" sperm out
of the cervix, then it will decrease the chance of getting
pregnant. If it's just spotting, it shouldn't affect it.
Implantation occurs about day 5-7 after fertilization. It
implants in the uterus usually in the top or top-back on a very
small area. I see why you are worried about the bleeding. If it
continues heavy it could prevent implantation. It's still very
possible, however, so just wait it out to see what happens.
47 y.o. with heavy clotting and pain each month (adenomyosis)
Your age and with the above history, the most likely cause
would be adenomyosis of the uterus. This is endometriosis interna
or endometrial glands that go down into the muscle of the uterus.
At the time of menses the endometrial tissue in those pockets
cannot get out of the muscle and it gives pain. Unfortunately,
adenomyosis is a diagnosis of exclusion. Other causes of the
heavy bleeding and pain need to be ruled out.
Your gyn doctor would probably recommend a vaginal ultrasound
( to rule out uterine fibroids or any ovarian cysts) with a
saline sonohysterogram (injection of fluid into the endometrial
cavity at time of ultrasound to detect any endometrial polyps or
submucous fibroids). If these are all normal, you could very
strongly suspect adenomyosis as the main cause of your problems.
Medical treatment for this at your age would be low dose birth
control pills (if you are a non smoker) or Depoprovera injections
to block your ovulation and menses until you become menopausal.
If any of the above studies suggest there is a mechanical
cause of the bleeding or pain (polyps, fibroids, ovarian cysts)
you will probably be recommended to have a D&C and hysteroscopy
and possibly a diagnostic laparoscopy as outpatient surgery
procedures.
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