Up to 14 percent of women experience irregular or excessively
heavy menstrual bleeding. This abnormal
uterine bleeding generally can be divided into anovulatory and ovulatory patterns. Chronic
anovulation can lead to irregular
bleeding, prolonged unopposed
estrogen stimulation of the endometrium, and increased risk of
endometrial cancer. Causes include
polycystic ovary syndrome, uncontrolled
diabetes mellitus, thyroid dysfunction,
hyperprolactinemia, and use of
antipsychotics or
antiepileptics. Women 35 years or older with recurrent
anovulation, women younger than 35 years with risk factors for
endometrial cancer, and women with excessive
bleeding unresponsive to medical
therapy should undergo endometrial biopsy. Treatment with combination
oral contraceptives or
progestins may regulate menstrual cycles. Histologic findings of
hyperplasia without atypia may be treated with cyclic or continuous
progestin. Women who have
hyperplasia with atypia or
adenocarcinoma should be referred to a gynecologist or gynecologic oncologist, respectively. Ovulatory abnormal
uterine bleeding, or
menorrhagia, may be caused by thyroid dysfunction, coagulation defects (most commonly
von Willebrand disease), endometrial
polyps, and submucosal
fibroids. Transvaginal ultrasonography or saline infusion sonohysterography may be used to evaluate
menorrhagia. The
levonorgestrel-releasing intrauterine system is an effective treatment for
menorrhagia. Oral
progesterone for 21 days per month and nonsteroidal anti-inflammatory drugs are also effective.
Tranexamic acid is approved by the U.S. Food and Drug Administration for the treatment of ovulatory
bleeding, but is expensive. When clear structural causes are identified or medical management is ineffective, polypectomy,
fibroidectomy,
uterine artery embolization, and
endometrial ablation may be considered.
Hysterectomy is the most definitive treatment.