Several years before menopause, many women notice changes in their menstrual cycles. Often, women notice that the interval between cycles becomes less. Instead of 28-30 days apart, menses occur every 21-28 days. The reason is that ovulation occurs earlier in the cycle, as estrogen levels decline. Along with this is a decrease in fertility. Coincident with this is a change in menstrual flow. Many women note that much of their bleeding occurs on the first one or two days of their cycle, with less flow on the remaining days, and sometimes a trailing off of bleeding that goes on for a total of 7-9 days. Some women will be changing a pad or tampon every two hours for a day or two. As a women gets even closer to menopause, she may note that she begins to miss cycles, maybe several in a row, followed by a resumption of regular bleeding. Cycles become harder to predict, and the flow may vary. These changes often occur for 2-7 years prior to menopause.
Besides the fact that cycles may become unpredictable, bleeding in the peri-menopausal years may become abnormal. Very heavy bleeding, prolonged bleeding, spotting between cycles, and cycles that are very frequent are all patterns that may indicate disease or hormonal imbalance. Maintaining a menstrual calendar is a helpful in monitoring patterns of bleeding. Bothersome symptoms such as breast tenderness and pain should also be noted.
Structural abnormalities of the uterus can cause abnormal bleeding. The most common benign tumors of childbearing women are uterine fibroids. Approximately 50% of women in their 40's will have at least one fibroid. Fibroids are muscle tumors of the muscular wall of the uterus. They are often multiple, and can cause marked enlargement of the uterus. Most of them are small, tucked into the body of the uterus, and may only be found if a sonogram is performed. One important aspect of fibroids is location, location, location. Fibroids can occur poking out of the wall of the uterus into the abdominal cavity. These are called subserosal fibroids and make the uterus larger and irregular. They can be felt on a pelvic exam. If fibroids grow in the muscular layers of the uterus, they are called intramural. They can make the uterus enlarged, asymmetric, or can go unnoticed. The most problematic fibroids are often the ones that are submucosal. Submucosal fibroids grow inward, into the cavity of the uterus. Because they disrupt the endometrial lining, they often make menstrual cycles very heavy. Some women have many fibroids, and in extreme situations, the uterus can be as large as a pregnant uterus.
How do you remove fibroids? Fibroids can be removed surgically by a procedure called a myomectomy. Myomectomies for large fibroids often are done via a laparotomy, which is an incision in the lower abdomen. Physicians who are skilled at laparscopic myomectomies may be able to removed an accessible fibroid with a laparoscope. Fibroids that protrude into the uterine cavity can be removed with a hysteroscope. A hysteroscope is inserted through the cervix. Instruments can be inserted through the scope that shave off the portions of the fibroid that protrude into the cavity. This procedure can markedly reduce bleeding. Because it is a same-day surgery procedure, there is little recovery time, minimal pain, and most often very well tolerated.
Polyps of the endometrial lining are very common. They are growths of the internal endometrial lining of the uterus. Polyps are not able to be palpated on exam, and are most often found when a sonogram is done for abnormal bleeding. Polyps most often cause irregular spotting, but multiple polyps in the uterus may make cycles heavier. Polyps are rarely malignant, but often are biopsied or removed with a D&C.
Abnormal bleeding is a symptom of endometrial cancer. Often a sonogram is performed for abnormal bleeding, and a thickness of the endometrial lining is noted. In a postmenopausal women, the uterine lining should be less than 5 mm. A biopsy of the uterine lining can be performed in the office.