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Menstruation continuous bleeding: Menorrhagia (heavy menstrual bleeding) – Symptoms and causes

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Abnormal Uterine Bleeding: Causes, Diagnosis & Treatment

Overview

Abnormal uterine bleeding is when you bleed between your monthly periods or when your periods are extremely heavy and/or prolonged.

What is abnormal uterine bleeding (menometrorrhagia)?

Abnormal uterine bleeding (formerly called menometrorrhagia) is when you bleed between your monthly periods or when your periods are extremely heavy and/or prolonged. Normal menstrual flow typically lasts about five days and occurs every 21 to 35 days.

Your provider should know about any abnormal bleeding you’re experiencing. What’s causing your bleeding may be harmless. But your bleeding may be a sign of cancer or conditions that may negatively impact your fertility.

What is the difference between menorrhagia and menometrorrhagia?

Menometrorrhagia was once an umbrella term for two different conditions that sound nearly the same:

  • Menorrhagia: excessive and/or prolonged menstruation.
  • Metrorrhagia: excessive, prolonged and/or irregular bleeding unrelated to menstruation.

In 2011, the International Federation of Gynecology and Obstetrics (FIGO) changed the names to prevent confusion. Menorrhagia is now called heavy menstrual bleeding. Menometrorrhagia is now called abnormal uterine bleeding.

Who does it affect?

The term “abnormal uterine bleeding” primarily describes bleeding in non-pregnant people in their reproductive years. But this doesn’t mean that irregular bleeding won’t affect you if you’re post-menopausal or pregnant.

If you’re bleeding and have experienced menopause, contact your provider. Bleeding after menopause is never normal. Blood may be red, pink, brown or even rust-like in appearance.

You should also contact your provider if you’re bleeding during pregnancy. Some causes are harmless, but others require medical attention, especially if the bleeding happens late in your pregnancy.

How common is abnormal uterine bleeding?

Not everyone who experiences abnormal uterine bleeding reports their symptoms. As a result, 10% to 35% of women worldwide may have abnormal uterine bleeding. But the numbers may be higher. It’s most common during menarche (when menstruation begins) and perimenopause (the years leading up to menopause).

Hormone imbalances are often to blame for abnormal uterine bleeding. They’re most common among people whose periods are just beginning or near ending.

Symptoms and Causes

What are the signs and symptoms of abnormal uterine bleeding?

The signs of abnormal uterine bleeding can vary. Some signs that your bleeding may be abnormal include:

  • Heavy menstrual bleeding (formerly called menorrhagia).
  • Bleeding at unusual times (between periods, after intercourse).
  • Unusually long periods (seven days or longer).
  • Inconsistent menstrual cycles.

What causes abnormal uterine bleeding?

Abnormal uterine bleeding can have many causes, including a variety of medical conditions and even stress:

Hormone imbalances

Weighing more than your ideal body weight can lead to hormone imbalances that may cause abnormal uterine bleeding, too.

Structural abnormalities in your uterus
Precancer and cancer
Infections
Other medical conditions
Medications
Retained foreign bodies and trauma

Forgetting to remove an IUD can lead to infection and abnormal bleeding. Trauma to your uterus, caused by an injury, can also cause bleeding.

Diagnosis and Tests

How is abnormal uterine bleeding diagnosed?

Your healthcare provider will ask you several questions when working to diagnose abnormal uterine bleeding. These questions may include:

  • What brings on the bleeding?
  • What other symptoms are you experiencing?
  • Are you pregnant?

Your healthcare provider will then do a physical exam, including:

  • A pelvic exam.
  • A cervical exam.
  • A Pap smear (Pap test).

What tests will be done to diagnose this condition?

Your healthcare provider may order several tests or procedures when diagnosing abnormal uterine bleeding. These tests may include:

  • A pregnancy test. A miscarriage causes heavy bleeding. You can test positive on a pregnancy test up to 35 days after a miscarriage. Light bleeding is also common in the early stages of pregnancy.
  • Blood tests. Your provider can check how your blood clots and do a complete blood count.
  • A thyroid test. Problems with your thyroid function may be a sign that there is also a problem with your ovary function that could be causing your bleeding.
  • Hormone levels test. Hormone imbalances may be causing your abnormal bleeding, or they may be a sign of a condition causing your bleeding.
  • A hysteroscopic exam of your uterus lining (endometrium). This test checks for fibroids, polyps or signs of cancer.
  • A pelvic ultrasound. Imaging allows your provider to check for any growths in your reproductive organs that may be causing your bleeding. A sonohysterogram, also called saline-infusion sonography, is a highly sensitive imaging procedure that can help your provider identify abnormal structures in your uterus, like polpys or fibroids.
  • A biopsy of your endometrium. Your provider can collect tissue samples from your uterus lining and check for signs of cancer or pre-cancer cells.

Management and Treatment

How is abnormal uterine bleeding treated?

Your treatment depends on what’s causing your bleeding. Medications and surgical options are available to manage your bleeding or treat what’s causing it.

Medications

Medications used to treat abnormal uterine bleeding include:

  • Birth control pills.
  • Progestin (can be given by a shot, implant or device placed in your uterus called an IUD).
  • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil®, Motrin®).
  • Gonadotropin-releasing hormone (GnRH) agonists can temporarily stop or reduce bleeding by preventing ovulation.
  • Gonadotropin-releasing hormone (GnRH) antagonists (elagolix®) can manage heavy period bleeding related to fibroids.
Surgery

There are several procedures available to treat abnormal uterine bleeding. Ask your provider about how often they perform a given procedure. Seeing a provider who frequently performs a procedure often leads to faster recovery with fewer complications.

  • Hysteroscopy. A procedure where your provider removes atypical structures in your uterus, like fibroids and polyps.
  • Uterine artery embolization. Stops blood flow to fibroids, causing them to shrink.
  • Myomectomy. Removes fibroids while keeping your uterus intact and preserving your ability to get pregnant and have children.
  • Endometrial ablation. Destroys your uterus lining through the use of a laser, heat, electricity, microwave energy or freezing. You shouldn’t have this procedure if you want to get pregnant and have children.
  • Hysterectomy. Removes your uterus. Hysterectomy is often used to treat cancer or cancerous changes in your endometrium. Advanced stages of cancer may need radiation or chemotherapy.

Prevention

How can I reduce my risk?

You can’t prevent many causes of abnormal uterine bleeding. But you can reduce your risk of certain conditions that lead to abnormal bleeding. For instance, maintaining a healthy weight plays a potential role in keeping your hormones balanced. Avoiding diets that contain a high amount of animal fat can reduce your risk of some cancers. Practicing safer sex can reduce your risk of certain sexually transmitted infections (STIs) that can cause abnormal uterine bleeding.

Outlook / Prognosis

What can I expect if I have this condition?

Your process for diagnosis and your options for treatment depend on what’s causing your bleeding. When making a diagnosis, your provider will consider multiple factors, including your age, symptoms, and risk factors for certain conditions that cause abnormal bleeding.

Your provider can individualize your care path – including diagnostic options and treatment — based on your physical exam and medical history.

Living With

When should I see my healthcare provider?

Schedule an appointment with your provider if you’re noticing abnormal uterine bleeding so that they can address the underlying cause.

Symptoms to watch out for include:

  • Passing blood clots that are the size of a quarter or larger.
  • Changing menstrual products less than every two hours.
  • Bleeding in between periods or for longer than a week.
  • Symptoms of anemia, like feeling fatigued, weak, or short of breath.
  • Symptoms of pica, which include hair loss, pale skin and the urge to eat non-food items (paper, hair, dirt, etc.)

If abnormal bleeding interferes with your quality of life, see your provider. You shouldn’t have to double up on menstrual products to manage your blood flow. You shouldn’t have to skip activities you enjoy or avoid going out in public because of heavy or unpredictable bleeding.

What questions should I ask my provider?

  • Do I have heavy menstrual bleeding?
  • Does my blood loss put me at risk for developing other health conditions?
  • Am I bleeding so much that I’m at risk of developing anemia?
  • What are the pros and cons of the treatment options available to me?
  • What are the best treatment options available if I wish to get pregnant in the future?
  • Will you administer my treatment alone, or will it involve a care team?
  • What surgical experience do you have in treating abnormal uterine bleeding? Is this a routine part of your practice?

A note from Cleveland Clinic

You’re the best judge of what’s normal for you — how long your periods usually last and how heavy your bleeding is. If your periods are especially heavy or lasting longer than usual, or if you’re bleeding outside your menstrual cycle, speak to your provider. You should never suffer in silence or be embarrassed. Many non-invasive treatment options are available to you that can provide relief from your bleeding.

Bleeding disorders | Office on Women’s Health

What types of bleeding disorders affect women?

Bleeding disorders in women and girls are often inherited, meaning the disorders run in families. Sometimes bleeding disorders happen when a girl or woman does not have any family history of a bleeding disorder. Women can also develop bleeding disorders as a side effect of certain medicines or from other health problems.

Von Willebrand disease (VWD)

VWD is the most common inherited bleeding disorder in women in the United States.3 Your blood contains a protein called von Willebrand factor. People with VWD either don’t have enough von Willebrand factor or it doesn’t work correctly. This can lead to heavy bleeding that can be difficult to stop. Women with VWD may have:4,5

  • Unusually heavy and long menstrual periods (this is the most common symptom)
  • Nosebleeds that are difficult to stop or happen often
  • Bleeding gums
  • Blood in stool or urine
  • Bleeding too much or for a long time after an injury, surgery, or dental work
  • Easy bruising
  • Heavy or prolonged bleeding during or after childbirth

Hemophilia

Hemophilia is another type of bleeding disorder that is well-known but rare. Hemophilia usually runs in families. Hemophilia affects both women and men, but most children born with hemophilia are male. Women can be carriers of hemophilia, meaning they have one active gene for hemophilia and one inactive gene for hemophilia. Women who are carriers of hemophilia can pass either the inactive or active hemophilia gene on to their children. Some women who are carriers have a mild or less serious form of hemophilia and are at risk for heavy bleeding and bleeding with pregnancy or after childbirth. If you have heavy bleeding, your doctor or nurse may test you for hemophilia.  

Learn about other types of common bleeding disorders.

Evaluation and Management of Abnormal Uterine Bleeding in Premenopausal Women

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Heavy, intermenstrual or irregular bleeding – Menomonie


Heavy, intermenstrual or irregular bleeding

Heavy or irregular vaginal bleeding is not just something you have to live with. For some, vaginal bleeding is minor and tolerable; for others, it is annoying and even debilitating. Heavy or Irregular vaginal bleeding can be an indication of a medical problem. There are many treatment options that can help improve your quality of life.

What’s normal?
Normal menstruation typically occurs every 21 to 35 days and lasts for seven or less days. There is a large range of what can be considered a normal menstrual cycle. It is normal for there to be some variation from cycle to cycle, and a woman’s menstrual cycle often changes over the course of her life. Determining if vaginal bleeding is normal depends on your age and circumstances.

Heavy menstrual bleeding
Heavy menstrual bleeding is when cycles are regular, but bleeding is heavy or prolonged. Bleeding is considered heavy when there is a need to change a pad or tampon every one to two hours because it is completely soaked or if you pass large clots. Bleeding is considered prolonged if it lasts more than eight days.

The most common causes of heavy menstrual bleeding are:

  • Adenomyosis — This happens when the cells that normally line the inner walls of the uterus start invading into the muscles of the uterus. This condition often causes heavy and painful periods.
  • Bleeding disorder — This is a condition that affects the way blood normally clots. A bleeding disorder is likely if heavy or prolonged menses began at menarche; if there is family history of bleeding issues; if there are signs of a bleeding problem, such as easy bruising; or if taking medications that can prevent normal clotting.
  • Fibroids — A fibroid is an abnormal growth of the muscles of the uterus. Approximately 80 percent of women will have fibroids during their lifetime, although not all of these women have bothersome fibroid symptoms.

Intermenstrual bleeding
Intermenstrual bleeding refers to vaginal bleeding at any time during the menstrual cycle other than during normal menstruation.

The most common causes of intermenstrual bleeding include:

  • Cancer or precancer — A cancer or a precancerous growth on the uterus or cervix can cause intermenstrual bleeding. This is more likely if a woman had previous abnormal pap smears or if there are other risk factors, such as obesity, family history of uterine cancer or bleeding that has been going on for a long time without evaluation.
  • Cesarean scar defect — Two-thirds of women who have had one or, in particular, multiple cesarean births may have a cesarean scar defect, and approximately one-third of women with this condition experience bleeding that starts just after the end of their regular menstruation.
  • Contraceptives — Many contraceptive methods used can cause intermenstrual and irregular bleeding, especially in the first few months after starting the method.
  • Pelvic infections — Intermenstrual bleeding can be a sign of an infection in the uterus or on the cervix. Women who have infection usually experience pelvic pain or increased vaginal discharge in addition to the bleeding. Pelvic infections are more common in women who are exposed to sexually transmitted infections or in women who recently had childbirth or a surgery on the uterus or cervix.
  • Polyps — A polyp is an overgrowth of cells around a small blood vessel and can arise inside the uterus or on the cervix.

Irregular bleeding
Irregular bleeding is when a woman goes through phases of no bleeding that may last for two or more months and other phases with either spotting or episodes of heavy bleeding. Irregular bleeding most commonly is related to abnormal ovulation or what is more commonly known as polycystic ovarian syndrome.

What can you do?
Bleeding concerns should be evaluated if it persists for more than a few months to see if there is an underlying medical problem that needs to be addressed. There are many treatment options depending on the cause. If there is an underlying medical problem causing the bleeding, this will be addressed first.

There are special circumstances where irregular bleeding should be treated sooner rather than later to prevent other complications later in life. If you are concerned about bleeding, consult your health care provider immediately.

Menstrual Disorders – HealthyWomen

Overview

What Is It?

Menstrual disorders are a disruptive physical and/or emotional symptoms just before and during menstruation, including heavy bleeding, missed periods and unmanageable mood swings.

Some women get through their monthly periods easily with few or no concerns. Their periods come like clockwork, starting and stopping at nearly the same time every month, causing little more than a minor inconvenience.

However, other women experience a host of physical and/or emotional symptoms just before and during menstruation. From heavy bleeding and missed periods to unmanageable mood swings, these symptoms may disrupt a woman’s life in major ways.

Most menstrual cycle problems have straightforward explanations, and a range of treatment options exist to relieve your symptoms. If your periods feel overwhelming, discuss your symptoms with your health care professional. Once your symptoms are accurately diagnosed, he or she can help you choose the best treatment to make your menstrual cycle tolerable.

How the Menstrual Cycle Works
Your menstrual period is part of your menstrual cycle—a series of changes that occur to parts of your body (your ovaries, uterus, vagina and breasts) every 28 days, on average. Some normal menstrual cycles are a bit longer; some are shorter. The first day of your menstrual period is day one of your menstrual cycle. The average menstrual period lasts about five to seven days. A “normal” menstrual period for you may be different from what’s “normal” for someone else.

Types of Menstrual Disorders
If one or more of the symptoms you experience before or during your period causes a problem, you may have a menstrual cycle “disorder.” These include:

  • abnormal uterine bleeding (AUB), which may include heavy menstrual bleeding, no menstrual bleeding (amenorrhea) or bleeding between periods (irregular menstrual bleeding)
  • dysmenorrhea (painful menstrual periods)
  • premenstrual syndrome (PMS)
  • premenstrual dysphonic disorder (PMDD)

A brief discussion of menstrual disorders follows below.

Heavy menstrual bleeding
One in five women bleed so heavily during their periods that they have to put their normal lives on hold just to deal with the heavy blood flow.

Bleeding is considered heavy if it interferes with normal activities. Blood loss during a normal menstrual period is about 5 tablespoons, but if you have heavy menstrual bleeding, you may bleed as much as 10 to 25 times that amount each month. You may have to change a tampon or pad every hour, for example, instead of three or four times a day.

Heavy menstrual bleeding can be common at various stages of your life—during your teen years when you first begin to menstruate and in your late 40s or early 50s, as you get closer to menopause.

If you are past menopause and experience any vaginal bleeding, discuss your symptoms with your health care professional right away. Any vaginal bleeding after menopause isn’t normal and should be evaluated immediately by a health care professional.

Heavy menstrual bleeding can be caused by:

  • hormonal imbalances
  • structural abnormalities in the uterus, such as polyps or fibroids
  • medical conditions

Many women with heavy menstrual bleeding can blame their condition on hormones. Your body may produce too much or not enough estrogen or progesterone—known as reproductive hormones—necessary to keep your menstrual cycle regular.

For example, many women with heavy menstrual bleeding don’t ovulate regularly. Ovulation, when one of the ovaries releases an egg, occurs around day 14 in a normal menstrual cycle. Changes in hormone levels help trigger ovulation.

Certain medical conditions can cause heavy menstrual bleeding. These include:

  • thyroid problems
  • blood clotting disorders such as Von Willebrand’s disease, a mild-to-moderate bleeding disorder
  • idiopathic thrombocytopenic purpura (ITP), a bleeding disorder characterized by too few platelets in the blood
  • liver or kidney disease
  • leukemia
  • medications, such as anticoagulant drugs such as Plavix (clopidogrel) or heparin and some synthetic hormones.

Other gynecologic conditions that may be responsible for heavy bleeding include:

  • complications from an IUD
  • fibroids
  • miscarriage
  • ectopic pregnancy, which occurs when a fertilized egg begins to grow outside your uterus, typically in your fallopian tubes

Other causes of excessive bleeding include:

  • infections
  • precancerous conditions of the uterine lining cells

Amenorrhea
You may also have experienced the opposite problem of heavy menstrual bleeding—no menstrual periods at all. This condition, called amenorrhea, or the absence of menstruation, is normal before puberty, after menopause and during pregnancy. If you don’t have a monthly period and don’t fit into one of these categories, then you need to discuss your condition with your health care professional.

There are two kinds of amenorrhea: primary and secondary.

  • Primary amenorrhea is diagnosed if you turn 16 and haven’t menstruated. It’s usually caused by some problem in your endocrine system, which regulates your hormones. Sometimes this results from low body weight associated with eating disorders, excessive exercise or medications. This medical condition can be caused by a number of other things, such as a problem with your ovaries or an area of your brain called the hypothalamus or genetic abnormalities. Delayed maturing of your pituitary gland is the most common reason, but you should be checked for any other possible reasons.
  • Secondary amenorrheais diagnosed if you had regular periods, but they suddenly stop for three months or longer. It can be caused by problems that affect estrogen levels, including stress, weight loss, exercise or illness.

Additionally, problems affecting the pituitary gland (such as elevated levels of the hormone prolactin) or thyroid (including hyperthyroidism or hypothyroidism) may cause secondary amenorrhea. This condition can also occur if you’ve had an ovarian cyst or had your ovaries surgically removed.

Severe menstrual cramps (dysmenorrhea)
Most women have experienced menstrual cramps before or during their period at some point in their lives. For some, it’s part of the regular monthly routine. But if your cramps are especially painful and persistent, this is called dysmenorrhea, and you should consult your health care professional.

Pain from menstrual cramps is caused by uterine contractions, triggered by prostaglandins, hormone-like substances that are produced by the uterine lining cells and circulate in your bloodstream. If you have severe menstrual pain, you might also find you have some diarrhea or an occasional feeling of faintness where you suddenly become pale and sweaty. That’s because prostaglandins speed up contractions in your intestines, resulting in diarrhea, and lower your blood pressure by relaxing blood vessels, leading to lightheadedness.

Premenstrual syndrome (PMS)
PMS is a term commonly used to describe a wide variety of physical and psychological symptoms associated with the menstrual cycle. About 30 to 40 percent of women experience symptoms severe enough to disrupt their lifestyles. PMS symptoms are more severe and disruptive than the typical mild premenstrual symptoms that as many as 75 percent of all women experience.

There are more than 150 documented symptoms of PMS, the most common of which is depression. Symptoms typically develop about five to seven days before your period and disappear once your period begins or soon after.

Physical symptoms associated with PMS include:

  • bloating
  • swollen, painful breasts
  • fatigue
  • constipation
  • headaches
  • clumsiness

Emotional symptoms associated with PMS include:

  • anger
  • anxiety or confusion
  • mood swings and tension
  • crying and depression
  • inability to concentrate

PMS appears to be caused by rising and falling levels of the hormones estrogen and progesterone, which may influence brain chemicals, including serotonin, a substance that has a strong affect on mood. It’s not clear why some women develop PMS or PMDD and others do not, but researchers suspect that some women are more sensitive than others to changes in hormone levels.

PMS differs from other menstrual cycle symptoms because symptoms:

  • tend to increase in severity as the cycle progresses
  • are relieved when menstrual flow begins or shortly after
  • are present for at least three consecutive menstrual cycles

Symptoms of PMS may increase in severity following each pregnancy and may worsen with age until they stop at menopause. If you experience PMS, you may have an increased sensitivity to alcohol at specific times during your cycle. Women with this condition often have a sister or mother who also suffers from PMS, suggesting a genetic component exists for the disorder.

Premenstrual Dysphoric Disorder (PMDD)
Premenstrual dysphoric disorder is far more severe than the typical PMS. Women who experience PMDD (about 3 to 8 percent of all women) say it significantly interferes with their lives. Experts equate the difference between PMS and PMDD to the difference between a mild tension headache and a migraine.

The most common symptoms of PMDD are heightened irritability, anxiety and mood swings. Women who have a history of major depression, postpartum depression or mood disorders are at higher risk for PMDD than other women. Although some symptoms of PMDD and major depression overlap, they are different:

  • PMDD-related symptoms (both emotional and physical) are cyclical. When a woman starts her period, the symptoms subside within a few days.
  • Depression-related symptoms, however, are not associated with the menstrual cycle. Without treatment, depressive mood disorders can persist for weeks, months or years. If depression persists, you should consider seeking help from a trained therapist.

Diagnosis

To help diagnose menstrual disorders, you should schedule an appointment with your health care professional. To prepare, keep a record of the frequency and duration of your periods. Also jot down any additional symptoms, such as cramping, and be prepared to discuss health history. Here is how your health care professional will help you specifically diagnose abnormal uterine bleeding, dysmenorrhea, PMS and PMDD:

Heavy menstrual bleeding

To diagnose heavy menstrual bleeding—also called menorrhagia—your health care professional will conduct a full medical examination to see if your condition is related to an underlying medical problem. This could be structural, such as fibroids, or hormonal. The examination involves a series of tests. These may include:

  • Ultrasound. High-frequency sound waves are reflected off pelvic structures to provide an image. Your uterus may be filled with a saline solution to perform this procedure, called a sonohysterography. No anesthesia is necessary.
  • Endometrial biopsy. A scraping method is used to remove some tissue from the lining of your uterus. The tissue is analyzed under a microscope to identify any possible problem, including cancer.
  • Hysteroscopy. In this diagnostic procedure, your health care professional looks into your uterine cavity through a miniature telescope-like instrument called a hysteroscope. Local, or sometimes general, anesthesia is used, and the procedure can be performed in the hospital or in a doctor’s office.
  • Dilation and curettage (D&C). During a D&C, your cervix is dilated and instruments are used to scrape away your uterine lining. A D&C may also be used as a treatment for excessive bleeding and for bleeding that doesn’t respond to other treatments. It is performed on an outpatient basis under local anesthesia.

You can also expect blood tests to check your blood count for anemia and a urine test to see if you’re pregnant, as well as other laboratory tests.

The more information you can give your health care professional, the better. Take notes on the dates and length of your periods. You can do this by marking your calendar or appointment book. You might also be asked to keep a daily track record of your temperature to determine when you are ovulating. Ovulation kits, that use a morning urine sample, are available without a prescription and are easy to use.

During your initial evaluation with your health care professional, you should also discuss the following:

  • current medications
  • details about menstrual flow and cycle length
  • any gynecologic surgery or gynecologic disorders
  • sexual activity and history of sexually transmitted diseases
  • contraceptive use and history
  • family history of fibroids or other conditions associated with AUB
  • history of a breast discharge
  • blood clotting disorders—either your own or in family members.

PMS and PMDD

There are no specific diagnostic tests for PMS and PMDD. You’ll probably be asked to keep track of your symptoms and write them down. A premenstrual symptom checklist is one of the most common methods currently used to evaluate symptoms. With this tool, you can track the type and severity of symptoms to help identify a pattern.

Generally PMS and PMDD symptoms:

  • tend to increase in severity as the menstrual cycle progresses.
  • tend to be relieved when menstrual flow begins or soon afterward.
  • are present for at least three consecutive menstrual cycles.

Treatment

Treatments for menstrual disorders range from over-the-counter medications to surgery, with a variety of options in between. Your treatment options will depend on your diagnosis, its severity, which treatment you prefer, your health history and your health care professional’s recommendation.

Abnormal uterine bleeding

Medication and surgery are used to treat AUB. Typically, less invasive therapies should be considered first. Treatment choices depend on your age, your desire to preserve fertility and the cause of the abnormal bleeding (dysfunctional or structural). Some treatments may reduce your menstrual bleeding to a light to normal flow.

Medication

Medication therapy is often successful and a good first option. The benefits last only as long as the medication is taken, so if you choose this route, you should know that medical treatment is a long-term commitment.

Low-dose birth control pills, progestins and nonsteroidal anti-inflammatory drugs (NSAIDs) may help control heavy or irregular bleeding caused by hormonal imbalances. If your periods have stopped, oral contraceptives and contraceptive patches are highly effective in restoring regular bleeding, although they will not correct the reason you stopped bleeding. Both can also help reduce menstrual flow, improve and control menstrual patterns and relieve pelvic pain during menstruation.

They are considered for PMS treatment if your symptoms are mostly physical, but may not be effective if your primary symptom is mood changes. However, a newer brand of oral contraceptive containing a form of progesterone called drospirenone and marketed under the names YAZ, Yasmin, Ocella, Gianvi and Zarah, may reduce some mood-related symptoms such as anxiety, irritability, tearfulness and tension. And Yaz is FDA-approved for the treatment of PMDD.

Natazia, which contains the synthetic estrogen estradiol valerate, is the first birth control pill FDA-approved for treatment of heavy menstrual bleeding that is not caused by a condition of the uterus. The combination estrogen-progesterone pill may help women who choose oral contraceptives for contraception and do not have risk factors that may make using hormonal birth control inadvisable.

Birth control pills may not be an appropriate treatment choice if you smoke, have a history of pulmonary embolism (blood clots in your lungs) or have bothersome side effects from this medication. The risk of these side effects is even higher if you use the birth control patch, because it contains higher levels of estrogen.

Progestins, either oral or injectable, are also used to manage heavy bleeding, particularly that resulting from a lack of ovulation. Although they don’t work as well as estrogen, they are effective for long-term management. Side effects include irregular menstrual bleeding, weight gain and, sometimes, mood changes.

The levonorgestrel intrauterine system (Mirena) is FDA-approved to treat heavy menstrual bleeding in women who use intrauterine contraception as their method of birth control prevention. The Mirena system may be kept in place for up to five years. Over this time, it slowly releases a low dose of the progestin hormone levonorgestrel into the uterus. Mirena is also referred to as an intrauterine device, or IUD.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are available over the counter and with a prescription and can help reduce menstrual bleeding and cramping. These medications include ibuprofen (Advil, Motrin) and naproxen (Aleve). Mefenamic acid (Ponstel) is a prescription-only NSAID. Common side effects include stomach upset, headaches, dizziness and drowsiness.

Tranexamic acid (Lysteda), although new to the United States, has been used successfully to decrease heavy menstrual bleeding in other countries for many years. These tablets are only taken on the days you expect to have heavy bleeding.

Surgery

Except for hysterectomy, surgical options for heavy bleeding preserve the uterus, destroying just the uterine lining. However, most of these procedures result in the loss of fertility, ending your ability to have children.

There are other important considerations for each of these treatment options. Risks common to all surgical options include infection, hemorrhage and other complications.

Menstrual cramps

If you are experiencing severe menstrual cramps (called dysmenorrhea) regularly, your health care professional might suggest you try over-the-counter and prescription medications and exercise, among other strategies.

Medications such as nonsteroidal anti-inflammatories (NSAIDs), like ibuprofen and naproxen, can be purchased without a prescription. Treatment works best if started hours before the onset of cramping. If you wait until you have pain, it doesn’t work as well. This will also help reduce heavy bleeding.

Oral contraceptive pills are also effective for menstrual cramps. If active pills are taken continuously for 90 to 120 days in a row, periods will only occur three to four times a year.

Other ways to relieve symptoms include putting heat on your abdominal area and mild exercise.

PMS and PMDD

To help manage PMS symptoms, try exercise and dietary changes suggested here and ask your health care professional for other options. If you suffer from PMDD, however, don’t try to treat on your own; make sure you talk to your health care professional.

Dietary options for PMS include:

  • Cutting back on alcohol, caffeine, nicotine, salt and refined sugar, which can make PMS and PMDD symptoms worse.
  • Increasing the calcium in your diet from sources such as low-fat dairy products, soy products, dark greens such as turnip greens and calcium-fortified orange juice. Increased calcium may help relieve some menstrual cycle symptoms.
  • Increasing the amount of complex carbohydrates in your diet; these include fruits, vegetables, grains and beans.

Exercise is another good way to relieve menstrual cycle symptoms. You will get the greatest benefits from exercise if you do it for at least 30 minutes, five days a week. But even taking a 20- to 30-minute walk three times a week can:

  • Increase brain chemicals that give you more energy and improve mood.
  • Decrease stress and anxiety.
  • Improve deep sleep at night.

Other medical therapies your health care professional might suggest include:

  • Low doses of antidepressants such as paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa) and fluoxetine (Prozac). These are prescribed because they are effective in regulating the brain compound serotonin, which is related to PMS. Often these can be taken just during the times of expected symptoms.
  • GnRH agonists (Lupron), sometimes in combination with estrogen or estrogen-progestin hormone therapy, for short-term treatment (less than six months). This treatment is used for very severe symptoms since it has numerous side effects, including hot flashes, headaches and vaginal dryness.
  • Oral contraceptives that contain a progesterone called drospirenone may help reduce some mood-related PMS symptoms, such as irritability, anxiety, tearfulness and tension.
  • Diuretic medications, such as spironolactone (Aldactone) to help with water weight gain and bloating.

There’s evidence that some nutritional supplements such as calcium, magnesium and vitamin B-6 may help ease symptoms of PMS. Discuss these and other strategies with your health care professional before taking any dietary supplement.

Prevention

You cannot prevent abnormal uterine bleeding, but you can manage it once it develops.

Women who experience chronic ovulation problems—failure to ovulate—can regulate their bleeding by continuing to take oral contraceptives.

For other menstrual cycle-related problems, such as cramping or premenstrual syndrome, you can take steps to prevent or minimize your discomfort and pain as described in the Treatment section of this entry.

Additionally, changing your diet, exercising and adopting a regular sleep pattern can all help with PMS and PMDD symptoms. Specifically, try:

  • Changing your diet by reducing refined sugars, salt, nicotine, caffeine and alcohol, which can aggravate PMS symptoms
  • Exercising at least 20 to 30 minutes three times a week, ideally for at least 30 minutes, five days a week
  • Sleeping consistent hours and establishing a bedtime routine to help cue your body and mind for sleeping
  • Keeping a premenstrual symptom checklist to be prepared for highs and lows

For PMDD, antidepressants or anti-anxiety medications, particularly a type called selective serotonin reuptake inhibitors (SSRIs), can help prevent disruptive symptoms. It may not be necessary to take an SSRI every day; taking the medication only during your luteal phase (starting 14 days before your next period) may be sufficient.

Facts to Know

  1. Abnormal uterine bleeding (AUB) includes menorrhagia (heavy menstrual bleeding), metrorrhagia (bleeding in between menses) and hypermenorrhea (menses too long). Abnormal uterine bleeding also includes amenorrhea or absence of menstrual periods.
  2. Abnormal uterine bleeding can occur at any age, but it is more likely to occur at certain times in a woman’s life. For instance, before menopause, your periods may suddenly become lighter or heavier because you are ovulating less often. If you have just begun to menstruate, you may also experience AUB.
  3. Sometimes abnormal bleeding is caused by hormonal problems. A significant number of women with excessive menstrual bleeding fall into this category. Hormonal imbalances occur when your body produces too much or not enough of certain hormones.
  4. Aside from hormonal problems, there are many other causes of abnormal uterine bleeding. They include:• certain birth control methods, such as the copper-T intrauterine device (IUD) and birth control pills
    • infection of the uterus or cervix
    • uterine fibroids
    • blood clotting problems
    • some types of cancer, including uterine, cervical and vaginal
    • chronic medical problems, such as hypo- and hyperthyroidism, liver disease, kidney disease and diabetes
  5. Hysterectomy is the only treatment that completely guarantees heavy menstrual bleeding will end permanently. However, this is a radical surgery where your uterus is removed and you will no longer be able to have children.
  6. Some premenopausal women don’t have periods at all. Called amenorrhea, or the absence of menstruation, this condition is normal before puberty, after menopause and during pregnancy. There are two kinds of amenorrhea: primary and secondary. Primary amenorrhea is diagnosed if you reach the age of 16 and haven’t yet begun to menstruate. Secondary amenorrhea is diagnosed if you’ve had regular periods, but they suddenly stop for more than three to six months.
  7. Pain from menstrual cramps is caused by contractions of your uterus triggered by prostaglandins, hormone-like substances found in many types of tissue.
  8. Both medication and surgery can be used to treat AUB. Typically, less invasive therapies should be considered first. Treatment depends on your age, desire to preserve fertility and the cause of the bleeding.
  9. Premenstrual syndrome (PMS) is a term commonly used to describe a range of severe physical and psychological symptoms that some women experience about five to seven days prior to the start of their periods and end just after. To qualify as PMS symptoms, they must be associated with the menstrual cycle, become more severe as the menstrual cycle progresses and be present for at least three consecutive menstrual cycles.
  10. Premenstrual dysphoric disorder (PMDD) is different from the more common PMS; it’s far more severe. Women who experience PMDD (about 3 to 8 percent of all women) say that it significantly interferes with their lives. The most common symptoms of PMDD are heightened irritability, anxiety and mood swings. Women who have a history of major depression, postpartum depression or mood disorders are at higher risk for PMDD than other women.

Questions to Ask

Review the following Questions to Ask about menstrual disorders so you’re prepared to discuss this important health issue with your health care professional.

  1. Once you’ve diagnosed my condition, can we try treatment with medications before trying any surgical procedures? If you are recommending a surgical treatment, why haven’t we considered a less invasive route first?
  2. What are the advantages, disadvantages and risks connected with the treatment option you are suggesting to control or end my abnormal uterine bleeding (AUB)?
  3. Do any of the recommended diagnostic procedures hurt?
  4. If I have a problem that’s causing my AUB, such as uterine fibroids, polyps or scar tissue, can it be successfully treated without a hysterectomy?
  5. If you are recommending any surgical procedure, how many of these procedures have you performed? How many in situations like mine? Have you had any complications with this procedure? If you haven’t done many, can you refer me to someone who has, if you think this is the best course of treatment?
  6. What can I do to relieve my menstrual cramps and PMS symptoms?

Key Q&A

  1. How is abnormal uterine bleeding (AUB) defined? Is my condition serious enough to be considered AUB?
    Abnormal uterine bleeding refers to menstrual periods that are abnormally heavy, prolonged or both. The term may also refer to bleeding between periods or absent periods.
  2. I used to have regular periods, and they’ve suddenly disappeared over the past few months. Is this something to be concerned about?
    This condition, called secondary amenorrhea, can be caused by problems that affect estrogen levels, including stress, weight loss, exercise or illness. Also you may experience secondary amenorrhea because of problems affecting the pituitary, thyroid or adrenal gland. This condition can also occur if you’ve had ovarian cysts or have had your ovaries surgically removed. You should consult with a health care professional to determine what is causing you to skip periods.
  3. Is there a certain age group of women who are more likely to have problems with AUB?
    Abnormal uterine bleeding can occur at any age, but it is more likely to occur at certain times in a woman’s life. For instance, for a few years before menopause, your periods may suddenly become lighter or heavier because you are ovulating less often. If you have just begun to menstruate, you may also experience AUB.
  4. Can AUB be a problem for me if I’ve already gone through menopause?
    If you are post-menopausal, any uterine bleeding is considered abnormal and should be evaluated by a health care professional as soon as possible.
  5. Aside from excessive or lengthy bleeding, what other problems can be described as AUB?
    Other types of AUB could include:
    • absence of periods (no bleeding)
    • bleeding between regular periods
    • spotting
  6. What are my treatment options for AUB?
    Generally, both medications and surgery are options. Typically, less invasive therapies should be considered first. Treatment choices depend on your age, your desire to preserve fertility and the cause of the bleeding (dysfunctional or structural).
  7. Is PMS (premenstrual syndrome) a problem I have to learn to live with every month or is there anything I can do to relieve my symptoms?
    PMS is not a disease but a collection of symptoms. Still, there are many things you can try to alleviate your pain, discomfort and emotional distress. They include dietary changes, exercise and medication options . Ask your health care professional for more information.

Lifestyle Tips

  1. No periods? Find out why.
    If your period is irregular most of the time, or if you’ve never had a period, see a health care professional for an evaluation. Amenorrhea—the absence of menstruation—during the childbearing years can be caused by a variety of medical conditions, medications or lifestyle issues. For example, anorexia nervosa, hyperthyroidism and excessive exercise affect the menstrual cycle. A complete medical history and blood tests will be the first steps your health care professional takes to identify the cause of your amenorrhea and develop a treatment plan.
  2. Don’t put up with painful periods.
    If your menstrual periods cause mild to moderate discomfort, relief may be as close as your medicine cabinet. Acetaminophen (Tylenol) often relieves mild menstrual pain. Ibuprofen, naproxen and mefenamic acid (brands such as Motrin IB, Advil, Bayer Select Pain Relief Formula, Midol IB) can relieve moderate to more severe pain. These medications work best when symptoms first begin. If menstrual pain lasts several days, your doctor may prescribe another type of pain reliever. Discuss your symptoms and treatment options with your health care professional.
  3. Relax yourself to ease painful menstruation.
    Next time you get painful menstrual cramps, lie down with a heating pad on your abdomen. Then use your fingertips to lightly massage your belly in a circular motion. Drinking warm, noncaffeinated beverages can help, as can taking a warm shower or performing waist-bending exercises or walking.
  4. Oral contraceptives or contraceptive patches often alleviate menstrual pain.
    If you have menstrual pain, your doctor may offer to put you on an oral contraceptive as a means of treating your discomfort. Unless you wish to stay on the pill for contraception, you can discontinue taking it after six to 12 months. Many women report continued relief from menstrual pain even after they stop taking oral contraceptives.
  5. Call your health care professional about excessive menstrual bleeding.
    If you have one or two periods with heavy or prolonged bleeding, there’s probably no reason to worry. If, however, heavy bleeding (menorrhagia) recurs during three or more consecutive menstrual periods, or if you have bleeding after menopause, or the abnormal bleeding is accompanied by fever or other symptoms, consult your health care professional. Also call your health care professional if the heavy bleeding is accompanied by pain that is not relieved by ibuprofen or acetaminophen. Avoid taking aspirin because it could worsen the bleeding problem.

Organizations and Support

For information and support on coping with Menstrual Disorders, please see the recommended organizations, books and Spanish-language resources listed below.

American Association of Gynecologic Laparoscopists (AAGL)
Website: http://www.aagl.org
Address: 6757 Katella Avenue
Cypress, CA 90630
Hotline: 1-800-554-AAGL (1-800-554-2245)
Phone: 714-503-6200

American College of Obstetricians and Gynecologists (ACOG)
Website: http://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: [email protected]

American Sexual Health Association (ASHA)
Website: http://www.ashasexualhealth.org/
Address: P.O. Box 13827
Research Triangle Park, NC 27709
Phone: 919-361-8400
Email: [email protected]

American Society for Reproductive Medicine (ASRM)
Website: http://www.asrm.org
Address: 1209 Montgomery Highway
Birmingham, AL 35216
Phone: 205-978-5000
Email: [email protected]

National Family Planning and Reproductive Health Association (NFPRHA)
Website: http://www. nfprha.org
Address: 1627 K Street, NW, 12th Floor
Washington, DC 20006
Phone: 202-293-3114
Email: [email protected]

National Institutes of Health (NIH) Office of Research on Women’s Health (ORWH)
Website: http://orwh.od.nih.gov
Address: 6707 Democracy Blvd., Suite 400
Bethesda, MD 20892
Phone: 301-402-1770
Email: [email protected]

PERIOD
Website: https://www.period.org/
Address: 1801 NW Upshur St. Suite 565,
Portland, OR 97209
Email: [email protected]

Planned Parenthood Federation of America
Website: http://www.plannedparenthood.org
Address: 434 West 33rd Street
New York, NY 10001
Hotline: 1-800-230-PLAN (1-800-230-7526)
Phone: 212-541-7800

Society for Menstrual Cycle Research
Website: http://www.menstruationresearch.org
Address: The Gordon and Leslie Diamond Health Care Centre
2775 Laurel Street, Room 4111 – 4th Floor
Vancouver, BC V5Z 1M9
Email: [email protected] ubc.ca

Books

A Gynecologist’s Second Opinion
by William H. Parker and Rachel L. Parker

Break in Your Cycle: The Medical & Emotional Causes & Effects of Amenorrhea
by Theresa Francis-Cheung

Curse: Confronting the Last Unmentionable Taboo: Menstruation
by Karen Houppert

Dr. Susan Love’s Menopause and Hormone Book: Making Informed Choices
by Susan M. Love and Karen Lindsey

Honoring Menstruation: A Time of Self-Renewal
by Lara Owen

Is Menstruation Obsolete?
by Elsimar M. Coutinho and Sheldon J. Segal

Yale Guide to Women’s Reproductive Health: From Menarche to Menopause
by Mary Jane Minkin and Carol V. Wright

Spanish-language resources

US Dept of Health and Human Services

Website: https://espanol.womenshealth.gov/menstrual-cycle
Address: National Women’s Health Information Center (NWHIC)
Hotline: 1-800-994-9662

Medline Plus: Menstrual periods – heavy, prolonged, or irregular
Website: https://medlineplus. gov/spanish/menstruation.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: [email protected]

Spotting vs. Periods: What’s the Difference?

A menstrual cycle can last anywhere from 15 to 45 days, according to research, during which a woman usually has her period for anywhere between three to seven days. 

However, there can be times during a woman’s cycle where she experiences bleeding that isn’t quite a period. It can happen at any time — right before you get your period, mid-cycle or even after period bleeding. We call this spotting, and if you aren’t sure of the difference between this occurrence and your actual period, here’s what you need to know.

What is Spotting?

Spotting can occur at various times throughout your cycle and even when you initially get pregnant. About 20 percent of women experience spotting during the first 12 weeks of their pregnancy, while nearly 5 percent of women experience spotting during the middle of their cycle.

Several things can cause spotting, including stress, an infection, changing your birth control medication, a hormone imbalance, polyps and fibroids, both of which are abnormal, often benign, growths that can develop in a woman’s reproductive system. Pregnancy, breastfeeding, ovulation, transitioning to menopause and even cervical, uterine or ovarian cancer also can cause spotting.

How to Tell the Difference Between Spotting and Your Period

The biggest difference between spotting and your period is the amount of blood. A period can last for several days and require a tampon or pad to control your flow. However, spotting produces much less blood and doesn’t typically require the use of these products. 

When the bleeding occurs, also, is a good indicator of whether it’s your period or spotting. Most women generally have an idea of when their period will come and how long it’ll last, so if you notice bleeding off cycle but it’s not as heavy as your regular period, then it’s likely spotting. The color of the blood also is different. Blood produced during your period often is darker than the blood that appears when you’re spotting.

Another good indicator the bleeding may be due to spotting, is if you don’t have any other menstrual symptoms, like breast tenderness or cramping. If you normally have these symptoms right before your period, but they aren’t present during the time you notice some irregular bleeding, then it’s probably spotting.

Getting Treatment

If you spot bleed on a regular basis, you should schedule an appointment to see your doctor. Your doctor will go over your symptoms and do a physical exam to assess you and likely will do other tests, such as a pelvic exam, a Pap smear, a pregnancy test or a vaginal or abdominal ultrasound to diagnose what is causing the irregular bleeding. Once you get a diagnosis, you could be placed on an antibiotic if the cause is an infection or receive birth control or hormone therapy to regulate your cycle if the issue is a hormone imbalance. If you have polyps or fibroids, your doctor will need to perform surgery to remove these growths.

Every woman’s cycle varies, and you may occasionally experience spotting between periods. However, if this becomes a regular occurrence, there could be an underlying health issue you need to address. If you have irregular bleeding, don’t wait too long to see a doctor. Even if the cause of the spotting turns out to be something minor, getting timely medical treatment and care will help you resolve this issue.

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How I treat heavy menstrual bleeding associated with anticoagulants | Blood

Modification of anticoagulant treatment in the setting of HMB has become more common with the widespread use of DOACs. With warfarin, dose reduction or temporary interruption is not practical. However, DOACs can be transiently withheld because of their short half-life and rapid return to therapeutic levels once they are resumed. Dose reduction and temporary interruption of rivaroxaban have been reported in observational studies.15,20,22  As noted above, recent evidence suggests that a 10-mg dose of rivaroxaban decreased menstrual bleeding without an increased risk of thrombosis when compared with a 20-mg dose of rivaroxaban.19  The effectiveness of a lower-dose DOAC for prevention of recurrent thrombosis in patients who have received at least 6 months of therapy has been demonstrated with apixaban and rivaroxaban.64,65  One observational study reported successful HMB management by switching from rivaroxaban to apixaban in 5 (70%) of 7 women.17  In our practice, we do not temporarily discontinue or reduce the dose of rivaroxaban during the active treatment period (usually within 3 months of acute VTE). In women with HMB who are beyond 3 months from their acute VTE, we advise some patients taking rivaroxaban to reduce their dose to 10 mg during their menstrual period. Use of dabigatran for long-term secondary prevention of VTEs is also reasonable.23  Use of usual doses of apixaban might be an alternative option on the basis of limited evidence.17  Low-dose apixaban (2.5 mg given twice per day) probably attenuates HMB similarly to low-dose rivaroxaban, but evidence supporting this recommendation is lacking. It is important to note that in patients who require extended anticoagulant treatment, there is no evidence to support the use of low-dose rivaroxaban (10 mg orally once per day) or low-dose apixaban (2.5 mg orally twice per day) in combination with estrogen-containing hormonal therapy, DMPA, or tranexamic acid for the treatment of HMB. Whether the reduced-dose DOACs provide sufficient anticoagulant effect to overcome the prothrombotic risk of these therapies remains unknown. At this time, avoiding this combination of treatments seems reasonable.

90,000 Women’s Health and Education Center – Gynecology

Dysfunctional uterine bleeding

WHEC Practice and Clinical Management Principles Bulletin for Healthcare Professionals. Education Grant provided by Women’s Health and Education Center (WHEC).

Dysfunctional uterine bleeding (DUB) is an abnormal bleeding from the uterus to the endometrium that is unrelated to the anatomical lesion of the uterus (GSCH, 1989).It is associated with abnormal ovarian function and anovulation but can occur during ovulatory cycles. Prepubertal or postmenopausal uterine bleeding is a separate entity that requires different diagnostic and therapeutic consideration. Significant differences in menstrual patterns often cause difficulty in identifying abnormal bleeding. In practice, any bleeding that is excessive in duration, frequency, or amount for a particular patient should be considered abnormal and investigated accordingly.

The purpose of this document is to provide guidelines for the treatment of patients with menstrual irregularities associated with anovulation based on the best available evidence. Uterine bleeding of the dysfunctional anovulatory type is the most common form of non-cyclic uterine bleeding, and it is a condition for which women often seek gynecological care and account for significant patient anxiety and discomfort. The choice of regimen for anovulatory bleeding depends on several factors, including the woman’s age, her bleeding severity, and her desire for fertility.Over the past decades, significant advances have been made in evaluating and managing women with anovulatory bleeding.

Normal menstrual cycle:

Ovulatory normal cycle is a consequence of endocrine interactions of the hypothalamus-pituitary-ovary axis. In addition, in case of menstruation occurs as a result of a sudden decrease in progesterone and estrogen secretion due to the demise of the corpus luteum. In ovulatory cycles, successive histological changes in the endometrium of the uterus from the proliferative phase to the secretion phase reflect ovarian function, which is characterized by a cyclical pattern of estrogen and progesterone secretion.In anovulatory cycles, these predictable changes in the histology of the endometrium and ovarian steroid hormones are lacking.

Normal menstruation is subjectively determined by the volume and duration of blood flow and in between the menstrual cycle. In reproductive life, most women experience a consistent cycle interval that ranges from 25 to 34 days. The duration of normal menstruation is 3 to 7 days. Although blood loss cannot be accurately quantitated, blood loss in a normal menstrual cycle ranges from 25 ml to 75 ml.Clinically, however, the number of pads or tampons used often gives some indication of any change in menstrual flow, although these are not reliable indicators of the actual amount from blood loss.

Causes of excess uterus Bleeding:

  1. Dysfunctional uterine bleeding: anovulatory bleeding, corpus luteum dysfunction, atrophic endometrium
  2. Intrauterine lesions: submucous fibroids, endometrial polyp, endometritis, intrauterine contraceptive device, uterine endometrium
  3. Leiomyomas from uterus
  4. Pelvic inflammatory disease
  5. Adenomyosis
  6. Early pregnancy complications: abortion, ectopic pregnancy, hydatidiform mole
  7. Pelvic diseases not clinically detected: damage to the uterus, inflammation of the pelvic organs, endometriosis, ovarian tumors
  8. Miscellaneous endocrinopathy: hypothalamic / psychogenic, polycystic ovary syndrome, hyperprolactinemia, thyroid dysfunction, adrenal dysfunction.
  9. Systemic diseases: blood dyscrasia, liver disease, kidney disease, and iatrogenic causes.

Abnormal Uterine Bleeding Model:

  1. Polymenorrhea: Frequent periods regularly occur at intervals of less than 21days.
  2. Hypermenorrhea: Excessive bleeding over amounts of the normal duration of regular periods.
  3. Hypomenorrhea: Decrease in bleeding in the amount in the next menstrual cycle.
  4. Menorrhagia: Prolonged term bleeding occurs at regular intervals.
  5. Metrorrhagia: Uterine bleeding occurs at different intervals.
  6. Menometrorrhagia: Uterine bleeding, usually excessive and prolonged, occurs irregularly, at frequent intervals.

Diagnostic tests:

History should include detailed diagrams of the menstrual cycle in terms of time intervals, duration and volume of flow, list of medications; obstetric history, sexual and contraceptive history, and general medical history.It should also include recent surgical and gynecological diseases.
Physical examination focuses on general health conditions that can cause DUB. Checking the thyroid, breast, liver, and skin is essential. Assessment of the presence and absence of ecchymotic lesions, obesity, and hirsutism is essential. Pelvic analysis of external and internal organs, the source and extent of bleeding, the size and shape of the uterus and any adnexal abnormalities are checked for diagnosis.Complete blood count, Pap smear, coagulation profile, HCG serum, iron concentration and binding capacity, ovulation detection, thyroid function tests, serum androgens, hepatic function tests, endometrial biopsy, hysteroscopy and hysterogram, pelvic ultrasound, MRI and usually , is done depending on the clinical results and make an accurate diagnosis.

Treatment:

It is individualized according to the patient’s age, her desire for contraception and fertility, as well as the severity and chronic bleeding.The goal of treatment is to arrest an acute episode of bleeding, to prevent relapse, and to induce ovulation in a patient wishing to conceive. If a pelvic examination reveals a normal uterus and no systemic disease is suspected, hormone replacement therapy is usually effective in managing DUB.

Acute, Profuse Bleeding: When a patient presents with acute, profuse and uncontrolled bleeding, usually steps for any other serious bleeding should be instituted immediately.High-dose estrogen therapy or progesterone injections are sometimes helpful in controlling bleeding. Emergency dilation and curettage or hysterectomy may be required in some cases to control bleeding and save the patient’s life.

Chronic, Recurrent Bleeding: Treatment is based on patient complaints, age, and desire for fertility. Observation is the only sensible approach for adolescent girls with no evidence of anemia. However, if the patient is sexually active, a combination oral contraceptive is provided.

Surgical Therapy: Although most patients with DUB can be managed with hormone therapy, D&S can be effective both diagnostically and therapeutically. For those over 35, histology evaluation of the endometrium is essential to either endometrial biopsy or D&S to exclude endometrial and endometrial hyperplasia. Endometrial ablation with either a hot air balloon or Nd: YAG laser or electrocoagulations via a HYSTEROSCOPE are surgical options.A hysterectomy is considered a final treatment. Please talk with your healthcare provider to decide what is right for you.

Clinical considerations and proposed approach:

Adolescents (13-18 years old): Anovulatory bleeding is a normal physiological process during the perimenarchal years of the reproductive cycle. An ovulatory menstrual cycle may not be established until one year or more after menarche. This phenomenon is attributed to immaturity or hypothalamus-pituitary-gonadal axis.Occasionally, adolescents with bloody dyscrasias, including von Willebrand disease and prothrombin deficiency, have severe vaginal bleeding during menarche. Acute infectious diseases such as leukemia, idiopathic thrombocytopenic purpura, and hypersplenism can all produce platelet dysfunction and cause excessive bleeding. These conditions require special treatments, and routine screening for coagulation disorders is offered in adolescents.

For chronic anovulation, treatment with a low-dose oral contraceptive is the treatment of choice.Oral contraceptives suppress both ovarian and adrenal androgen production and increase sex hormone binding globulins.

Women of reproductive age (19-39): Although anovulation may be considered in physiological adolescents, adult women of reproductive age who have menorrhagia, metrorrhagia, or amenorrhea require evaluation for specific cases. Laboratory tests include a pregnancy test that stimulates thyroid hormone (TSH) levels and prolactin levels.Chronic anovulation, which is the result of hypothalamic dysfunction, as it is diagnosed with a low follicular stimulating hormone (FSH) level, can be the result of excessive psychological stress, exercise, or weight loss. The history of hirsutism is developing rapidly, accompanied by virilization suggests swelling. In most cases, tumors can be ruled out by testing serum testosterone and dehydroepinandrostetrone sulfate levels. The incidence of endometrial cancer increases with age.Therefore, based on age alone, an assessment of the endometrium of the uterus to rule out this is indicated in any woman over 35 years of age who is suspected of anovulatory uterine bleeding. Adult women of reproductive age with anovulatory uterine bleeding can be safely handled with any cyclic progestrogen or oral contraceptive. If pregnancy is desired, ovulation induction with clomiphene citrate is the initial treatment of choice.

Later in women of reproductive age (40 years of menopause): The incidence of anovulatory uterine bleeding in women increases as they approach the end of reproductive age.In perimenopausal women, the onset of anovulatory cycles represents a continuation of the decline in ovarian function. These patients must be educated about the specific health risks associated with menopause so that an active approach to preventing the onset of menopause-related conditions such as osteoporosis can be initiated. In addition to the use of cycle hormone replacement therapy, important lifestyle changes include exercise, dietary changes, and smoking cessation.The incidence of endometrial cancer in women aged 40-49 was 36.2 per 100,000 in 1995. Therefore, all women over 40 who are suspected of present anovulatory uterine bleeding should be assessed with an assessment of the endometrium (after pregnancy have been excluded). Women who are not drug therapy and have no desire for future childbearing are candidates for endometrial ablation, which appears to be an effective and cost-effective treatment for hysterectomy for anovulatory uterine bleeding.However, removal of the endometrium may not be a definite therapy.

Medicine versus Surgical Treatment:

Women who experience acute, profuse anovulatory bleeding are candidates for estrogen therapy. In about 90% of cases, acute bleeding does not require surgery, but it can be treated with medical therapy. Conjugated equine estrogen therapy can be administered intravenously (25 mg every 4 hours for 24 hours). However, oral conjugated estrogen therapy at 10–20 mg per day in four divided doses may substitute for intravenous estrogen administration. Patients who fail to respond to a 1–2 dose of estrogen with a significant decrease in blood, loss or not hemodynamically stable should undergo dilatation and curettage. In addition, high doses of estrogen therapy are usually associated with nausea; concomitant medical therapy with antiemetics should be considered. After an acute episode of bleeding is under control, amenorrhea must be maintained for several weeks in order for the anemia to resolve.The best treatment is a combination of oral contraception. To extend the interval until the next menstrual period, continuous oral contraceptives (without placebo, pills) can be given for several months, but over time the patient will be exposed again to breakthrough bleeding. Once the patient’s anemia has resolved, cyclic oral contraceptives may be prescribed. All anemic patients should be given iron therapy.

Currently, there are several randomized trials compared to surgical medical therapy for anovulatory uterine bleeding.Several randomized trials that compared with endometrial resection by medical management for women with menorrhagia found that women who received medical treatment were less likely to be satisfied with their treatment. However, due to its reduced costs and risks, drug therapy should be offered prior to surgery if it is otherwise contraindicated. Surgical treatment is indicated for women with excessive anovulatory bleeding in whom medical control has failed and who have completed their childbirth.Avoiding anemia, reducing excessive bleeding, and increased, albeit imperfect, predictability of bleeding are goals that are appropriate to try to provide medical treatment. The success or failure of drug therapy must be determined in partnership with the patient in order to better achieve the therapeutic goal.

Efficacy between Surgical Methods:

Surgical to include this hysterectomy and endometrial ablation. Recent studies have reported an incidence of 7% and 15% of women undergoing hysterectomy for various indications.The overall mortality rate for hysterectomy is 12 deaths per 10,000 procedures, for all surgical indications. An alternative to surgical hysterectomy is removal of the endometrium. Endometrial ablation can be performed with or without the assistance of hysteroscopy. Hysteroscopic assisted endometrial ablation can be performed with a resectoscope. Using a resectoscope, the endometrium can be removed or resected with an electrocautery loop or ablated with a roller-ball. Endometrial ablation can also be performed with a YAG laser.The most common complication of hysteroscopy is uterine perforation, which occurs in about 14 per 1000 procedures and fluid overload, which occurs in about 2 per 1000 cases. Women with anovulatory uterine bleeding are candidates for endometrial removal unless they have drug therapy and have completed their childbirth. The proportion of women who, after undergoing amenorrheic and endometrium removal, is approximately 45%, and the proportion of women at 12 months after surgery who are satisfied with their therapy approaches is 90%.This is a high degree of satisfaction, indicating a reduced flow of adequate symptom control for most women, and achieving amenorrhea is not so important.

Numerous studies have compared the costs and benefits of surgery between endometrial resection or removal and hysterectomy. Evidence suggests that hysteroscopic endometrial ablation results in less morbidity and shorter recovery periods, and is more cost effective than hysterectomy.However, if more than one third of women who undergo endometrial ablation undergo a hysterectomy within the next 5 years, that will have a significant impact on the cost of these tests. The long-term satisfaction of women who underwent endometrial ablation has been questioned. In a 3-year follow-up study, 8.5% of women who underwent endometrial ablation subsequently underwent repeat ablation, and an additional 8.5% underwent hysterectomy. In a 5-year follow-up study, 34% of women who underwent hysteroscopic ablation subsequently had a hysterectomy.Since women who undergo endometrial ablation may have residual active endometrium, these women should receive a progestogen if they are prescribed estrogen replacement therapy.

Resume:

Treatment of choice for anovulatory uterine bleeding is drug therapy with oral contraceptives. Cyclic progestins are also effective. Women who do not have drug therapy and have no desire for future childbearing are candidates for endometrial removal, which appears to be an effective and cost-effective alternative hysterectomy treatment for anovulatory uterine bleeding.However, removal of the endometrium may be definitive therapy. Lying coagulopathy, such as von Willebrand disease, should be considered in all patients (especially adolescents) with abnormal bleeding, especially if the bleeding is not otherwise easily explainable, or does not respond to medical treatment. Although there are limited data evaluating the effectiveness of equine estrogen conjugate therapy in anovulatory bleeding, it is effective in controlling abnormal uterine bleeding.

Resources:

National Institutes of Health – Dysfunctional Uterine Bleeding

Further reading:

  1. Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP).Available at: www.hcupnet.ahrq.gov. Retrieved December 4, 2008
  2. Dysfunctional uterine bleeding. In: Clinical Gynecology Endocrinology and Infertility . Editors: Speroff L and Fritz MA; 7th edition; 2005, Lippincott Williams & Wilkins publishers.
  3. ACOG Practice Bulletin. Management of anovulatory bleeding. Number 14, March 2000
  4. Bevan JA, Maloney KW, Hillery CA et al. Bleeding disorders: a common cause of menorrhagia in adolescents. J Pediatr 2002; 138 (6): 858-861
  5. PhilippCS, Faiz A, Dowling NF et al.Development of a screening tool for identifying women with menorrhagia for hemostatic evaluation. Am J Obstet Gynecol 2008; 198 (2): 163.e1-e8
  6. ACOG Technology Assessment in Obstetrics and Gynecology. Hysteroscopy. Obstet Gynecol 2005; 106: 439-442
  7. Kingman CE, Kadir RA, Lee CA et al. The use of levonorgestrel-releasing intrauterine system for treatment of menorrhagia in women with inherited bleeding disorders. BJOG 2004; 111 (12): 1425-1428
  8. Eskandar MA, Vilos GA, Aletebi FA et al.Hysteroscopic endometrial ablation is an effective alternative to hysterectomy in women with menorrhagia and large uteri. J Am Assoc Gynecol Laparosc 2000; 7: 339-345. (Level II-2)
  9. Gurtcheff SE, Sharp HT. Complications associated with global endometrial ablation: the utility of the MAUDE database. Obstet Gynecol 2003; 102: 1278-1282. (Level III)
  10. ACOG Practice Bulletin. Endometrial ablation. Number 81, May 2007
  11. Sculpher M, Mana A, Abbott J et al.Cost effectiveness of laparoscopic hysterectomy compared with standard hysterectomy: results from a randomized trial. BMJ 2004; 328: 134-140
  12. Kho RM, Hilger WS, Hentz JG et al. Robotic hysterectomy: technique and initial outcomes. Am J Obstet Gynecol 2007; 197: 113.e1-e4
  13. Bratzler DW, Houck PM; for the Surgical Infection Prevention Guidelines Writers Workgroup. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004; 38: 1706-1715
  14. Falcone T, Walters MD. Hysterectomy for benign disease. Obstet Gynecol 2008; 111: 753-767

Published: 23 September 2009

Medicine Information | Public services portal

In order to avoid the spread of coronavirus infection, you can get free testing for coronavirus infection at the clinic at the place of attachment.For this you need:

  1. Using the portal of public services of the Moscow region: https://uslugi.mosreg.ru/zdrav/, go to your personal account (enter the number of your compulsory health insurance policy and your date of birth) and make an appointment with a doctor, then in the “Clinical laboratory diagnostics “choose a convenient date and time for the test.
  2. If you do not have access to the Internet, you can call the Single number 8-800-550-50-30 and make an appointment by phone.
  3. If you are not attached to the clinic, but you have a compulsory medical insurance policy issued in the Moscow region, use our service. Find the nearest test point on the map and sign up by phone.
  4. Networks of commercial medical centers and laboratories are also available for you, use our service. Find the nearest test point on the map and sign up by phone.

Testing is carried out by the method Polymerase chain reaction (PCR) .This is a high-precision method of molecular genetic diagnostics, which makes it possible to identify various infectious and diseases in a person, both in the acute stage and long before the disease can manifest itself.

A swab is taken from the nose and oropharynx.

Simple preparation required for research:

  • Two hours before the test, it is recommended not to eat, drink or smoke.
  • For 30 minutes, do not chew gum or suck on candy, gargle, use a spray or nasal drops.

Networks of certified government and commercial medical organizations and laboratories are available for you in which you can get tested on a paid basis, use our service. Find the nearest point on the map and sign up by phone.

Appointments to doctors:

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  • Appointment to narrow specialists: cardiologist, endocrinologist, neurologist – by referral from a general practitioner, pediatrician and general practitioner;
  • it is possible to make an independent appointment with a narrow specialist if you are registered with him at the dispensary.

Temporarily suspended:

  • preliminary, periodic preventive medical examinations;
  • vaccine prophylaxis;
  • planned prophylactic medical examination;
  • hospitalization in day hospitals.

IF you have a fever, cough and runny nose, you need to stay at home and call a doctor in one of the following ways:

  1. Call 8-800-550-50-30;
  2. Place a call on the public services portal;
  3. Call an ambulance at 112.

DIETCYCLENE 0.002 + 0.03MG N21 TABLE P / PLEN / SHELL

Irregular intake can lead to acyclic bleeding and reduce the contraceptive efficacy of the drug.

Before starting or resuming the use of the drug, it is recommended to conduct a thorough general medical and gynecological examination (including examination of the mammary glands and cytological examination of scrapings from the cervix), to exclude pregnancy.In addition, disorders of the blood coagulation system should be excluded. When using the drug, it is necessary to carry out preventive control examinations at least once every 6 months.

The drug does not protect against HIV infection (AIDS) and other sexually transmitted diseases.

Diseases of the cardiovascular system

Venous thromboembolism (VTE) may occur in the form of deep vein thrombosis and / or pulmonary embolism when using hormonal contraceptives.The approximate incidence of VTE in women taking oral contraceptives with a low dose of estrogen (less than 50 μg ethinylestradiol) is up to 4 per 10 thousand women per year, compared with 0.5-3 per 10 thousand women who do not use oral contraceptives. However, the incidence of VTE developing when taking combined oral contraceptives is less than the incidence of VTE associated with pregnancy (6 per 10 thousand pregnant women per year).

In women taking combined oral contraceptives, extremely rare cases of thrombosis of other blood vessels, for example, hepatic, mesenteric, renal and veins or veins and arteries of the retina, have been described.The relationship of these cases with the use of combined oral contraceptives has not been proven. A woman should stop taking the drug and consult a doctor if symptoms of venous or arterial thrombosis develop, which may include unilateral pain in the lower limb and / or edema; sudden severe chest pain; with or without irradiation in the left hand; sudden shortness of breath; sudden attacks of coughing; any unusual, severe, prolonged headache; increased frequency and severity of migraines; sudden partial or complete loss of vision; diplopia; slurred speech or aphasia; dizziness; collapse with or without partial seizure; weakness or very significant loss of sensitivity, suddenly appearing on one side or in one part of the body; movement disorders; “sharp” abdomen

The risk of thrombosis (venous and / or arterial) and thromboembolism increases: with age, in smokers (with an increase in the number of cigarettes smoked or with increasing age, the risk further increases, especially in women over 35), if family history (i.e.(i.e. venous or arterial thromboembolism ever in close relatives or parents at a relatively young age), obesity, dyslipoproteinemia, arterial hypertension, heart valve disease, prolonged immobilization, major surgery, any operation on the lower extremities or major trauma, atrial fibrillation.

In case of prolonged immobilization, in case of serious surgery, any surgery on the legs or extensive trauma, it is advisable to stop using the drug (in case of a planned operation, at least 4 weeks before it) and not resume taking it within 2 weeks after end of immobilization.

The possible role of varicose veins and superficial thrombophlebitis in the development of venous thromboembolism remains controversial. Consideration should be given to the increased risk of thromboembolism in the postpartum period.

Microcirculatory disorders can also occur in diabetes mellitus, SLE, hemolytic uremic syndrome, Crohn’s disease, ulcerative colitis and sickle cell anemia.

Tumors

Persistent human papillomavirus infection is the most significant risk factor for developing cervical cancer.There are reports of a slight increase in the risk of developing cervical cancer with long-term use of combined oral contraceptives. However, the relationship with the use of combined oral contraceptives has not been proven. The possibility of interrelation of these data with the screening of cervical diseases and with the peculiarities of sexual behavior (more rare use of barrier methods of contraception) is discussed.

A meta-analysis of 54 epidemiological studies has shown that there is a slightly increased relative risk of developing breast cancer diagnosed in women currently taking combined oral contraceptives (relative risk 1.24).The increased risk gradually disappears over 10 years after you stop taking these drugs. Due to the fact that breast cancer is rare in women under 40 years of age, the increase in the number of breast cancer diagnoses in women taking combined oral contraceptives currently or recently is insignificant in relation to the overall risk of this disease. The relationship between the development of breast cancer and the use of combined oral contraceptives has not been proven.The observed increase in risk may also be due to close monitoring and earlier diagnosis of breast cancer in women using combined oral contraceptives. Women who have ever used combined oral contraceptives have earlier stages of breast cancer than women who have never used them.

In rare cases, with the use of combined oral contraceptives, the development of benign, and in extremely rare cases, malignant liver tumors was observed, which in some cases led to life-threatening intra-abdominal bleeding.In the event of severe abdominal pain, liver enlargement or signs of intra-abdominal bleeding, this should be taken into account when making a differential diagnosis.

Other conditions

Women with hypertriglyceridemia or a family history of hypertriglyceridemia may have an increased risk of developing pancreatitis when taking combined oral contraceptives.

Although a slight increase in blood pressure (BP) has been described in many women taking combined oral contraceptives, clinically significant increases were rare.The relationship between taking combined oral contraceptives and an increase in blood pressure has not been established.However, if persistent, clinically significant arterial hypertension develops during their intake, it is advisable to cancel combined oral contraceptives and treatment of arterial hypertension. The use of combined oral contraceptives can be continued if normal blood pressure values ​​are achieved with the help of antihypertensive therapy.

Influence on the menstrual cycle

While using combined oral contraceptives, irregular (acyclic) bleeding (“spotting” spotting or “breakthrough” bleeding) may occur, especially during the first months of use.Therefore, assessment of any irregular bleeding should only be done after an adaptation period of approximately 3 cycles.

If irregular bleeding recurs or develops after previous regular cycles, a careful examination should be carried out to rule out malignant neoplasms or pregnancy.

Some women may not develop ‘withdrawal’ bleeding during a pill-break. If combined oral contraceptives were taken as directed, pregnancy is unlikely. However, if combined oral contraceptives were previously taken irregularly, or if there are no two withdrawal bleeding in a row, then pregnancy must be excluded before continuing to take the drug.

Influence on laboratory tests

The use of oral combined contraceptive drugs may affect the results of some laboratory tests, including biochemical blood tests (indicators of liver, thyroid, kidney and adrenal gland function, concentration of transport proteins in blood plasma ( such as SHBG), carbohydrate metabolism, lipid / lipoprotein fractions), as well as indicators of coagulation and fibrinolysis.Nevertheless, the changes in these indicators remain within the normal range.

Influence on the ability to drive vehicles and mechanisms

There is no data on the negative effect of Diecyclen on the ability to drive vehicles and engage in potentially hazardous activities that require increased concentration of attention and speed of psychomotor reactions.

Overdose

Possible symptoms of drug overdose: nausea, vomiting, irregular spotting, absence of menstrual bleeding.

If necessary, symptomatic therapy is performed.

Menstrual irregularities and bleeding

See also 4.3 – Female endocrinology

BOOKS:

1000 questions and answers in gynecology (2017)
These are all hormones!

SEMINARS AND WEBINARS:

Menstrual cycle and its disturbances

VIDEOS:

Myths in gynecology
TOP 5 commercial diagnoses in gynecology
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About menstrual irregularities (3)
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Another case study

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About the need for menstruation
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Menstrual irregularities when taking antipsychotic drugs
The effect of steroid hormones on the menstrual cycle
Vacuum aspiration performed without indications
Ovarian dysfunction and irregular cycles 902 menses?
Reference values ​​of the norm of hormonal levels

4.4.1. Painful periods

BOOKS:

1000 questions and answers in gynecology (2017)

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Endometriosis: Commercial Diagnosis or Reality

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Painful periods
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4.4.2. Menstrual irregularities

BOOKS:

1000 questions and answers in gynecology

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Menstrual cycle and its disturbances

VIDEOS:

Periods of irregularity in the menstrual cycle
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Q&A:

Is it possible to restore the normal functioning of the ovaries without OC in case of failure of the second phase of MS?
Is there a connection between regular sex life and the regularity of MC?
How to properly restore MC after irradiation?
Should I be worried about a violation of the MC after tubal ligation?
How to identify the true cause of menstrual irregularities?
Do I need to urgently call my period?
Terzhinan with vaginal bleeding

4.4.2.1. Weight and menstrual irregularities

BOOKS:

It’s all hormones!
1000 questions and answers in gynecology (2017)
Hormone therapy in obstetrics and gynecology: illusions and reality, in which read
5.4. Progesterone and adipose tissue

VIDEOS:

How to get better for a thin woman
Menstrual irregularities

Q&A:

Abrupt weight loss and absence of menstruation
Menstruation stopped after weight loss.What to do?
Prolonged absence of menses due to severe weight loss
Absence of menstruation at a comfortable weight for me. What examinations do you need to undergo?
Overweight amenorrhea
FSH, LH, low weight and cycle problems
Improper diet and menstrual cycles

4.4.2.2 Age and menstrual cycles

4.4.2.2.1. Menstrual cycle up to 21-22 years

BOOKS:

It’s all hormones!
1000 questions and answers on gynecology (2017)
Mothers and daughters: Everything your mother did not tell you about and what you should teach your daughter
Hormone therapy in obstetrics and gynecology: illusions and reality, in which read

moreHide

eight.4.1. Menstrual cycle is normal
8.4.2. Formation of a normal menstrual cycle
8.4.3. Menstrual cycles in adolescent girls

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Stress and the menstrual cycle in adolescents
Menstrual cycles in adolescent girls
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Q&A:

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4.4.2.2.2. Menstrual cycle after 37-38 years

BOOKS:

Hormone therapy in obstetrics and gynecology: illusions and reality, in which read

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8.7. Progesterone and ovarian reserve
8.7.1. Age and fertility
8.7.2. The concept of “ovarian reserve”
8.7.3. Progesterone level and ovarian reserve
8.7.4. Anti-Müllerian hormone

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Women’s health after 35 years and menopause

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4.4.2.3. Delayed menses, long cycles

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Delayed periods and pregnancy tests
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Delayed menstruation or menopause?
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Cause of prolonged periods – tests?
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Delay in menstruation after cancellation of COC
Delay in menstruation in 30 days

4.4.2.4. Short cycles

Q&A:

Shortening of the menstrual cycle and severe headaches. How to prolong women’s health at 47?

4.4.2.5. Highlights mid-cycle

(see also 4.3.4. “Ovulatory syndrome”)

Q&A:

About acne, intermenstrual bleeding and treatment of breast fibroadenoma
Intermenstrual spotting

4.4.2.6. Menstrual irregularities after taking hormonal drugs

Q&A:

Regulation of the cycle with hormonal contraceptives
Failure of the menstrual cycle after skipping hormonal contraceptives. How do I get my balance back?
Hormonal contraceptives and menstruation
Hormonal failure and absence of menstruation after stopping the use of COCs
How quickly menstrual cycles are restored after continuous use of COCs

4.4.2.7. Menstrual cycle after childbirth

(see also 5.18 – Postpartum period)

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Postpartum

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Change in the cycle after pregnancy and childbirth
Restoration of ovulation after childbirth

Q&A:

Prolonged absence of menstruation after hepatitis B and Dostinex
Half a year after childbirth there is no menstruation: should you worry?

4.4.3. Violation of the maturation of germ cells (anovulation)

BOOKS:

It’s all hormones!
1000 questions and answers in gynecology (2017)
Hormone therapy in obstetrics and gynecology: illusions and reality, in which read

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8.5.2. The role of estrogens in the maturation of germ cells
8.6.2. Sexual relations and ovulation
8.6.3. Ovulation disorders during normal menstrual cycles
10.3. Progesterone and anovulation
10.3.1. Anovulatory follicular waves
10.3.2. Causes of anovulation
10.3.3. Diagnostics of anovulation
10.3.4. Anovulation and progesterone deficiency
10.3.5. Anovulation treatment

VIDEOS:

Anovulation and phase of the cycle
Anovulation

Q&A:

Regular periods, but ovulation, they say, no. What to do?
Are two ovulations possible in one menstrual cycle?
Menstrual cycle without ovulation – normal or pathological?
Menstruation is observed only against the background of taking hormonal drugs
With a long delay, progesterone injections are prescribed

4.4.4. Endometrial hyperplasia

BOOKS:

It’s all hormones!
1000 questions and answers in gynecology
Hormone therapy in obstetrics and gynecology: illusions and reality, in which read

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10.6. Progesterone and endometrial hyperplasia
10.6.1. Classification of endometrial hyperplasia
10.6.2. What kind of hyperplasia turns into cancer?
10.6.3. Is it necessary to treat endometrial hyperplasia?

VIDEOS:

About the endometrium
Endometrial hyperplasia
Prophylactic examinations, ultrasound and endometrium

Q&A:

What is the best method of obtaining endometrium for diagnosing cancer?
What is the cause of endometrial hyperplasia?
What is the difference between endometrial hyperplasia and endometriosis?
Lack of menstruation and endometrial hyperplasia
Endometrial hyperplasia against the background of prolonged absence of menstruation
Endometrial hyperplasia: treat with dietary supplements or Mirena?

4.4.5. Menstrual irregularities

BOOKS:

It’s all hormones!
1000 questions and answers in gynecology (2017)
Hormone therapy in obstetrics and gynecology: illusions and reality, in which read

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9.1.5. Biochemical changes in the endometrium
9.1.6. Phases of the state of the endometrium
9.2. Progesterone and menstruation
9.2.3. The concept of “critical” days
9.2.4. Occurrence of natural menstrual bleeding
9.2.5. Phases of menstruation
9.2.6. Process of endometrial detachment
9.2.7. Occurrence of artificial menstrual bleeding

VIDEOS:

Menstruation
Changes in the nature of menstruation
Bloody discharge before or after menstruation
Clots in menstrual blood

ARTICLES:

Asherman’s syndrome, or the consequences of medical care

Q&A:

About “critical days” and the mechanism of the onset of menstruation
Spotting before menstruation

4.4.5.1. Heavy menstruation

Q&A:

Abundant menstruation after cessation of hepatitis B and medical abortion
Abundant irregular menstruation in a young girl
Abundant, prolonged menstruation with pain after active physical exertion
Dark discharge during menstruation after cessation of hepatitis B
Bleeding the next day after the end of menstruation

4.4.5.2. Lean menses

Q&A:

Restoration of the cycle after curettage
Decrease in discharge during menstruation at 22 years old
Malfunction of the menstrual cycle: the amount of discharge has decreased
Lean menstruation after the abolition of OK.How to normalize your cycle before planning a pregnancy?

4.4.5.3 Absence of menstrual cycles (amenorrhea)

BOOKS:

It’s all hormones!
1000 questions and answers in gynecology (2017)
Hormone therapy in obstetrics and gynecology: illusions and reality, in which read

moreHide

10.4. Progesterone and amenorrhea
10.4.1. Causes of amenorrhea
10.4.2. Treatment of amenorrhea

Q&A:

Overweight amenorrhea
Why is the absence of menstruation dangerous?
Prolonged absence of menstruation and diagnosis of PCOS by ultrasound Amenorrhea: different diagnoses and no use

4.4.6. Abnormal and dysfunctional uterine bleeding

BOOKS:

1000 questions and answers in gynecology (2017)

Q&A:

Bleeding for two months, do curettage?
What is the cause of small bleeding before menstruation?

4.4.7. Hereditary uterine bleeding

BOOKS:

1000 questions and answers in gynecology (2017)

4.4.8. Lifestyle and menstrual cycle

BOOKS:

It’s all hormones!
Hormone therapy in obstetrics and gynecology: illusions and reality, in which read

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5.9. Nutrition and progesterone
5.9.1. Fiber intake and progesterone assimilation
5.9.1.1. Fiber types
5.9.1.2. The role of fiber in human nutrition
5.9.1.3. Fiber and assimilation of sex hormones
5.10. Alcohol and progesterone
5.10.1.Alcohol and conception of a child
5.10.2. Alcohol and sex hormones
5.10.3. Effect of alcohol on progesterone levels
5.11. Smoking and progesterone

VIDEOS:

Sports and the menstrual cycle
Is it possible to play sports during menstruation
Sports and women’s health
Flat tummy, women’s health
Sports during menstruation
Sports and women’s health: Dr. Elena Berezovskaya visiting Aliona Hilt live
Women’s health and sports

ARTICLES:

What you need to know about running and menstruation

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Athletic triad – what is it?
Extreme “wild” recreation for women’s health
Disorders during intensive sports

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Endometrial hyperplasia | Disease Information

Classification

Gynecologists have developed a classification of endometrial hyperplasia based on the characteristics of tissue proliferation and the degree of risk of complications.In medical practice, the first classification of this disease, adopted by the World Health Organization (WHO) in 1994, is most often used. Experts who identified the types of hyperplasia described characteristic changes in glandular tissue, including atypical morphological changes. Today, this classification is used to assess the risk of malignant degeneration of tissues and the appointment of treatment.

Types of growth of the endometrium:

  1. Simple hyperplasia – an increase in the number of glands while maintaining the morphological structure of cells.In some cases, cysts grow in the endometrium without dysfunctions of the organ. According to studies, the risk of malignant transformation with this type of hyperplasia does not exceed 2%.
  2. Complex hyperplasia – the proliferation of glands is accompanied by a change in tissue structure. Areas of high density of glands appear in the endometrium. Morphological and functional changes in cells include an increase in the number of nuclei, an increase in mitotic activity, and an increase in individual structures of the cytoplasm.Like cancer epithelial cells, these cells begin to divide rapidly, but the tumor structure has not yet formed. Also, invasion of altered tissues into the stroma is not observed. According to studies, the risk of malignant transformation of such a structure is approximately 20%.

Like other types of hyperplastic disorders, endometrial hyperplasia is initially a physiological tissue response to estrogen exposure. At the same time, the glandular cells of the overgrown endometrium can change over time due to the influence of unknown factors.It is possible to clarify the type of tissue change in a patient only after a biopsy, since the clinical manifestations of different types of hyperplasia practically do not differ.

Causes of occurrence

As already mentioned, during the menstrual cycle there is a change in hormonal levels in the body and renewal of the endometrium. Endocrine changes are mainly manifested by fluctuations in the concentration of estrogen and progesterone. Estrogen binds to receptors in endometrial cells and provokes increased division of epithelial cells in this tissue, due to which the inner lining of the uterus thickens.The destruction of the endometrium against the background of a lack of fertilization occurs due to a change in the level of progesterone. When the ratio of these hormones is in harmony, menstrual cycles run smoothly. Endocrine imbalance can cause abnormal endometrial cell division.

Possible causes:

  1. Increased estrogen concentration and insufficient progesterone. This is the most common cause of endometrial hyperplasia. Hormonal imbalance can occur with primary endocrine diseases, improper lifestyle, taking certain medications.
  2. Medical procedures involving damage to the endometrium. We can talk about diagnostic tissue scraping, abortion or other intervention.
  3. Expression of genetic mutations. Disruption of DNA structure can contribute to abnormal development of endometrial cells.

The exact reasons for the change in cellular regulation are unknown.

Risk factors

In addition to the direct mechanisms of hyperplasia, doctors take into account the role of certain forms of predisposition to this condition.The risk of proliferation of uterine tissues increases with primary diseases, improper lifestyle and the influence of other negative factors.

Known risk factors for endometrial hyperplasia:

  1. Adverse family history. Genetic mutations can be passed on to children from parents. If a relative of the patient has been diagnosed with hyperplasia or a tumor of the uterus, the individual risk of morbidity increases.
  2. The emergence of other complications of hormonal imbalance.This can be a smooth muscle tumor of the uterus (myoma), ectopic growth of the endometrium, inflammation of the lining of the uterus and polycystic ovary syndrome. When these pathologies are identified, it is imperative to conduct a study to exclude endometrial hyperplasia.
  3. The onset of menopause. After the onset of the last menstruation, hormonal changes occur in the woman’s body. A decrease in the concentration of progesterone can provoke the proliferation of glandular cells in postmenopausal women.
  4. The onset of the perimenopausal period. This natural state does not yet lead to significant hormonal changes, however, irregular ovulation can be a risk factor for the disease.
  5. Use of estrogen-based hormone therapy. Most often, women are prescribed this therapy after menopause.
  6. No pregnancy in the individual history and menstrual irregularities.
  7. Refusal to use hormonal contraception.
  8. Identification of comorbidities such as obesity, diabetes mellitus, thyroid disease, adrenal gland disorders and mastopathy.Metabolic disorders can affect the risk of endometrial cell overgrowth.

All of the listed risk factors can cause the occurrence of diseases of the reproductive system. Detection of a form of predisposition to uterine hyperplasia is an indication for prophylaxis.

Pathogenesis

An abnormal increase in the number of endometrial cells occurs as a result of continuous stimulation of the uterus with estrogens and a decrease in the concentration of progesterone.It can be an endogenous or external source of estrogen. An endogenous increase in the concentration of the hormone occurs with chronic anovulation associated with cystic ovarian syndrome. Obesity also increases the concentration of estrogen, as the level of estradiol in the body rises. In rare cases, abnormal thickening of the glandular tissues of the uterus occurs due to estradiol-secreting ovarian tumors.

Estrogen therapy can be an external source of the hormone. At the same time, the use of combined replacement therapy, including progesterone, does not lead to thickening of the endometrium.The exact mechanism of transformation of the uterine lining under the influence of the hormone is unknown. It is believed that benign tissue thickening is due to genetic mutations and the external factors already listed. Thus, a mutation in a gene that suppresses tumor tissue growth was found in 55% of women with endometrial hyperplasia. In women suffering from uterine carcinoma, this mutation is found in 80%. Based on these data, scientists came to the conclusion that external influences increase the risk of abnormal division of endometrial cells only if there is a genetic predisposition to such a disease.

Symptoms

In many women, a change in the glandular epithelium of the uterus does not lead to any symptoms. At the same time, significant tissue overgrowth is often accompanied by menstrual disorders. Patients complain of increased uterine bleeding, pain in the lower abdomen and a violation of the duration of certain periods of the cycle. A change in the nature of uterine bleeding can be manifested by a general increase in the volume of bleeding or episodic increased blood flow.

Additional symptoms and signs:

  • Delayed menstruation;
  • Frequent discharge of blood clots;
  • weakness;
  • the spread of pain to the perineal region;
  • pallor of the skin;
  • dizziness;
  • decreased performance;
  • inability to conceive a child during 8-12 months of active sex life.

If you experience persistent pain and uterine bleeding not associated with menstruation, seek medical attention.These signs may indicate the development of uterine carcinoma.

Uterine cancer and hyperplasia

Endometrial cancer is a malignant neoplasm that forms from the glandular cells of the inner lining of the uterus. Due to the influence of negative factors and impaired internal regulation, epithelial cells begin to divide uncontrollably and form a pathological focus. Gradually, the tumor grows into deeper tissues, including the muscle and serous membranes. Also, cancer cells can enter the bloodstream and spread in the body, provoking the growth of secondary neoplasms (metastases) in other organs.This extremely dangerous disease is considered the most common type of cancer among women.

It is important to understand that uterine hyperplasia is not a malignant tumor. Unlike cancer, epithelial cells of an overgrown mucous membrane of an organ usually do not have specific structural changes. In addition, the focus of cell proliferation does not spread to other parts of the uterus and does not give metastases. At the same time, this condition may be an immediate precursor of carcinoma. The increased influence of hormonal imbalance, bad habits, inflammation and other unfavorable factors on the thickened endometrium can ultimately lead to the growth of neoplasms.

Diagnostics

To undergo all the necessary examinations, you should make an appointment with a gynecologist. The doctor will ask the woman about the complaints and examine the history information to identify risk factors for the disease. The next stage of diagnosis is a general examination of the genitals. Since such a study may not be enough to explain the suspicious symptoms, the gynecologist prescribes additional diagnostic procedures.

Conducted instrumental and laboratory research:

  1. Endoscopic examination of the uterine cavity (hysteroscopy).Before the examination, the doctor asks the woman to sit in the gynecological chair. After that, the doctor carefully expands the cervical canal and introduces a hysteroscope equipped with a light source and optics into the uterine cavity. This procedure allows the specialist to study in detail the state of the inner lining of the organ and carry out additional manipulations.
  2. Biopsy – tissue sampling in the area of ​​the altered endometrium. The gynecologist inserts a special syringe into the uterine cavity. With the help of a piston, cells are taken from a suspicious area of ​​the mucous membrane.The doctor can obtain cells at the same time from several parts of the organ. The ultrasound-guided procedure improves the accuracy of cell harvesting. In the laboratory, specialists study the obtained material using staining, microscopy and other methods. Thus, biopsy is the most reliable diagnostic method, which makes it possible to assess tissue morphology and exclude the presence of malignant cells in the organ. If necessary, curettage of cells is performed.
  3. Ultrasound diagnostics of the uterus.To obtain more accurate visual data, the doctor inserts the sensor through the opening of the vagina. The reflected ultrasound waves create an image of the uterus on a monitor. This painless examination allows the doctor to assess the condition of the organ and exclude the presence of a tumor process.
  4. Computed tomography or magnetic resonance imaging – auxiliary methods of visual diagnostics. Before the examination, the woman is asked to remove all metal objects from her. The results of tomography, presented in the form of volumetric images of organs, are necessary to search for even minor structural changes in tissues.If a tumor is suspected, CT scan helps to assess the prevalence of the pathology.
  5. Blood test. In the treatment room, the nurse draws venous blood. The study of the material allows you to assess the level of sex hormones. The blood test is repeated during the treatment of the disease.

A gynecologist can do just a few diagnostic procedures. If necessary, a consultation with an oncologist or an endocrinologist is appointed.

Therapeutic treatment

Accuracy of diagnostic data is essential for proper treatment based on the identified risk of tissue malignancy.After the diagnosis is made, the treatment chosen by the doctor depends on the biopsy data, the woman’s age, planning of pregnancy in the future and concomitant pathologies of the reproductive system. The doctor also needs to consider surgical risks such as bleeding and organ damage. With moderate hyperplasia, the gynecologist may prescribe drug therapy to reduce the risk of tumor growth. Within 3-6 months of such treatment, most patients experience the disappearance of signs of hyperplasia.

Drug therapy methods:

  1. Oral contraceptives and progestins.Such therapy usually involves taking medications for several months and regular diagnostic monitoring of the results of treatment. The use of progestins is an excellent method of preventing relapse in patients with persistent risk factors for the disease.
  2. Intrauterine administration of hormonal drugs. Such treatment is aimed at improving the condition of the endometrium.
  3. Prescribing drugs based on gonadotropin-releasing hormone agonists. Typically, these medications are prescribed for women over the age of 35.

In parallel with drug therapy of the disease, doctors prescribe drugs to eliminate complications of hyperplasia. These can be vitamin supplements and iron-based preparations. Physiotherapy methods help alleviate pathological processes in the uterus and reduce the intensity of uterine bleeding.

Surgical treatment

With confirmed atypical hyperplasia and complications, the gynecologist must prescribe an operation. The specific operation is selected based on the diagnostic data and the patient’s age.An important task is to preserve the structure of the organ and completely eliminate the risk of malignant degeneration of tissues, but such a result is not always possible.

Operation options:

  1. Endometrial ablation. With the help of laser exposure, the surgeon destroys the endometrial layer of the uterus and the superficial layer of the muscular membrane of the organ. The result of the procedure is the complete elimination of the risk of malignant degeneration of the epithelium. Reproductive function cannot be restored after this method of treatment.
  2. Endometrial resection – removal of the inner lining of the uterus using electricity. The surgeon inserts a special instrument through the cervical canal into the uterine cavity and removes tissue using the cutting loop of the electrode. The removed tissue is examined in a laboratory to exclude the presence of tumor cells.
  3. Supravaginal amputation – removal of the body of the uterus while preserving the cervix and organ appendages. The operation is performed under general anesthesia using a laparotomy.

If indicated, the surgeon can carry out a radical removal of the uterus and its appendages.This highly traumatic operation may be necessary if there is a suspicion of the spread of an already existing malignant process. After surgical treatment of hyperplasia, long-term rehabilitation is carried out.

Complications and prevention

Without timely treatment, the disease can cause dangerous complications due to further changes in the epithelium and constant hemorrhages. Doctors diagnose complications after identifying the disease.

Common complications:

  1. Anemia – a decrease in the concentration of hemoglobin in the patient’s blood.This substance, contained in red blood cells, is necessary for the transfer of oxygen to tissues. Constant uterine bleeding during the growth of the organ’s epithelium leads to the loss of a large number of red blood cells. Women with anemia complain of dizziness, chronic fatigue, insomnia, and pale skin.
  2. Changes in the menstrual cycle and the occurrence of infertility. With a slight proliferation of glandular cells, the doctor can restore reproductive function.

Methods for the prevention of pathology include the use of hormonal contraception under the supervision of a physician, normalization of body weight, control of diabetes and timely treatment of primary diseases of the reproductive system.It is also important to be examined by a gynecologist at least once a year. An oncologist’s consultation will help a woman learn more about the prevention and treatment of this ailment.

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Memorial Sloan Kettering Cancer Center

This document, provided by Lexicomp ® , contains all the information you need to know about the drug, including the indications, route of administration, side effects and when you should contact your healthcare provider.

Trade names: USA

Avastin; Mvasi; Zirabev

Trade names: Canada

Avastin; Mvasi; Zirabev

What is this drug used for?

  • Used to treat cancer.
  • This medicinal product may be used for other indications. Check with your doctor.

Children:

  • This medicine is not approved for use in children.However, your doctor may decide that the benefits of using this drug outweigh the risks associated with it. If your child has received this drug, ask the doctor about the benefits and risks. Talk with your doctor if you have any questions about how your child is using this drug.

What do I need to tell my doctor BEFORE taking this drug?

  • If you are allergic to this drug, any of its ingredients, other drugs, foods or substances.Tell your doctor about your allergy and how it manifested itself.
  • If you have high blood pressure.
  • If you have recently had bleeding or coughing up blood.
  • If this drug is used to treat ovarian cancer and there is cancer in certain parts of the intestine, or if there is a bowel obstruction.
  • If you have previously taken daunorubicin, doxorubicin, epirubicin, idarubicin, or mitoxantrone, please consult your doctor.
  • If you are or may become pregnant. This drug may have adverse effects on the fetus. If you are at risk of becoming pregnant, you must use birth control during treatment and for some time after your last dose of this drug. Ask your doctor how long to use contraception. If you become pregnant, contact your doctor immediately.
  • If you are a breastfeeding mother. Do not breast-feed while taking this drug or for 6 months after your last dose.

This list of drugs and diseases that may be adversely associated with this drug is not exhaustive.

Tell your doctor and pharmacist about all the medicines you take (prescription and over-the-counter, natural products and vitamins) and your health problems. You need to make sure that this drug is safe for your medical conditions and in combination with other drugs you are already taking.Do not start or stop taking any drug or change the dosage without your doctor’s approval.

What do I need to know or do while taking this drug?

  • Tell all healthcare providers that you are taking this drug. These are doctors, nurses, pharmacists and dentists.
  • This drug may have effects on wound healing, including delaying the healing of surgical wounds.Failure to heal the surgical wound can lead to death. If you need surgery, you may need to stop taking this drug before you have surgery. The drug should be resumed after surgery as directed by your doctor. Check with your doctor.
  • Very bad, sometimes deadly, GI (gastrointestinal) perforation or fistula has happened with this drug.Check with your doctor.
  • You may be at increased risk of developing an infection. Wash your hands often. Try not to come into contact with carriers of the infection, incl. with people with colds or flu.
  • If any signs of infection appear, such as fever, chills, flu-like symptoms, very severe sore throat, ear or sinus pain, cough, increased or discolored sputum secretion, pain when urinating, ulceration in the mouth or non-healing wounds, see a doctor immediately.
  • You may become more prone to bleeding. Be careful and avoid injury. Use a soft toothbrush and electric razor. In rare cases, some bleeding has resulted in death.
  • Call your doctor right away if any of these bleeding symptoms occur: bruising, black, tarry, or bloody stools, bleeding gums, blood in urine, coughing up blood, cuts that bleed for a long time, dizziness, feeling very tired, or weakness, nosebleeds, pain or swelling, vomiting of blood or coffee grounds vomit, or very severe headache.
  • Thrombosis has happened with this drug. Sometimes the blood clots that lead to a stroke or myocardial infarction were deadly. Check with your doctor.
  • Call your doctor right away if you have signs of thrombosis such as pain or tightness in your chest; coughing up blood; dyspnea; swelling, warmth, numbness, discoloration, or pain in your leg or arm; Difficulty speaking or swallowing.
  • A very serious and sometimes deadly brain disorder called posterior reversible encephalopathy syndrome (PRES) has happened with this drug.If you have symptoms such as confused thinking, decreased concentration, change or loss of vision, seizures, or a very severe headache, contact your doctor immediately.
  • Very bad and sometimes deadly kidney problems have happened with this drug. If you have delayed urination, blood in your urine, or a change in the amount of urine you pass, see your doctor right away.
  • High blood pressure has happened with this drug.Monitor your blood pressure as directed by your doctor.
  • In some patients, this drug has had very severe side effects. If during the administration of the drug you have any side effects, consult your doctor.
  • If you are 65 years of age or older, use this drug with caution. You may have more side effects.
  • Using this drug may stop menstruation in people who might get pregnant.This can negatively affect the ability to have children. It is not known whether this violation is reversible. Check with your doctor.

What side effects should I report to my doctor immediately?

WARNING. In rare cases, some people with this drug can have serious and sometimes deadly side effects. Call your doctor right away or get medical help if you have any of the following signs or symptoms, which may be associated with serious side effects:

  • Signs of an allergic reaction, such as rash, hives, itching, reddened and swollen skin with blisters or scaling, possibly associated with fever, wheezing or wheezing, tightness in the chest or throat, difficulty breathing, swallowing or speaking, unusual hoarseness, swelling in the mouth, face, lips, tongue, or throat.
  • Signs of high blood pressure, such as very severe headache, or dizziness, or loss of consciousness, or blurred vision.
  • Signs of high blood sugar, such as confusion, drowsiness, increased thirst and hunger, increased urination, facial flushing, rapid breathing, and fruity breath.
  • Signs of electrolyte imbalance such as sudden changes in mood, confusion, muscle pain or weakness, palpitations, seizures, lack of appetite, severe stomach upset or vomiting.
  • Weakness on one side of the body, difficulty speaking or thinking, trouble maintaining balance, drooping one side of the face, or blurred vision.
  • Shortness of breath, sudden weight gain, or swelling of the arms or legs.
  • Severe constipation or abdominal pain. These may be signs of a severe bowel disorder.
  • Excessive sweating.
  • Unusual burning, numbness, or tingling sensations.
  • Anxiety.
  • Pelvic pain.
  • Redness or irritation of the skin of the palms or soles of the feet.
  • People taking this drug have developed a very severe skin disorder (necrotizing fasciitis). Sometimes these cases were fatal. See your doctor right away if you have warm skin with red or purple swollen areas that spread quickly. See your doctor right away if you have sores, blisters, black spots on your skin, or any other skin changes that bother you.

What are some other side effects of this drug?

Any medicine can have side effects. However, many people have little or no side effects. Call your doctor or get medical help if these or any other side effects bother you or do not go away:

  • Headache.
  • Feeling dizzy, tired, or weak.
  • Pain in the back, muscles or joints.
  • Abdominal pain or diarrhea.
  • Pain in the neck.
  • Nausea or vomiting.
  • Lack of hunger.
  • Dry skin.
  • Changes in the state of nails.
  • Changes in the ability to perceive taste.
  • Weight loss.
  • Voice change.
  • Runny or stuffy nose.
  • Sleep disorders.
  • Increased lacrimation.
  • Irritation or pain in the mouth.

This list of potential side effects is not comprehensive.If you have any questions about side effects, please contact your doctor. Talk to your doctor about side effects.

You can report side effects to the National Health Office.

You can report side effects to the FDA at 1-800-332-1088. You can also report side effects at https://www.fda.gov/medwatch.

What is the best way to take this drug?

Use this drug as directed by your healthcare practitioner.Read all the information provided to you. Follow all instructions strictly.

  • This drug is administered by intravenous infusion continuously over a period of time.
  • Perform blood tests as directed by your healthcare practitioner. Please consult your doctor.
  • Perform urine tests as directed by your doctor.
  • If you develop symptoms such as nausea, vomiting, diarrhea, or lack of appetite, consult your doctor.There may be ways to mitigate these side effects.

What to do if a dose of a drug is missed?

  • Call your doctor for further instructions.

How do I store and / or discard this drug?

  • If you need to store this drug at home, ask your doctor, nurse, or pharmacist for information about how it is stored.

General information on medicinal products

  • If your health does not improve or even worsens, see your doctor.
  • You should not give your medicine to anyone and take other people’s medicines.
  • Store all medicines in a safe place. Keep all medicines out of the reach of children and pets.
  • Dispose of unused or expired drugs. Do not empty into toilet or drain unless directed to do so. If you have any questions about the disposal of your medicinal products, consult your pharmacist.There may be drug recycling programs in your area.
  • Some medicines may come with other patient information sheets. If you have questions about this drug, talk with your doctor, nurse, pharmacist, or other healthcare professional.
  • Some medicines may come with other patient information sheets. Check with your pharmacist. If you have questions about this drug, talk with your doctor, nurse, pharmacist, or other healthcare professional.
  • If you think an overdose has occurred, call a Poison Control Center immediately or seek medical attention. Be prepared to tell or show which drug you took, how much and when it happened.

Use of information by consumer and limitation of liability

This information should not be used to make decisions about taking this or any other drug. Only the attending physician has the necessary knowledge and experience to make decisions about which drugs are suitable for a particular patient.This information does not guarantee that the drug is safe, effective, or approved for the treatment of any disease or specific patient. Here are only brief general information about this drug. It does NOT contain all available information on the possible use of the drug with instructions for use, warnings, precautions, information about interactions, side effects and risks that may be associated with this drug. This information should not be construed as a treatment guide and does not replace information provided to you by your healthcare professional.