What is it? Heavy or abnormal bleeding, also called dysfunctional uterine bleeding, leads to a fifth of all hysterectomies in the United States.

What are the symptoms? To some women, it means very heavy periods, others have unpredictable bleeding throughout their cycles. In severe cases, it can lead to anemia. It is sometimes a sign of precancerous or cancerous conditions.

How is it best diagnosed? Abnormal bleeding calls for a thorough investigation, and that should start with a detailed history. The most important question: Is the bleeding cyclical, or is it unpredictable?

For women with irregular bleeding throughout their cycles, a Pap test and endometrial sampling – to look for precancerous or cancerous cells in the cervix or uterus – is vital. This means scraping some cells from the cervix, the uterus, or both. “I do it in the office, and it takes about 10 seconds and causes a little cramping,” says Dr. Walsh. It’s also important to do an ultrasound to locate possible growths, such as fibroids, that might be causing the bleeding. For women with regular but heavy periods, biopsy is not as vital, but an ultrasound can supply important diagnostic information.

When is a hysterectomy inappropriate? Hysterectomies are not appropriate when the cause of the bleeding hasn’t been diagnosed or when medications such as hormones haven’t yet been tried. Most experts agree that hysterectomy should only be considered as a last resort. According to some experts, fewer than 10 percent of cases of genuine abnormal bleeding require a hysterectomy.

What are the treatment alternatives? Depending on the cause of the bleeding, treatments might include the following options.
Nonsteroidal anti-inflammatory drugs (NSAIDs). These can sometimes help slow down bleeding.

Combination oral contraceptives (OCs). These are often ideal for women who are not ovulating regularly and are therefore bleeding throughout the month. OCs can give wonderful regularity and they can help ward off the risk of endometrial cancer, a disease which is more likely to strike women with irregular ovulation.

Progesterone. This can be helpful for women with irregular ovulation leading to unusual bleeding. Dr. Walsh often uses it for women who don’t want to take or can’t tolerate birth control pills.

How does it work? Progesterone regulates the monthly growth and shedding of the uterine lining. “If you don’t have progesterone,” Dr. Walsh explains, “this lining gets thicker until it gets very unstable, and a little piece may fall off, and sometimes you have spotting. Other times a whole chunk falls off, and you have very heavy bleeding.” Taking a progestin for 10 to 14 days can regularize the cycle. (For women who cannot tolerate synthetic progestins, natural progesterone can be a more comfortable choice.)

Endometrial ablation. This is another alternative to hysterectomy. In this procedure, the endometrium (the inner lining of the uterus) and the basilis (the layer under it) are destroyed. “We can do it vaginally. It’s a minor procedure, and you can keep your uterus,” says Dr. Fugh-Berman. “It’s permanent, but it’s much less invasive than hysterectomy.”