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Uterine Fibroids / Abnormal Bleeding

Other than for routine care and pregnancy, heavy and abnormal uterine bleeding is one of the most common reasons a woman might seek the care of a gynecologist.   In many cases, abnormal uterine bleeding is the results of structural issues with the uterus like polyps or fibroids.  In other cases, it can be the result of hormonal dysfunction in ovarian / uterine communication.  Either way, if you have these problems you need the help of an expert gynecologist to figure it out and offer a solution.  The good news is that abnormal uterine bleeding is one of the most solvable problems a woman can have.  If you are struggling, with such issues, we would love to help.  

As a national expert practice in minimally invasive gynecology, we offer surgical and non-surgical treatments for all types of uterine bleeding issues, including adenomyosis, fibroids, uterine polyps, in additional to hormonal issues causing abnormal bleeding.   We offer minimally invasive hysterectomy, minimally invasive myomectomy (removal of fibroids), hysteroscopic myomectomies, and laparoscopic fibroid ablation, all performed through tiny incisions for quick recovery, and a very low complication rate.  

So How do I know if My Period is Abnormal?
What are the reasons for abnormal bleeding? 

A normal menstrual cycle comes on the average every 28 days in a woman's life, though some women have somewhat longer or somewhat shorter cycles.  Most women bleed for 3-5 days a month, with the first day being somewhat heavy and decreasing every day after that.  Some women bleed lightly for one day before it becomes heavier.  Most women experience some cramping with their cycle, which can get better with Tylenol or ibuprofen.  Most women use pads or tampons during their cycle, and require a single pad or tampon at most every hour the cycle is heaviest, though most need them less frequently.

Abnormal menstrual cycles could be:

  • Bleeding that requires a pad or tampon every hour for many days, or even more frequently.

  • Bleeding that is painful enough that a woman cannot work or enjoy other activities

  • Bleeding that is unpredictable in onset, with no real pattern to cycles

  • Bleeding that is so heavy that a woman feels feint, or has documented iron deficiency anemia.

  • Bleeding so heavy that a woman bleeds past normal hygiene products like pads or tampons, or regularly passes large clots with her cycle.

There are two fundamental reasons a menstrual cycle is abnormal - either there is something structurally wrong with the uterus, like fibroids, polyps, or adenomyosis, or the signaling system between the ovaries and uterus is not functioning correctly, or both.

A uterus (and thus a woman) bleeds every month because of a regular cycle of estrogen and progesterone coming from the ovary.   At the beginning of each cycle, the ovary prepares to ovulate and makes estrogen, which in turn creates a thickening in the uterine lining.  In mid cycle, the ovary ovulates, after which it begins to make progesterone.  This progesterone stabilizes the uterine lining.  If a woman gets pregnant that month, the progesterone continues throughout the pregnancy.  If she does not get pregnant, after two weeks the progesterone levels falls, which triggers a sloughing off of the uterine lining, which is the menstrual cycle.  

Any disruption of this ordered series of hormonal signals can create abnormal bleeding.  In many cases, the fundamental issue is a lack of regular ovulation, leading to too much estrogen and not enough progesterone.  When this is the reason that a uterus is bleeding in a disordered way, treatment is generally through medications that will help the ovarian / uterine communication work better.  In many cases this involves using hormones that will create new signals that will trigger bleeding and non-bleeding to the uterus, such as birth control pills.

The other fundamental reason for heavy and disordered bleeding is, for all intents and purposes, a uterus that just doesn't know how to stop bleeding.   

A uterus controls its own bleeding because it is a muscle that can contract, smashing together the walls of its cavity and putting pressure on the area where the bleeding is coming from.  Just like putting pressure on a cut area in your skin, this stops the bleeding readily.  When the uterus is a normal shape and has a smooth lining, this works well. 

When a uterus, however, is not of normal shape and does not have a smooth lining, it can have a hard time making itself stop bleeding.  For example, fibroids in the uterus can give the uterine wall an abnormal shape, making it hard for the uterus to contract correctly.   Sometimes there can be fibroids in the lining of the uterus as well, that make it impossible for the uterine cavity to completely contract.  Uterine polyps can cause the same effect.   Adenomyosis is another structural condition of the uterus that can cause heavy and painful bleeding.

When structural issues are causing abnormal bleeding, the answer is either to make the entire uterus to bleed less with hormonal treatment, or to fix the structural issue surgically, either by repairing the uterus (removing fibroids or polyps) or removing the uterus entirely.

What are fibroids?

Fibroids are muscle tumors within the wall of the uterus.   They may lie in the cavity of the uterus (submucosal), in the wall of the uterus (intramural), or in the skin of the uterus (subserosal).

Fibroids cause heavy bleeding because they are large masses of muscle that require blood to survive, and in turn they cause the total blood flow into the uterus to increase.   They also cause heavy bleeding by causing the uterus to contract improperly, preventing the uterus from stopping its own bleeding.  This is especially true for submucosal fibroids in the cavity of the uterus.


Many women have fibroids that are asymptomatic, meaning they aren't causing any problems.   Other women have fibroids that are large, numerous, or in a position to cause significant symptoms.  In those cases, we recommend some kind of treatment. 

How can fibroids be treated?

When fibroids require treatment and medical therapy to reduce bleeding is either ineffective or not desired, surgical treatment becomes the optimal course. The goal of surgical treatment is to either remove the fibroids or to shrink them to the point that they no longer cause symptoms.  In our practice, we offer minimally invasive myomectomy to remove fibroids while preserving the uterus and the ability to carry additional children (or a first child!)  For women who are no longer desiring fertility, minimally invasive hysterectomy if often an optimal path.   We also offer fibroid ablation via Access, a new technology for shrinking fibroids using a laparoscopically guided ablation device.  We also refer to interventional radiology for uterine artery / uterine fibroid embolization when appropriate (and we favor Mary Costantino in Portland, an outstanding IR physician focused on women's health.)  

What is Adenomyosis?

Adenomyosis is a condition of the uterus where the uterine glands (the endometrium) is growing within the muscular wall of the uterus.  This causes the uterus to be enlarged, to bleed more heavily, and to be painful during the menstrual cycle (and in some women at all times).  Adenomyosis is most common in women who have had many children, as the most common mechanism to get it is from the lining of the uterus to grow into the uterine wall after the placenta has separated after childbirth, leaving a portal for the endometrium to grow into the wall.  Adenomyosis is also occasionally present in women who have not had children, though it is relatively less common.

How is adenomyosis treated?

Some women with adenomyosis have adequate improvement with hormonal therapy such as birth control pills or a progesterone IUD.  Other women find that this is not effective, and they require surgery for adequate resolution of their symptoms.  When surgery is required, the most effective way to treat adenomyosis is a minimally invasive hysterectomy.   There is also a relatively unusual procedure for removing adenomyosis while preserving the uterus called an Osada procedure, though we do not presently offer this in our practice.

Why should I see Dr Fogelson for my abnormal or heavy bleeding?

Dr. Fogelson is one of the most experienced gynecologic surgeons on the West Coast, seeing patients from Oregon, Washington, California, and around the country.  He is sought out for his high level of surgical skills in management of all types of gynecologic issues.   After having performed over 1,000 minimally invasive hysterectomies as well as many other gynecologic procedures, Dr. Fogelson is able to almost guarantee a minimally invasive approach to any gynecologic surgery, no matter how complex.  While the possibility of complications in surgery cannot be completely eliminated, Dr. Fogelson's experience leads to a dramatically lower rate of issues than the national average.  Whether you have severe endometriosis and require surgery or just have very heavy bleeding from fibroids or adenomyosis, Dr. Fogelson will provide you with world class surgical care.  Dr. Fogelson is also happy to see you about non-surgical management of your bleeding issues, and can give you all the time required to thoroughly evaluate your issue and find the best possible solution.

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