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    heavy periods and passing tissue
    ruthy0374 posted:
    i have been having irregular periods ever since jan. i believe i had an ectopic pregnancy in jan but was never confirmed because an ultrasound was never ordered. but i had a positive urine pregnancy test but negative blood test. one month later when i did have an u/s, i was diagnosed with an ovarian cyst and a hydrosalpinx. 15 mths ago i had my 4th child and the removal of my left ovary and tube due to many cysts and a tubal ligation performed on the right tube. but my periods are way worse now than they were in my teens. i also have PCOS and am IR. my periods are super heavy where i pass a golf ball sized clot every time i have to empty bladder and standing up makes it worse. but my last period was actually sooner than it should have been and on day 4 i had very bad cramping and when i went to the bathroom, i passed a large piece of tissue that was not a clot. it was like a piece of liver or meat. it was not flexible like a clot is. and yes i inspected it to see what it was because it felt very weird coming out of me. i continued to have bad cramping for a couple of hours later and had to take something for pain. the next day i woke up to bad cramping but didn't pass anything other than clots. is this normal and should i be having an endometrial biopsy? as of now, no one wants to remove the ovarian cyst or the ovary unless it grows larger, but i don't know what size it is at this moment. i don't feel that my periods are normal and that something is wrong. and i wonder if i am getting pregnant but losing it before it gets started. i was told i could take a progestin only pill but the gyn wanted to do an endometrial biopsy first and i don't want to have that done since i have had 4 sections. thanks for any info on this.
    J_Harrison_Hohner responded:
    Dear ruthy: Let's take each of your concerns in order, OK. You are correct, an ovarian cyst, and PCOS (with insulin resistance) can both cause missed ovulations and excessive bleeding with huge clots. Your possibly have endometrial hyperplasia. Simply stated, if the uterine lining is like grass or lawn, estrogen is like the fertilizer (causes proliferation and a thickening of the lining or hypertrophy), 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 endometrial hyperplasia and endometrial cancer. The most common reasons for a woman to not be ovulating (no lawn mower activity so thicker lawn) are being heavy set, PCOS or being early perimenopausal. Endometrial hyperplasia is a common cause of heavy and prolonged bleeding. The diagnosis can be made by ultrasound or endometrial biopsy. The ultrasound image measures the thickness of the lining ("endometrial stripe"); with hypertrophy it is usually more than 12-15 mm. I had a patient once with a stripe of 30mm! The endometrial biopsy takes a sample of lining tissue and the pathologist can then make a very accurate diagnosis base upon the cells seen under the microscope. The treatment for simple hyperplasia/hypertrophy which does not contain abnormal cells is synthetic progesterone pills or shots. This shrinks down the too thick lining. A very heavy flow (eg from a too thick lining) can produce VERY large clots. Normally there is an enzyme produced in the uterus which keeps the menstrual flow liquid so it can pass out the cervix easier. When the flow is very heavy it can outstrip the enzyme's ability to keep thing liquid. Hence the large clots passed with cramping as the uterus tries to expel them through the cervix. In terms of tissue passage, most commonly, when we send such specimens to the lab, the report returns as: white blood cells, red blood cells, fibrin, and other components of uterine lining tissue. It can look different as it is more solid that the liver-like consistence of blood clots. Many women worry that this is linked to a missed miscarriage, but that is not the usual explanation. If this is a concern to you than a sensitive pregnancy test can be done. VERY rarely a woman will pass a "uterine cast". This is when the lining is passed as a triangular shaped bit of tissue similar to the shape of the inside of the uterus. The predisposing condition for passing a uterine cast is abrupt cessation of high dose progesterone therapy. I have also seen a cast associated with an ectopic/tubal pregnancy. There is no easy way to clearly document an early miscarriage unless one has blood tests drawn at 48 hour intervals. It is even more difficult to absolutely document a miscarried ectopic. Yet miscarried ectopics are very uncommon. If you were my patient I would try and do an endometrial biopsy given your heavy bleeding and risk factors for a too thick lining. The progestin only pills are an excellent place to start because their minimal side effects. If you are insulin resistant drugs (eg metformin) or losing 10% of current body weight can help to restore regular ovulations. It sounds like you are getting good care from your GYN so I would urge you consider their advice. Yours, Jane
    ruthy0374 responded:
    thank you Jane. i am taking metformin and i have lost over 30 lbs in the last 5 mths and i thought that would have helped with the periods but so far it hasn't. i am working on losing weight and exersising but i admit it is hard to do with pain and the heavy bleeding. i don't think it was a uterine cast, but probably the fibrin since it was somewhat thicker than a clot. at my 6 week pp check up last year i had an abnormal pap smear and i have had normal ones this year and i go for the last pap this month and if it is normal then i go back to yearly. i am worried about having a biopsy just because of the uterine scar i have. i also read about tubal ligation syndrome and adenomyosis. i do have thick lining but i do believe that the removal of one ovary and then the tubal on the other side has made it worse because my periods were never like this in between my children and i wasn't taking BCPs or any other contraceptive. only metformin which is how i conceived the last 3. if not for metformin i would have never ovulated to get pregnant cause i had to take clomid with my 1st. thanks again for the information. i appreciate it very much. Ruthy

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