Abnormal Uterine Bleeding: Symptoms and Concerns

Abnormal bleeding

I have had irregular menstrual cycles for the past 3-4 years, with a low volume of menstruation.
There have been 3-4 instances where my period returned just 9 days after it ended.
(I had hormone tests done in 2016 that were normal.) I have seen 2-3 gynecologists, most of whom said it was due to stress and irregular cycles.
Recently, in the last 3-4 months, my menstrual flow has increased, and during my period on April 21, I experienced persistent cramping in my lower abdomen and left side for three days, which is a situation I have not encountered in these years! I have had Pap smears done annually, and in March, I also had a human papillomavirus (HPV) test that came back normal.
After my period, the endometrial thickness has been between 0.6-0.4 cm (approximately 1 cm before menstruation).
There is still a small amount of dark brown discharge since my period on April 21.
One doctor suggested an endometrial biopsy, but most doctors believe my endometrial thickness is within normal limits and that such a procedure is unnecessary.
I would like to ask if endometrial cancer always presents with a thickened endometrium, and if the endometrium is within normal limits, should I not suspect endometrial cancer? P.S.
I have a small uterine fibroid.
Thank you, doctor!

Ai Li Si, 40~49 year old female. Ask Date: 2017/05/02

Dr. Huang Jianzhong reply Obstetrics and Gynecology

I have had irregular menstrual cycles for the past 3-4 years, with a low volume of menstruation.
There have been 3-4 instances where my period returned just 9 days after it ended.
(I had hormone tests done in 2016 that were normal.) I have consulted 2-3 gynecologists, most of whom attributed my irregular cycles to stress.
Recently, in the last 3-4 months, my menstrual flow has increased, and during my period on April 21, I experienced persistent cramping in my lower abdomen and left side for three days, which is a new symptom for me! I have had Pap smears done annually, and in March, I also underwent testing for human papillomavirus (HPV), both of which were normal.
After my period, the endometrial thickness was measured at 0.6-0.4 cm (approximately 1 cm before menstruation).
I still have a small amount of dark brown discharge since my period on April 21.
One doctor suggested I undergo a dilation and curettage (D&C) procedure, but most doctors believe my endometrial thickness is within normal limits and that such an examination is unnecessary.
I would like to know if endometrial cancer always presents with thickened endometrium, and if having a normal endometrial thickness means I should not suspect endometrial cancer.

Answer: The presentation of endometrial cancer does not always involve thickened endometrium, and having a normal endometrial thickness does not rule out the possibility of endometrial cancer.
Most doctors believe that if the endometrium is within normal limits, there is no need for such examinations, primarily due to the risks associated with anesthesia.
Undergoing a hysteroscopy or a D&C may provide more reassurance.
Additionally, I have a small uterine fibroid.

Reply Date: 2017/05/02

More Info

Abnormal uterine bleeding (AUB) can be a significant concern for many women, and understanding its symptoms and underlying causes is crucial for effective management. Based on your description, it appears that you have been experiencing irregular menstrual cycles, varying menstrual flow, and abdominal pain, which can be indicative of several underlying conditions.

Firstly, it is essential to recognize that AUB can manifest in various forms, including intermenstrual bleeding, prolonged menstrual bleeding, or heavy menstrual bleeding. The symptoms you described, such as experiencing menstrual bleeding shortly after your period ends, abdominal pain, and changes in the color and consistency of your menstrual flow, warrant further investigation.

The fact that you have seen multiple gynecologists and undergone various tests, including hormone level checks and Pap smears, is a positive step toward understanding your condition. Hormonal imbalances are often a significant contributor to AUB, and stress can exacerbate these imbalances. However, given that you have had normal hormone levels in the past, it may be necessary to explore other potential causes.

One possible explanation for your symptoms could be the presence of uterine fibroids, which you mentioned having. Fibroids can lead to heavy menstrual bleeding, prolonged periods, and abdominal pain. While many women with fibroids may not experience significant symptoms, those who do can have varying degrees of discomfort and bleeding patterns. It is essential to monitor the size and location of the fibroid, as these factors can influence your symptoms.

Another consideration is the possibility of endometrial hyperplasia, which is a thickening of the uterine lining that can lead to abnormal bleeding. While you mentioned that your endometrial thickness has been within normal limits, it is crucial to continue monitoring this, especially if you experience changes in your bleeding patterns. Endometrial cancer is a concern, particularly in women with risk factors such as obesity, prolonged exposure to estrogen, or a family history of gynecological cancers. However, having a normal endometrial thickness does generally reduce the likelihood of endometrial cancer.

Additionally, the abdominal pain you are experiencing, especially if it is new and severe, should not be overlooked. Conditions such as ovarian cysts, pelvic inflammatory disease, or even endometriosis could be contributing to your symptoms. These conditions can cause significant discomfort and may also lead to changes in your menstrual cycle.

Given your history and current symptoms, it may be beneficial to consider further diagnostic procedures, such as a transvaginal ultrasound or a hysteroscopy, to visualize the uterine cavity and assess for any abnormalities that may not have been detected in previous examinations. A hysteroscopy, in particular, allows for direct visualization of the endometrial lining and can be used to obtain biopsies if necessary.

In conclusion, while your endometrial thickness appears to be within normal limits, it is essential to continue monitoring your symptoms and maintain open communication with your healthcare providers. If your symptoms persist or worsen, seeking a second opinion or further evaluation may be warranted. Managing stress, maintaining a healthy lifestyle, and keeping track of your menstrual patterns can also be beneficial as you navigate this challenging situation. Remember, you are not alone in this, and there are effective treatments available to help manage abnormal uterine bleeding.

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