Diagnosis

Introduction
Terminology
Patterns of Bleeding
Causes of Menstrual Abnormailities
Diagnosis
Treatment
Myths
Summary

The diagnostic approach to a woman with abnormal menstrual cycles depends upon her age, the degree of menstrual abnormality, her desire for pregnancy, and the presence of other complicating factors. Whether the irregular bleeding is of recent onset or has been present for the woman's entire adult life is also of great importance.

Recent advances in technology have totally changed the diagnostic approach to women with irregular cycles or post-menopausal bleeding. Up to about 5 years ago, a D&C was the standard approach to a woman with irregular periods. However, all D&C does is remove a small percentage of the endometrium from inside the uterus.

A D&C rarely, if ever, permanently corrects irregular bleeding. The once exception might be if a woman has a polyp but that should be diagnosed prior to the D&C. In such a situation, a hysteroscopy should be done at the same time.

The first two steps in the diagnosis of woman with irregular bleeding is a vaginal ultrasound and the measurement of various hormone levels. The thickness of the lining of the uterus ( the endometrial cavity) is measured and the uterus is carefully examined for possible causes of abnormal bleeding such as fibroids or adenomyosis.

MEASURING THE THICKNESS OF THE ENDOMETRIAL CAVITY BY VAGINAL ULTRASOUND COMBINED WITH A SONOHYSTEROGRAM IS PERHAPS THE SINGLE MOST IMPORTANT DIAGNOSTIC STEP IN EVALUATING A WOMAN WITH IRREGULAR OR POST-MENOPAUSAL BLEEDING.

Careful studies have been done in post-menopausal women. In women not on Estrogen, if the endometrial cavity is 5 millimeters or less in thickness, endometrial cancer is rarely found. The critical level for women who are receiving Estrogen is 8 mm. Because of this, if a post-menopausal woman has any bleeding and the vaginal ultrasound shows a thin endometrial cavity, an office endometrial biopsy is still necessary because of the low but measurable risk of cancer.

The same approach can be taken to pre-menopausal women as well, with a few modifications. For instance, interpreting the thickness of the endometrium depends on knowing where in her cycle the woman is and how long she has been bleeding.

If a woman has a thickened endometrial cavity, the next step is a SONOHYSTEROGRAM. A SONOHYSTEROGRAM is a more accurate vaginal ultrasound in which saline (salt water) is injected into the uterus using a very thin plastic catheter. This procedure is either painless or minimally uncomfortable. Because of the way in which ultrasound works, the saline outlines the endometrial cavity and shows up quite clearly if there are any localized abnormalities.

If the SONOHYSTEROGRAM shows that the endometrial lining is uniformly thickened, an office endometrial biopsy is accurate and reliable and is all that is necessary.

If the SONOHYSTEROGRAM shows that most of the endometrial lining is thin and that there is one area that is abnormally thickened, an office biopsy should not be done since it might miss the abnormal area and a proper diagnosis cannot be made.

In such instances, the woman will require a Hysteroscopy to visualize the abnormal area. The D&C or biopsy that accompanies the Hysteroscopy can then be directed to the specific area in question.

As you can see from this explanation, in those instances where the SONOHYSTEROGRAM has indicated the need for a biopsy, it must be done in conjunction with a Hysteroscopy to make sure the area in question has indeed been biopsied. There is no reason to do a D&C in the hospital by itself without doing a Hysteroscopy at the same time.

Hysteroscopy is now becoming an office procedure since for most women, the level of discomfort is minimal. Having this done in the office if far better than having to go into the hospital unless there is known pathology inside the uterus which will require treatment at the same time. Even then, the entire procedure can be carried out in the office if the woman is willing to tolerate some discomfort and cramping. It is certainly better than having to go into the hospital.