One of the most poignant moments this past week occurred when a patient disclosed how long she had been bleeding. She was in her mid- to late-50s and had experienced menopause without batting an eyelash. She was such a sturdy character, and I could tell by our discussion that she was focused on managing the costs of her health care that day. She stated without hesitation that she wanted just an exam, no ultrasound. Nothing more, nothing less.
With gentle questioning I asked how long she had been bleeding. I was surprised when she told me more than a year had gone by, with the bleeding becoming more frequent and heavier. She continued with her daily routine, carrying extra clothes with her to work for the inevitable "accident."
The reality of her diagnosis was evident when I told her she was going to be admitted to the hospital due to the excessive bleeding she experienced during her exam.
For women over the age of 40, there are, pardon the pun..."red flags" that should clearly tell you it's time to ditch the stoicism and pursue medical care. In gynecology we call this condition abnormal uterine bleeding. It can occur at any age. From age 13 to 18 it's typically associated with immature physiology, pelvic infection, blood disorders or tumors. Between age 19 and 39, most bleeding is related to pregnancy, fibroids, polyps, hormones, contraceptive problems or abnormal growth of the lining of the uterus.
However, the bleeding that becomes the most ominous is the bleeding which occurs in the postmenopausal woman.
In women age 40 to post-menopause, abnormal uterine bleeding may encompass decline of the ovarian function with cycles characterized as anovulatory (not ovulating because of a medical condition, suppression by drugs or menopause). However, the three most concerning reasons for abnormal bleeding are related to abnormal growth of the endometrium, the hormonally responsive lining of the uterus; abnormal cervical cells and abnormal endometrial cells.
The Big Three
Endometrial Hyperplasia: Hyperplasia is defined as the abnormal increase in normal cells. There are many factors that contribute to the risk of endometrial hyperplasia. Obesity is a strong risk factor. The association is believed to be due to increased circulating estrogen levels. Interestingly, oral contraceptives can decrease the risk of over-stimulation of the endometrium due to the progestin in combined oral contraceptives. The protection begins after one year of use and continues for approximately 15 years after discontinuation. Abnormal uterine bleeding is often the most frequent symptom of hyperplasia.
Endometrial Cancer: Endometrial carcinoma is recognized as the most common malignancy of the female genital tract in the United States. The type of hyperplasia which can progress to endometrial cancer is known as complex atypical hyperplasia. The rate at which hyperplasia may progress to endometrial cancer is still unclear. Premenopausal women with irregular bleeding and postmenopausal women with any vaginal bleeding should seek medical attention.
Cervical Cancer: The woman with the bleeding I mentioned above was subsequently diagnosed with a cervical carcinoma. Women with carcinoma of the cervix typically have symptoms such as abnormal bleeding or brown discharge. These women tend to be anywhere in age from their 40s to 60s, with a median age of 52 years, worldwide. Research has demonstrated that the incidence of cervical cancer is highest among Hispanic women, however African-American women have the highest mortality rate.
Please don't ignore the red flag of abnormal uterine bleeding.