Treatment for abnormal vaginal bleeding depends in great part on what is causing the bleeding and what about the bleeding is abnormal. For infrequent bleeding, the treatment goal is to have a period no less than once every three months. For too much bleeding, the treatment is generally hormones if the cause of the bleeding is hormonal or surgery if the cause is structural.
For women who have infrequent bleeding, an evaluation is needed to determine the cause and to rule out something dangerous. This generally includes a physical exam, blood work, and sometimes an endometrial biopsy. Unless the cause of the infrequent periods is menopause, it is important to have a menstrual cycle at least every three months. Bleeding less frequently increases the risk of significant hemorrhage and uterine cancer. For women that desire contraception, any of the hormonal birth control methods will adequately treat infrequent menstruation. If birth control is not needed then using a medication called Provera can be used. I generally instruct my patients to take the Provera for 10 days if two months have passed without a menstrual period. The Provera should be taken in the morning as it can cause insomnia for some women if taken at night. Provera is usually very well tolerated with few or no side effects. Bleeding generally occurs sometime the week after the Provera is finished.
Women that have too much bleeding can be categorized into two main causes, structural problems or hormonal problems. Structural problems include: fibroids (myomas), polyps, and infections. Infections are generally treated with antibiotics whereas fibroids and polyps are often treated with a surgical approach. Polyps can be endocervical or intrauterine. Endocervical polyps can usually be removed in the office. The procedure is not painful and no anesthesia is needed. The removal of an endometrial polyp can cause some vaginal bleeding for a few days but should not cause any other problems. Intrauterine polyps are usually removed in the operating room with a procedure called a hysteroscopy D&C. General anesthesia is typically used. A small camera is placed into the uterus through the cervix using a speculum in the vagina. The polyps can then be removed by scraping the inside of the uterus with an instrument called a uterine curette. This can cause some menstrual like cramping and some bleeding but most women do very well after the procedure.
Hormonal causes of bleeding are usually treated with hormone therapy as the first line of approach. Any of the hormonal contraceptive agents can be effective. This includes the pill, the patch, the ring, the shot, or the hormonal IUD. If birth control is not needed Provera can be used. For too much bleeding I prescribe Provera to be taken for 14 days each month. This can often give a nice, light, normal monthly menses. If the patient is bleeding very heavily, high dose hormone treatment may be used for a short time to get the bleeding under control. This can then be followed by a smaller maintenance dose of hormone treatment. If the hormone treatment does not control the abnormal bleeding, a surgical approach may be necessary. This can be a D&C, an endometrial ablation, or a hysterectomy.
A D&C (dilatation and curettage) is a procedure that is usually done in the operating room with the patient asleep. An instrument called a curette is placed inside the uterus through the cervix using a speculum in the vagina. The curette is then used to scrape the inside of the uterus. The patient can go home after a couple of hours and except for mild bleeding and some cramping, the patients tend do do very well. This can be used to control bleeding in an emergency or when hormone therapy is not working. For most women the results are temporary and the abnormal bleeding pattern often returns after some amount of time. A hysteroscopy is often done at the same time. Hysteroscopy is using a small camera to look inside the uterus.
If the woman does not desire future children, an endometrial ablation can be performed with a D&C. An ablation is also an outpatient procedure. It involves destroying the inside of the uterus to prevent it from being able to bleed. It is not safe to have children after an ablation is done. There are different techniques to doing an ablation. It can be done using an electric current, using hot fluid, or a balloon filled with hot fluid. These techniques all accomplish the same end point, burning the inside lining of the uterus. About 40% of women will never bleed again after the ablation. About 40% of women will have some regular bleeding but very light. So there is about an 80% success rate with endometrial ablation. The other 20% will either get no improvement or the improvement will be temporary. After the procedure some will have menstrual like cramping for a day or two. Most women will get a watery discharge, this can be pretty heavy and quite obnoxious. It can last from a few days to several weeks.
Hysterectomy is the removal of the uterus. It is the most invasive treatment for abnormal vaginal bleeding but also the one treatment that will absolutely stop the problem. It is usually reserved as a last option when less invasive treatments have failed. Depending on the individual circumstances of the patient hysterectomy can be performed through the vagina, through a laparoscope, or through an abdominal incision.