Wednesday, April 3, 2013

Break-Through Bleeding, aka "BTB"

I asked my nurse today what she gets the most telephone questions about on a day-to-day basis and she said without hesitation:  Break-Through Bleeding!  What is BTB, anyway?  Generally we doctors refer to bleeding between periods as BTB or "metrorrhagia", heavy bleeding with the period as "menorrhagia", and both together as "menometrorrhagia".  Depending on your age, BTB can be caused by different things.  Probably the most common cause in our younger patients is starting a new (<3months), hormonal contraceptive  (pill/patch/ring/shot/etc).  While your body is getting used to having the exogenous hormones controlling the bleeding cycle, there can still be the occasional irregular shedding of uterine lining, leading to the bleeding.  This is more likely nowadays with the very low estrogen dose pills, which are a little more unforgiving if the pill is taken at different times of day.  Even perfect usage can be associated with some BTB at first though. BTB does not mean that the contraceptive is not working to prevent pregnancy, however.

More concerning is bleeding that occurs between periods without any exogenous hormone treatment.  A normal menstrual cycle is between 21--45 days in length.  I tell patients that I need them to tell me if they have bleeding episodes less than 21 days apart (counting from the first day of the period to the first day of the next period).  Sometimes we discover benign polyps or fibroids of the cervix or uterus.  Rarely, we diagnose pre-cancer or cancer of the uterus, however.  This is higher risk in patients at the end of their reproductive years of course, but I've also seen it in younger patients with long periods of absent periods followed by heavy or irregular bleeding episodes.  I like patients to let me know if they miss more than 3 menstrual periods in a row, as hormonal treatments can make them more regular and prevent mutations that could lead to abnormal cells in the uterine lining.

Sometimes we do an office biopsy ("EMB") for abnormal bleeding, sometimes an ultrasound, sometimes both.  Occasionally we do a procedure with a hysteroscope that allows us to see inside the uterus fiberoptically and identify pathology during a D and C procedure (dilitation and currettage).
If abnormal bleeding patterns persist despite all our best efforts and diagnosis and medical management, we do have surgical procedures that can decrease or eliminate menstrual bleeding.

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