Abnormal Bleeding

Heavy menstrual bleeding (called menorrhagia) can negatively interfere with your normal daily activities and sexual life. Menorrhagia may be due to hormonal causes, structural changes in the uterus, bleeding disorders, and/or different medications. Common structural gynaecological conditions that cause menorrhagia include adenomyosis, uterine fibroids, and endometrial polyps.

•  An endometrial polyp is a finger-like growth from the  lining of the womb, that is usually benign. It can cause heavy menstrual bleeding, irregular bleeding/spotting, infertility and postmenopausal bleeding.
• A uterine fibroid is a common benign tumour that grows in the muscle wall of the uterus or into the uterine cavity. Symptoms of uterine fibroids include heavy periods, irregular periods, back or pelvic pain, pressure sensation in the pelvis, frequent urination. Fibroids that grow into the uterine cavity can cause infertility.
• Adenomyosis is a benign condition where the cells that line the uterine cavity grow within the muscle wall of the uterus. Symptoms of adenomyosis include heavy menstrual bleeding, painful periods, painful intercourse, and bleeding between periods. 
• Heavy menstrual bleeding may also be caused by an overgrowth of the uterine lining, called endometrial hyperplasia. 

Pelvic ultrasound is used in the evaluation of heavy uterine bleeding, and is able to detect uterine abnormalities. Saline infusion sonohysterography (SIS) is a specialised ultrasound scan that may also be ordered by your doctor, as this scan improves the detection of polyps and fibroids in the uterine cavity.

Other causes of heavy periods may be related to your hormonal status. Heavy menstrual bleeding can occur with metabolic disorders such as polycystic ovarian syndrome (PCOS) and thyroid disease.

Bleeding between periods may occur for several reasons. Vaginal spotting may occur at the time of ovulation or if you are taking hormonal birth control (birth control pill, Mirena, Depo Provera, Implanon). Irregular bleeding may also be caused by conditions such as endometriosis or adenomyosis. Structural abnormalities in the uterine cavity such as uterine fibroids and polyps can also cause irregular bleeding. Less commonly, cancers or precancerous diseases of the cervix or uterus can cause bleeding between periods.  

Menopause is defined when a woman ceases to have menstrual periods for 12 consecutive months. Vaginal spotting or bleeding after menopause is called "post-menopausal bleeding" and needs to be checked out by your doctor. There are several causes for post-menopausal bleeding; the cause is usually benign and treatable. Benign causes include inflammation and thinning of the lining of the vagina, thinning of the lining of the womb, and uterine or cervical polyps.  Other causes include a thickening of the lining of the womb or abnormalities in the uterus or cervix. In a small percentage of women, post-menopausal bleeding is due to endometrial or cervical cancer.

Missing a period is not necessarily cause for concern. Your cycle may be irregular from time to time, and this may be due to lifestyle changes, stress, weight loss, medications, birth control, pregnancy, and breastfeeding. Irregular periods may also be due to hormonal changes (i.e. polycystic ovarian syndrome, thyroid disease, and pituitary tumours). Menopause is another cause for irregular or missed periods.

Complete absence of periods for 6 months or more is called "amenorrhea" and can be due to the same causes as mentioned above for missing a period. When the cause for amenorrhea is not easily explained, investigations will likely be ordered by your doctor. Examples of conditions causing amenorrhea that require treatment include polycystic ovarian syndrome, chronic stress, pituitary tumours, premature ovarian failure, and Asherman's syndrome (when scar tissue is found in the uterus).

PCOS

Polycystic ovary syndrome (PCOS) is the most common hormonal disorder in women of reproductive age. It affects about one in 10 women, from when their periods begin to when they reach menopause. PCOS can cause period problems, trouble falling pregnant, acne, excess hair growth and excess weight. The cause of PCOS is thought to be multifactorial (genetics, hormone imbalance and lifestyle factors). 

The hormone imbalance caused by PCOS can affect your menstrual cycle; the ovaries develop multiple small follicles (not cysts) but no egg is released (monthly ovulation does not occur), and in turn, regular monthly menstrual bleeding does not occur. The lining of the womb can become overgrown and thickened if there are extended timeframes between your periods, and you may have episodes of irregular prolonged heavy vaginal bleeding (not actually your "period") due to the overgrowth of the endometrial lining.  

In order to regulate menstrual bleeding in PCOS, the recommended medical treatment is usually the combined contraceptive pill or progestin therapy (Mirena),  but you may also require a medication for blood glucose control (Metformin) if you have insulin resistance.  If you are concerned you have symptoms of PCOS, discuss these symptoms with your doctor and investigations can be ordered to confirm the diagnosis of PCOS.