Abnormal Uterine Bleeding: Causes and Concerns for Women

What is wrong with me?

From September to November, I experienced seven episodes of abnormal bleeding (I am unsure which one was a normal menstrual cycle).
On November 11, I underwent a transvaginal ultrasound, during which the doctor informed me that there were no follicles in either ovary and that the endometrial thickness was 4.5 millimeters.
The doctor indicated that this endometrial condition might be the cause of the seven episodes of bleeding from September to November.
On November 11, the doctor administered progesterone, and I had light bleeding for three days until the 25th, when I bled again.
This time, the volume of blood was similar to that of a normal menstrual cycle, and I also experienced dull pain in my lower abdomen.

Given that the doctor did not observe any follicles on November 11, is it possible to ovulate on November 12? Is this episode of bleeding considered abnormal or a normal menstrual cycle? The doctor advised that if the bleeding lasts for five days without stopping, I should undergo a dilation and curettage (D&C) procedure for further evaluation.
Could this indicate endometrial hyperplasia? What is the likelihood of malignant tumors, or is it more likely to be purely a hormonal imbalance?

Wo shi Hong Hai, 40~49 year old female. Ask Date: 2014/11/27

Dr. Lin Wenbin reply Obstetrics and Gynecology

The absence of visible follicles in the ovaries does not necessarily indicate that ovulation has occurred; it may also suggest that no follicles have matured.
Abnormal growth of the endometrium can lead to menstrual irregularities.
The initial treatment approach is to use progesterone to see if it can induce normal bleeding.
If normal shedding of the endometrium is still not achieved, a dilation and curettage (D&C) procedure may need to be considered.
Based on your description, it is not possible to determine whether this is endometrial hyperplasia, hormonal imbalance, or a malignant tumor.
A pathological examination is required for a definitive diagnosis.

Reply Date: 2014/11/27

More Info

Abnormal uterine bleeding (AUB) is a common concern among women and can arise from a variety of causes, ranging from hormonal imbalances to structural abnormalities in the reproductive system. Your situation, characterized by multiple episodes of abnormal bleeding over a short period, raises several important questions regarding the underlying causes and potential implications for your health.

Firstly, it is essential to understand that AUB can be classified into several categories based on the underlying causes. These include hormonal imbalances, structural issues (such as polyps or fibroids), and systemic conditions (like thyroid disorders or clotting disorders). In your case, the absence of ovarian follicles during the ultrasound suggests that ovulation may not have occurred, which can lead to hormonal fluctuations that contribute to irregular bleeding.

The thickness of the endometrial lining (4.5 mm, as noted in your ultrasound) is also a critical factor. A normal endometrial thickness varies throughout the menstrual cycle, typically ranging from 2-4 mm in the early follicular phase to 8-14 mm in the luteal phase. An endometrial thickness of 4.5 mm could indicate that your body is in a transitional phase, possibly due to hormonal dysregulation. This could explain the irregular bleeding episodes you have experienced.

Regarding your question about ovulation, it is unlikely that you would ovulate on November 12 if there were no visible follicles on November 11. Ovulation typically occurs when a mature follicle releases an egg, and without the presence of follicles, ovulation is improbable. Therefore, the bleeding you experienced on November 25 could be attributed to either a continuation of abnormal bleeding or a new menstrual cycle, depending on the hormonal status of your body at that time.

The concern about endometrial hyperplasia (thickening of the endometrium) is valid, especially given your history of irregular bleeding. Hyperplasia can occur due to prolonged estrogen exposure without adequate progesterone to counterbalance its effects. This condition can lead to abnormal bleeding and, in some cases, may increase the risk of endometrial cancer. However, the risk of malignancy largely depends on the presence of atypical cells, which can only be determined through a biopsy.

Your doctor’s recommendation for a dilation and curettage (D&C) procedure is a common approach to obtain tissue samples from the endometrium for further evaluation. This procedure can help rule out hyperplasia or malignancy and provide clarity on the underlying cause of your bleeding. It is essential to follow through with this recommendation, especially given the frequency and nature of your bleeding episodes.

In summary, while hormonal imbalances are a likely cause of your abnormal uterine bleeding, it is crucial to rule out structural abnormalities and potential hyperplasia through appropriate diagnostic measures. The risk of malignancy cannot be dismissed without further investigation, and a D&C can provide valuable information to guide your treatment options. It is also advisable to maintain open communication with your healthcare provider about your symptoms and any concerns you may have, as this will facilitate a more tailored approach to your care.

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