Like everything else in life, "normal" encompasses a great many variations. Normal also does not necessarily mean average. Having said that, normal bleeding is bleeding that occurs at intervals no closer than 21 days, and no further apart than 35-40 days. Normal bleeding should not result in anemia and should last between two and seven days requiring a pad or tampon to be changed no more than every three to four hours. Most important…normal is what has always been normal for you. If there is a deviation from your normal bleeding pattern, particularly if persistent, there may be a problem that is worthy of evaluation.
The most common cause of abnormal bleeding is anovulation. Anovulation is just what it sounds like…the absence of ovulation. In a normal cycle, women make estrogen, release an egg from an ovarian follicle, make progesterone, and then get their period. Women who don't ovulate do make estrogen; they just don’t release an egg. The lining of the uterus gets stimulated with estrogen alone and essentially bleeds at random times. Sometimes the bleeding can be quite heavy or prolonged. It is usually totally unpredictable and women rarely have the premenstrual prodrome of breast tenderness, PMS and cramping that typically occurs in ovulatory cycles.
Anovulatory cycles are more common in women who are under stress, dieting, traveling, or have other medical problems such as thyroid dysfunction. It is also common in women who are in their forties, even if menopause is years away. The other end of the spectrum is the adolescent who is making estrogen, but hasn't yet started ovulating.
The diagnosis is often suspected in young women with irregular cycles, and since other problems (such as uterine cancer) are rarely seen in the under thirty crowd, it is reasonable to treat presumptively; that is, without doing a biopsy to confirm.
Perimenopausal bleeding is generally caused by anovulatory cycles that occur during the years in which the ovaries are winding down. Again, the ovaries are secreting estrogen, but no egg is released, and no progesterone is produced.
Many other conditions can potentially cause abnormal bleeding in the perimenopausal years. Therefore, it is essential to make a definitive diagnosis rather than assume that irregular or abnormal bleeding is from anovulation. Endometrial biopsy is required to assure that no pre-cancerous cells are present. Ultrasound and saline infused sonography are useful to determine if fibroids or polyps are present since they are potentially responsible for abnormal bleeding.
Postmenopausal bleeding is always abnormal and must be investigated. Ninety percent of post-menopausal bleeding is not cancer, but must be checked out nevertheless. Benign polyps, atrophic (very thin tissue) endometrial lining, fibroids, and cancer are all conditions which can cause postmenopausal bleeding.
Growths (Polyps, Fibroids)
Benign growths in the uterus commonly are responsible for abnormal bleeding. Fibroids generally cause heavy bleeding during menstruation, while bleeding from a polyp is non-cyclic and unpredictable.
Polyps are benign growths that project from the surface of the uterine lining. It is not unusual for someone to have multiple polyps, or have recurrence of polyps once removed. Ten to twenty percent of women will have polyps at some point in their lives, but most do not bleed. The most common time to have polyps is in the fifties, but they can occur anytime after age twenty.
While polyps originate from the uterine surface, it is not unusual for one to be on a stalk and actually emerge through the cervical opening. It is common for women who have such a polyp to have spotting after intercourse.
Post-menopausal hormone replacement and birth control pills do not seem to influence the formation of polyps and should not be discontinued just because a woman has them.
Treatment is dependent on the cause of the bleeding so it is essential to make an accurate diagnosis. The process of evaluating the bleeding will sometimes also treat the problem, particularly if a D&C and/or hysteroscopy is needed. Your doctor will discuss various treatments with you including hormones, IUD, endometrial ablation, or other options.
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