The evaluation for abnormal vaginal bleeding may include a physical exam, an endometrial biopsy, an ultrasound, and blood work. The first step is to make sure that the bleeding is not caused by something dangerous like a cancer or a pre-cancer. The next step is to determine if the cause of the bleeding is from a structural problem or a hormonal problem.
The physical exam may include a speculum exam. This feels like a pap smear. A speculum is placed in the vagina so the doctor can look at the cervix as well as the inside of the vagina. A lesion on the cervix, a polyp coming through the cervix, or signs of infection of the cervix or uterus may be evident on physical inspection with a speculum exam. Cultures may be taken from the cervix to evaluate for infections. The physical exam may also include a bimanual exam. A bimanual exam involves the doctor placing two fingers in the vagina and pushing on the lower abdomen with the other hand. This allows the doctor to feel the contour of the cervix for size and irregularities. The uterus is palpable for shape, size, position, and motility. The ovaries are also palpable. This part of the exam can help us to find fibroids or other masses that may be present. It also gives information about which structures are tender or inflamed.
An endometrial biopsy is a minor office procedure that allows us to collect tissue from inside the uterus. A small plastic tube is placed through the cervix into the endometrium and a tissue sample is collected. This sample is sent to pathology where doctors exam the tissue under a microscope. This can rule out cancer or pre-cancer as a cause of the bleeding. It can also give some information about the dominate hormone condition affecting the uterus. The endometrial biopsy does cramp and it is often recommended that the patient take some ibuprofen prior to coming to the office.
Ultrasound examination of the uterus can be very helpful in the evaluation of abnormal vaginal bleeding. This is the same type of exam that is done in pregnancy to look at the baby. The ultrasound probe may be placed on the lower abdomen. In some cases a special probe is placed in the vagina. This is no more uncomfortable than a speculum exam and it can often give much more information than the abdominal scan. The ultrasound will look at the size of the uterus and ovaries. It will look for tumors such as fibroids in the uterus as well as tumors or cysts in the ovaries. It can also evaluate the endometrial strip. The endometrium is the inside lining of the uterus. This is the part that sheds during menses. A thin endometrial strip can reassure us that there is no cancer or other dangerous lesion in the endometrium. A thick strip does not necessarily mean there is a cancer present, this more often represents a benign polyp or benign thickening of the endometrium. A thickened endometrial strip does necessitate further evaluation. Hydrosonagraphy is a vaginal probe ultrasound done in conjunction with water being placed through the cervix into the uterus. This non-painful exam can give additional information about the structures in the inner uterus.
Blood tests are often ordered in the evaluation of abnormal vaginal bleeding. A test for anemia is probably the most important. Checking a blood count or a hemoglobin level is the way anemia is checked. Women can become severely anemic, sometimes even requiring a blood transfusion, from abnormal vaginal bleeding. The test for anemia can help give the doctor an idea about how much blood has been lost as well as how the woman’s body has been able to replace the blood loss from the formation of new blood cells. An FSH can be checked if there are concerns that the woman may be perimenopasual. An LH to compare with the FSH is also sometimes ordered. Abnormal thyroid function can also cause abnormal vaginal bleeding. A TSH can be ordered to check the correct functioning of the thyroid. If the thyroid is not producing the correct amount of hormone, treatment of the thyroid rather than the uterus is what is necessary to treat the abnormal bleeding. Prolactin is a hormone that is produced by the brain. Prolactin regulates breast milk but can also affect the menses. Prolactin levels may be ordered in the evaluation of abnormal vaginal bleeding.