Constant Menstrual Bleeding at Age 39
Frederick R. Jelovsek MD, MS
"I have had nearly constant menstrual-type bleeding for the last two years. I have been diagnosed in the past with uterine cysts and cervical dysplasia. Even though I am very concerned about the bleeding, my gynecologist is not. Should I get a second opinion?"
"I am 39, and have had regular periods from age 14 through 36. After the birth of my child (at 36), periods have been very long (15-20 days) or I have intermittent bleeding all month. I had one laparoscopy after a "mass" was found, but nothing was removed (it had disappeared)." Gyl
Yes. You should go get a second opinion. Constant bleeding like you are having is not normal and above the age of 35 is often associated anatomical abnormalities inside the uterus such as polyps or submucosal fibroids. While cancer of the uterus is not common before the age of 40, it is possible. Also possible are some of the premalignant lesions of the lining of the uterus called hyperplasias. Therefore you need an evaluation to rule out malignancy or premalignancy and also to see if there is a polyp or submucosal fibroid that can be removed to stop this bleeding problem.
Before the age of 35, the most common cause of this type of constant bleeding is a defect in the endocrine control of the uterine lining (endometrium). Often this is associated with anovulation and lack of a regularly functioning ovary. Bleeding of this endocrine nature is termed "dysfunctional" uterine bleeding. It also occurs after age 35 but the anatomical causes of bleeding occur more frequently and so they need to be ruled in or ruled out.
Could It Be Fibroids?What is the best way to diagnose if my bleeding problem is due to polyps or fibroids?
Different methods to detect polyps inside the uterus include injection of dye into the uterine cavity and then taking an x-ray (hysterography), injecting saline (water at body salt concentration) into the uterus and then viewing with an ultrasound imaging saline (sonohysterogram), and finally hysteroscopy which uses a telescope-like instrument to look into the cavity when a woman in under anesthesia.
Illustration of hysteroscopy modified from the Encyclopedia of Women's Health and Wellness, American College of Obstetricians and Gynecologists, 2000.
Each of these techniques are of similar diagnostic value in that if they are negative, it is very unlikely that polyps or submucosal fibroids are present (1, 2). All of the techniques can sometimes be fooled by just an irregular thickening of the endometrial lining (hyperplasia) or any blood clots in the uterus from bleeding either due to the procedure itself or just abnormal uterine bleeding.
If hysteroscopy is performed in an outpatient surgical unit, for example, then a D&C can be performed at the same time as a hysteroscope and any polyps removed. This is successful at curing the bleeding about 80% of the time (3). Sometimes the bleeding persists even after D&C and polyp removal because the original source of the bleeding was probably a combination of dysfunctional (endocrine) and mechanical (polyp).
If I have a saline sonohysterogram or a hysterography in the office and it shows a possible polyp, do I then have to have a D&C done?
In general, yes. Endometrial biopsy in the office is effective for diagnosing hyperplasia or cancer but it is not very good at removing polyps or submucous fibroids. That is usually best done under anesthesia because a moderate amount of discomfort would take place with distension of the uterine cavity with fluid and then scraping (D&C) the lining of the uterus to remove all polyp tissue.
Sometimes if a polyp is small, it can be removed during office hysteroscopy without general anesthesia so what specific procedure is performed is a product of your physician's skills and office equipment.
Normal hysteroscopy view with a smooth endometrium
Is there a difference between an endocervical polyp and an endometrial polyp?
The two look somewhat different under a microscope and endocervical polyps are generally smaller and attached to the cervical entrance into the uterus. Endometrial polyps can be larger and are attached to the inside of the uterus itself, but otherwise both types similar. Both can cause abnormal menstrual bleeding and their removal often permanently cures the bleeding. About 20-30% of the time polyps can recur but it may be years later.
|Small endocervical polyp in canal leading into the uterine cavity||Hysteroscopic view showing an endometrial polyp|
What if a fibroid is found at the time of hysteroscopy, can it be removed?
If the fibroid is on a stalk like a polyp (submucosal fibroid) it can almost always be removed at the time of hysteroscopy and D&C. If it is a very broad based fibroid that is mostly in the muscle of the uterus but it is deforming the cavity of the uterus, it may not be able to be removed at all without significant risk of perforating the entire uterine wall.
Hysteroscopy showing small submucosal fibroid
Where should I go from here either with my doctor or a new doctor?
You need to make sure your Pap smear is up to date and that there is not a lesion of the cervix causing the bleeding. Then your doctor may suggest a regular pelvic ultrasound or a saline sonohysterogram because of that previous "mass" you said you had. The ultrasound will tell if there are any fibroids in the wall of the uterus that may be contributing and if the endometrial cavity is irregular on regular ultrasound or if a cavity defect is seen on injection of saline, then you will need a hysteroscopy and D&C to look for and remove any tissue that is causing the bleeding.
I would guess that at age 39-40 and a two year history of constant bleeding, there is over a 75% chance you have a polyp or fibroid in the uterine cavity that is causing the problem.
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