Women's Health Community

Dear brigidsmom: Actually both your surmises contain some truth. The increase in heavy bleeding could be hormonal. Hormonal causes are usually linked to missed or erratic ovulations. As you may know, in a normal cycle, estrogen is produced all month. Estrogen is responsible for building up the lining of your uterus so you have something to shed each month. In a normal cycle, progesterone production increases following ovulation. Progesterone "stabilizes" the uterine lining in preparation for a possible implantation of a new pregnancy. If you are not pregnant that month the levels of estrogen and progesterone fall, triggering the release of the uterine lining—your period.

So, if you do not ovulate, the estrogen build up of the lining continues, but without the usual ovulation associated progesterone. Thus, the hormone levels don't decline, and the lining stays up inside the uterus--or gets thicker and thicker. Alternatively the lining can begin to shed under its own weight producing prolonged bleeding. This may have been what happened when your period arrived nine days early.

Another way inadequate progesterone production from missed ovulations can create too heavy a flow is as follows. Simply stated, if the uterine lining is like grass or lawn, estrogen is like the fertilizer (causes proliferation and a thickening of the lining ), and progesterone is like the lawnmower (keeps the lining thin by three different mechanisms). This is why DepoProvera (high dose synthetic progesterone) brings about a thin lining, and why birth control pills (relatively progesterone dominant) bring about shorter, lighter periods. It is also why women who miss ovulations (no progesterone produced) are at a greater risk for too thick lining.

Causes for not ovulating are multifold: thyroid problems, pituitary problems, ovarian cysts, physical stressors (eg sudden increases in exercise, crash dieting), emotional stressors (problems with spouse, children, finances), increased body weight, anorexia, rotating shifts at work, etc. You mentioned that a small ovarian cyst was seen. They can interfere with ovulations.

Perimenopause is definitely a cause of missed or decreased ovulations. Technically perimenopause is the 4-5 years before the last natural period. On average it begins about age 46-47. However, as we move into our 40's the incidence of ovulation, and/or the amount of progesterone produced, can begin to decrease--even without being overtly perimenopausal.

A 12mm thick lining MIGHT be within the range of normal, depending upon what time of your menstrual month the ultrasound was done. Still, it is thickened. Moreover you have been having abnormally heavy flows over the past nine months. It deserves to be evaluated. One should rule out that abnormal cells have developed within a too thick lining. ...Likely treatment for a too thick lining is to be prescribed a short course of progesterone if indicated.

Hopefully your GYN visit will yield your most "for sure" answer.

Yours,
Jane

Jane,

Thank you so much for your extensive reply. I can't tell you how much I appreciate you taking the time to really explain every aspect of the situation, from what is normal to what could possibly be happening to cause the changes. Your explanation has really helped me to get an idea of what could be going on, and actually does allow me to look at the big picture and what is most likely happening rather than immediately thinking the worst!
When I had my U/S I was about exactly halfway through my cycle, two weeks before I ended up getting my period. I am glad my physician is being proactive and hopefully exploring all possibilities.
Thank you again for your help and expertise, and I will be sure to come back with an update.
Jeanine

Dear Jeanine: Gosh, if you would be wiling to give us all the results of your work up that would be so great. Many, many more persons read these posts than ever write a reply. Generally they are looking for a person whose symptoms match their own. So when you share your final results it's like completing a short story. When you write an update you can either add it to this thread--or post as a new entry. Be sure to add my name in the subject line so we can find you.

As an aside, the measure of uterine lining thickness is the lowest right after menstruation (eg 3 mm). The thickest lining may occur as estrogen levels peak (eg 8-13 mm). We don't usually get worried until the lining is over 15 mm. The thickest I have ever had with a patient was 30 mm!

Yours,
Jane

I have the same thing going on with me and am scared and constantly stressing over this until my next ultrasound, but on top of this i have a cyst in both ovaries and in cervix.. Do I need to worry?

Hi 69 puppy,

This was actually my post with a response from Jane....I had a very fortunate ending to this story. I had the biopsy, and everything came out negative. It seems that this is probably just how my body is changing moving towards menopause. I also have cysts on my ovaries, which are most likely benign. I was given options to try to reduce the heavy bleeding with medication, but I chose not to because I would rather not start artificially regulating when it is really not a big problem for me, just have to be vigilant during my period! Hope all works out well for you.

Jeanine

68puppy,
How thick has your lining gotten and at what point in your cycle? As Jane stated, there shouldn't be a concern unless the lining is over 15mm. As far as ovarian cysts, they are very common and almost always benign so probably no need to worry.

I am too going thru this. I have been bleeding for one and a half years very heavy with no rhythm or reason. I have had two ultrasound about a year apart and at different stages of the bleeding and my uterus both times measured 24mm. I am scheduled for a biopsy today. Also my TSH came back at the highest normal (normal was .04 to 5.5) mine was 5.5. I am over weight (size 14) and I am 38 years old. I too have a cyst on my left ovary and the last ultrasound showed multiple tiny cysts in my uterus. I'm very nervous about all of it.

It's good you're having this thick lining checked. Here's some info on heavy bleeding and endometrial hyperplasia -
Heavy bleeding [br> Endometrial Hyperplasia

I'm surprised the top of the range for TSH at your lab is 5.5. I thought most labs high was 4.0 or 5.0 (and I'd read that should be reduced to 3.0). Also, even if 5.5 is considered "normal" it's tending toward hypothyroid. If you have symptoms of hypothyroidism, thyroid meds may be warranted. Thyroid problems can cause menstrual problems. A couple of good websites about thyroid problems are http://thyroid.about.com/ and http://www.stopthethyroidmadness.com/

Post back and let us know what you find out.

I probably also should have posted these links since you mentioned ovarian cysts and uterine "cysts" (fibroids?).
Ovarian cysts and ovarian cancer
Fibroids

hi Jane Harrison Hohner! i wish you could shed light unto my somehow similar prob with them. i had bleeding 2010,ultrasound showed with myoma 1.3cm and thickened lining. i was given primolut n. after finishing the required 30 tabs i went back and my ultrasound showed still the myoma and reduced lining. after two years 2012 i had again bleeding. btw, i am an overweight person (178lbs) age 41, tried dieting and go to the gym by 2012 sept. sept 24,2012 i experienced heavier bleeding than that of 2010. i was so scared i took primolut n again to stop bleeding. the following day i get to see a another ob gyne and she said to continue my primolut n then take quiloria pills for 28 days and if during the treatment i'll be experiencing heavier flows i should be taking hemostan with an NSAID drugs. i am also experiencing pain in my buttocks area. the myoma near the lining measures 3.59cm already. and it seems it is growing so very near the thick lining of about 14 and the ob gyne said it was the cause of my heavy bleeding. i told her that i wanted it removed for we have a history of CA deaths. she said that i continue taking the pills for now. and we'll just wait and see. would u suggest me to see a gyne oncologist rather than a ob gyne perintologist? is drinking pill would address my thickening lining? will that exempts me from getting a CA of uterus? scary! please help. thanks a lot!

Dear dezereevee: Let's take each of the concerns in order,OK?

Myoma/fibroid--Size was 1.3 cm in 2010, now is 3.59 cm. Myomas tend to thrive in an estrogen rich environment--just like a thickened uterine lining. Fibroids tend to grow larger in our 30s and especially 40s. Moreover, being heavy set has been linked with higher estrogen levels (body fat coverts precoursors to estrogens). Both the size and the position of a fibroid can have an impact on the amount of bleeding they can cause.

Thickened uterine lining ("endometrium")--The Primolute is norethindrone (same synthetic progesterone used in birth control pills). As you may have read, if the uterine lining is like grass or lawn, estrogen is like the fertilizer (causes a thickening of the lining ), and progesterone is like the lawnmower (keeps the lining thin by three different mechanisms). This is why DepoProvera (high dose synthetic progesterone) brings about a thin lining, and why birth control pills (relatively progesterone dominant) bring about shorter, lighter periods. This is why the month of Primolut made the lining thinner. This is also why the second round in 2012 of Primolute followed by the birth control pills was recommended by your current GYN.

What she has recommended is a reasonable treatment option. If the lining does not shrink back down she may want to do a biopsy of the uterine lining or a D&C to see if any abnormal cells are present. Synthetic progesterone is considered an acceptable treatment as long as no abnormal cells are present.

Long term treatment--You mentioned you wanted it removed. It's not clear to me if you meant to remove the uterine lining as in an endometrial ablation (EA) or a hysterectomy. EAs are not done if there are abnormal cells. Hysterectomies definitely have their place as a treatment, but not always as the first or second step.

If you want to get a second opinion, you could certainly choose to see a GYN oncologist. Yet sometimes you will need a referral You could also see a second GYN. Just be aware that any endometrial biopsies done while you are actively using some type of progesterone may make it more difficult to identify abnormal cells in the lining because of the secretory changes caused by the progestin (synthetic progesterone).

Your have some risk factors for continued bleeding problems. Heavy set women can miss more ovulations (no progesterone produced) and are at a greater risk for too thick lining. You have a fibroid which can prompt more bleeding as well.

Bottom line, I would urge you to follow the treatment plan of your current GYN. Get a second opinion if you prefer. I would suspect that your own GYN will be monitoring you closely given your history and risk factors.

In Support,
Jane

Hi - Im trying to get some more info on my situation.
I am 40 yrs old, a little over weight, have one child and have been bleeding really heavy for the past 2 yrs.
I went to new ob/gyn last week and had a pap, havent had one in 5 yrs--no insurance.
Told her my probs, she said need to do ultrasound, then biopsy. I also have the hpv virus, and had precancer cells froze off 10 yrs ago.
ultrasound showed very thick lining, no fibr showings.
she tells me that the thick lining along with me having the hpv virus-precancer cells- could mean i have uterian cancer. ovaries looked good. took some blood to test my thyroid
having no insrance and doing all this is expensive.
my sister had the same thing....bad bleeding,etc. and had the endometrial ablation - so i said i wanted that and the doc says no until we have biopsy to rule out cancer.
is she tryin to really watch out for me? is cancer somethign i should be really worried with? or is she jsut tryin to make more money from me? what way should i go? which way? more tests? is this normal? i have a period every 18-20 days and bleed 7-8 days...so im always on the rag...ugh...
tried birth control for yrs and never could get regulated after i had my daughter 10 yrs ago...so igave up on the pill..
i need some help with direction..not sure what to do.
dont have alot of money to keep going to dr and or seeing another dr to get another opinion...
can anyone help?
i would apprecaite it!!
blessings!

Here are my thoughts -
Yes, there are some small studies that say ablation is contraindicated for hyperplasia. So it makes sense that your doctor wants to do a biopsy first. Ablation can make it difficult to diagnose hyperplasia. Google "pubmed endometrial ablation hyperplasia." Also, if considering ablation, you may want to read the 166 replies to the WebMD discussion "Endometrial Ablation Side Effects" here - http://forums.webmd.com/3/gynecology-exchange/forum/12649/164#164.







Thyroid disease can cause menstrual cycle irregularities so it's good she's doing thyroid labs. Being overweight can also cause heavy bleeding (and predispose you to hyperplasia) and if you happen to be hypothyroid, that can make it difficult to lose weight!


I thought HPV was only associated with abnormal cervical cells and had nothing to do with endometrial abnormalities. So I searched PubMed and found this link - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2233766/ . It says "It appears that the presence of HPV in the endometrium, as detected by PCR, does not play any role in the initiation or prognosis of endometrial adenocarcinoma."




These links may be helpful in understanding hyperplasia:
http://www.acog.org/~/media/For%20Patients/faq147.pdf?dmc=1&ts=20121016T1122451597
http://www.jfponline.com/Pages.asp?AID=3184 .
Table 2 shows "Regression, persistence, and progression rates of endometrial hyperplasia"
As you can see, simple and complex hyperplasia without atypia have an 80% regression rate and only a 1% or 3%, respectively, progression rate.






Hormonal therapy is generally the first-line treatment for hyperplasia. This is stated in both of the above links.

Hello, my story is somewhat similar but still different. I am 51 yo and have had 5 kids by c-section. My periods have always been 4 weeks like clockwork til May. I went 6 weeks with no period and then once I started I had some type of flow for about 7 weeks. Did the ultrasound on stomach and vaginal, had a dnc performed which did not show much of anything irregular. 5 weeks no period then started and had daily flow for another 5 weeks straight. Did another ultrasound and dnc..This time he saw some benign cysts and said my uterus was enlarged to about 32cm. He performed an ablation and hysteroscopy, said there was alot of blood up there and sent off samples for biopsy. Mean while I feel like I am 3 months pregnant with the swollen stomach. I have slight discharge but it has only been 7 days. I am wondering how the uterus enlarged so much in about 2 months.
Does anyone have some information that might help? I want to start working on getting my uterus back to a normal size and patience is not my middle name. Any help will be appreciated!
Thanks
Jane