Diagnosis of abnormal uterine bleeding, fibroids, and adenomyosis

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It is usually quite simple to find the cause of abnormal menstrual bleeding, although occasionally the cause may not be found.  Since abnormal uterine bleeding can be caused by disorders of the uterus, hormone imbalance (usually not ovulating), and pregnancy, it is helpful to look at each area separately.  When I see someone for abnormal bleeding, I ask the following questions:

• Is she pregnant?
• Is she ovulating?  (Or is she taking hormonal medication that may cause bleeding?)
• Is there a problem with the uterus?
  

A pregnancy test is simple to do and inexpensive, and should be done if there is even the most remote possibility of being pregnant. 

Evaluating Ovulation

Many women can tell that they are ovulating because they have regular menstrual periods, and have pain on one side mid-cycle that is caused by ovulation.  Regular menstrual bleeding (although there may be bleeding in between periods) suggest that a woman is ovulating, while a history of skipped periods followed by irregular uterine bleeding suggests she is not ovulating regularly.

A number of tests can help determine ovulation.  Since progesterone is secreted from the ovary after ovulation, a blood test showing a high progesterone level indicates ovulation.  Obviously, this has to be drawn in the time of cycle after ovulation.   It is also possible to examine a sample of the lining of the uterus (endometrial biopsy) in the laboratory to determine if ovulation has taken place.

A simple, inexpensive, and non-invasive method of determining ovulation makes use of the fact that progesterone will cause a woman's temperature to rise.  Since body temperature can vary throughout the day, it is important to take the temperature first thing in the morning, before getting out of bed.  An electronic thermometer, selling for less than $10, is sufficiently accurate, and takes less than a minute.   Temperature is taken every day for at least one complete cycle (or month if the bleeding is irregular) and charted.  If a woman is ovulating, the temperature will be low before ovulation, and then stay elevated after ovulation until just before the next period.  If she is not ovulating the temperature will not show any pattern.   Although this method is not perfect, it is simple and fairly accurate.  More information about basal body temperature can be found in books about fertility.

Evaluating the Uterus

Physical examination allows the clinician to feel the uterus.  While this is a good start, other things, such as adenomyosis, can cause the uterus to become enlarged.  Furthermore, fibroids and polyps on the inside of the uterus cannot be felt on examination.  For this reason, when there is a problem with abnormal bleeding it is helpful to do a vaginal probe ultrasound exam. Ultrasound uses soundwaves make a picture of the uterus and ovaries.   The exam takes only a few minutes, is not uncomfortable, and frequently identifies the cause of bleeding.  In my practice I see many women who have had multiple procedures over a period of several years and who are told they need a hysterectomy, only to identify the cause of bleeding with the ultrasound in less than a minute during their first office visit! 

It is possible to fill the uterus with fluid while doing an ultrasound to outline the uterine cavity.  This is called hysterosonography or saline enhanced ultrasound.  While this provides a better picture of the inside of the uterus than regular ultrasound, I prefer to actually look inside the uterus by using a tiny telescope called a hysteroscope. 

Diagnostic hysteroscopy allows excellent visualization of the inside of the uterus.  It usually takes a few minutes, and is easily done in the office by a gynecologist who is skilled in the procedure.  Submucous fibroids, polyps, and other problems can be seen directly.  In addition, it is possible to remove some polyps during the procedure, and to take a sample of the lining of the uterus.

Copyright © 1998 Paul D. Indman, M.D.