Changes to the structure of the uterus and other pelvic organs can cause HMB.

Uterine polyps

What are uterine polyps?

A uterine polyp is a finger-like growth, originating from either the endometrial lining or the muscles of the uterus. They can be round or oval, and can range from a few millimetres to a few centimetres. They are usually benign, but can contain pre-malignant or malignant cells.

What causes uterine polyps?

It is not clear why polyps form in some women, but it seems that estrogen levels may be associated with uterine polyps. They are most commonly diagnosed in women between 40 and 50 years of age.

What are the symptoms of uterine polyps?

The symptoms of uterine polyps include irregular periods, heavy menstrual bleeding, spotting between periods, and infertility. Uterine polyps are also a common cause of vaginal bleeding after menopause .

How are uterine polyps diagnosed?

Along with your menstrual history, your doctor may advise one or several imaging procedures. These include pelvic or transvaginal ultrasound, sonohysterography, hysteroscopy, or endometrial biopsy.

How are uterine polyps treated?

If your polyps are not causing any symptoms, there may be no treatment required.  Medications to help regulate excessive bleeding, such as hormonal oral contraceptives may be used. If you are experiencing symptoms, your polyps will likely be removed surgically. Uterine polyps sometimes return after removal.

Endometrial hyperplasia

What is endometrial hyperplasia?

Endometrial hyperplasia is an overgrowth of the lining of the uterus. It is not cancer in itself, but left untreated it can progress to cancer. Endometrial hyperplasia typically occurs in women who have just begun menstruating or who are approaching menopause.

What causes endometrial hyperplasia?

This overgrowth usually occurs when excess estrogen is present, which stimulates the growth of the endometrium.

What are the symptoms of endometrial hyperplasia?

The primary symptom of endometrial hyperplasia is heavy or irregular menstrual bleeding.  This includes periods that last longer than usual, menstrual cycles that are shorter than 21 days (from the first day of one period to the first day of the next period), bleeding between periods or any bleeding after menopause.

How is endometrial hyperplasia diagnosed?

Diagnosing endometrial hyperplasia typically involves a transvaginal ultrasound, to visualize the inside of your uterus. An endometrial biopsy  is required to determine whether cancer or pre-cancer changes are present.

How is endometrial hyperplasia treated?

Many cases of endometrial hyperplasia can be treated with progestin, which has the opposite effect of estrogen and can stop the endometrial overgrowth.  Progestin can be administered as a pill, a shot, an intrauterine device, or an injection. If biopsies show that you have atypical hyperplasia and your risk of developing uterine cancer is high, a hysterectomy may be recommended.

Endometriosis

See the Endometriosis section for more information.

Adenomyosis

What is adenomyosis?

Adenomyosis happens when the endometrial tissue that normally grows on the inside of the uterus grows outwards into the muscle layer of the uterus. The uterus becomes enlarged and heavy menstrual bleeding occurs.

What causes adenomyosis?

Adenomyosis is not well understood, but it is thought that several hormones may be responsible for the condition. These include estrogen and progesterone, prolactin, and follicle stimulating hormone.

What are the symptoms of adenomyosis?

Sometimes the symptoms of adenomyosis are absent or very mild. In more severe cases, heavy, prolonged menstruation with large clots, and severe cramps may occur during menstruation. These heavy periods may cause anemia and fatigue. Adenomyosis may also cause pain during intercourse (but not typically constant pain).

How is adenomyosis diagnosed?

Your doctor will review your menstrual history, along with your signs and symptoms. A pelvic exam, ultrasound, sonohystography, or MRI can help diagnose adenomyosis. Your doctor may also recommend that an endometrial biopsy be taken to rule out more serious conditions. Because the symptoms of adenomyosis are so similar to endometriosis, fibroids, and polyps, diagnosing adenomyosis may only happen after these conditions have been ruled out.

How is adenomyosis treated?

Adenomyosis typically goes away after menopause, so if you are close to menopause your doctor may advise waiting and trying to manage the pain using anti-inflammatory drugs. Hormonal birth control (pill, patch, vaginal ring, IUD, shot) may also be used to manage symptoms by making your periods either very light or absent. In severe cases, where menopause is not imminent, hysterectomy may be recommended.

Fibroids

See the Fibroids section for more information.

Endometrial cancer

What is endometrial cancer?

Endometrial cancer happens when an overgrowth of cells occurs, originating from the endometrial lining of the uterus. It is most common in postmenopausal women.

What causes endometrial cancer?

The exact cause of endometrial cancer is unknown. It is known that increased estrogen that is not balanced by progesterone can make the endometrium susceptible to developing cancer.  Conditions that change the balance of estrogen and progesterone in the body can therefore increase the risk of endometrial cancer, such as polycystic ovary syndrome , obesity, and diabetes. Other risk factors include having taken prolonged hormone therapy, never having been pregnant, and more years of menstruation (e.g., early first period, no pregnancies). All of these factors can increase the exposure of the endometrium to estrogen.

What are the symptoms of endometrial cancer?

Symptoms of endometrial cancer include heavy menstrual bleeding, bleeding between periods, bleeding after menopause, and pelvic pain.

How is endometrial cancer diagnosed?

Endometrial cancer is diagnosed with a combination of a pelvic exam, pelvic and/or transvaginal ultrasound, hysterocope, and endometrial biopsy. Your doctor will review your menstrual history along with your signs and symptoms.

How is endometrial cancer treated?

The treatment for endometrial cancer depends on your age, the stage of the cancer, and your personal preference. Most women will opt to undergo a hysterectomy (removal of the uterus), along with removal of the ovaries and fallopian tubes. Radiation, hormone therapy, and chemotherapy may also be part of your treatment plan.

Uterine infections

What is a uterine infection?

An infection of the female reproductive organs can be caused by a number of different bacteria, including chlamydia, gonorrhea, ureaplasma, mycoplasma, and others. These infectious agents cause a condition known as pelvic inflammatory disease (PID).

What causes a uterine infection?

Sometimes PID is caused by a sexually transmitted infection , such as gonorrhea or chlamydia. Other risk factors include the use of an IUD, and douching.

What are the symptoms of a uterine infection?

Some infections (like chlamydia) can have no symptoms at all. Symptoms of a uterine infection may include pelvic pain, heavy menstrual bleeding, foul smelling discharge, bleeding between periods, pain during sex or urination, and fever or chills.

How is a uterine infection diagnosed?

Your doctor may suspect you have a uterine infection based on your symptoms. The diagnosis can be confirmed with a pelvic exam, taking a swab of your cervix, and testing your urine. You may have other tests to see if any of your pelvic organs have been damaged by the infection, such as a pelvic or intravaginal ultrasound or an endometrial biopsy.

How is a uterine infection treated?

Usually a uterine infection is treated with antibiotics. If the cause of your uterine infection was a sexually transmitted infection, your partner should also be treated.

Ehlers-Danlos syndrome

What is Ehlers-Danlos syndrome?

Ehlers-Danlos syndrome is group of more than 10 rare inherited disorders that affect the connective tissues of the body. It is a very rare cause of HMB. Affected tissues include skin, bone, joints, or the walls of the blood vessels. People with Ehlers-Danlos syndrome typically have very flexible joints, and stretchy, fragile skin. One type of Ehlers-Danlos syndrome also affects the walls of blood vessels, which can tear or rupture.  This disorder can also cause a bleeding tendency.

What causes Ehlers-Danlos syndrome?

This is a genetic syndrome that is passed on from parents to offspring. Even if only one parent has the syndrome, it can be passed down. The genetic mutation impacts one of the structural proteins of the body called collagen, or other related proteins, giving rise to this fragility and abnormal symptoms.

What are the symptoms of Ehlers-Danlos syndrome?

The symptoms of Ehlers-Danlos syndrome vary from person to person. Joints are typically very flexible, since the connective tissues within the joints are more stretchy than normal. The skin is very stretchy and fragile, and doesn’t heal well when injured. Women with Ehlers-Danlos syndrome are more likely to have heavy menstrual bleeding, pain with periods, and spotting.

How is Ehlers-Danlos syndrome diagnosed?

The clinical symptoms of Ehlers-Danlos syndrome (e.g., loose joints, stretchy skin) can be enough to make a diagnosis, particularly if there is a family history of the syndrome. Doing a genetic test on your blood can confirm the diagnosis.

How is Ehlers-Danlos syndrome treated?

Ehlers-Danlos syndrome cannot be cured, but the symptoms can be managed with medications, physiotherapy, and sometimes, surgery. Pain medications such as non-steroidal anti-inflammatory drugs (e.g., ibuprofen, naproxen) can be effective, or stronger medications may be prescribed by your doctor. For heavy menstrual bleeding, hormonal birth control methods can be used to regulate menstruation.