My wife is 43 and started bleeding daily five months ago. She had tests done to rule out cancer and was told to wait and see if it would go away on its own. Since it did not, the doctor put her on birth control pills. This has controlled the bleeding but has created mood problems. Are there other types of treatment available that our small-town doctor may not be aware of that would control the bleeding and not require mood-altering drugs?

--Frank

Many women experience abnormal bleeding beginning in their 40s. There are numerous reasons for such bleeding, ranging from hormone imbalance, to a blood clotting disorder, to taking too much aspirin, to abnormalities of the uterus such as fibroids or polyps, to cancer. The work up for abnormal bleeding can be extensive, but it should continue until all directly treatable causes are ruled out.

Because cancer is the worst thing that can cause abnormal bleeding, it must be eliminated as a possibility. This may be done by ultrasound to measure the thickness of the uterine lining -- a thin lining is unlikely to harbor cancer -- or by biopsy. Biopsy can be an office procedure (endometrial biopsy) or a full fledged D&C. Hysteroscopy (looking inside the uterine cavity with a telescope-like instrument) and directed biopsy or D&C is the most thorough means of assessing the uterine cavity, and this method can also identify fibroids or polyps that might contribute to abnormal bleeding.

Other tests to evaluate abnormal bleeding include tests of thyroid function and blood clotting. Both of these involve simple blood tests.

If a specific cause for abnormal bleeding is found, it is specifically addressed and treated, and the abnormal bleeding will stop. If, after other treatable causes are ruled out, the conclusion is that the bleeding is due to the hormonal changes that precede menopause, then hormone manipulation may be tried. Birth control pills are one type of hormone manipulation, and they work well for many women. Some women, however, cannot use birth control pills due to smoking or other medical conditions. Other women have problems with side effects of the pill. Progesterone therapy is another option for these women. Either a synthetic or one of the new natural progesterone like Prometrium or Crinone are taken for 12-14 days each month to regulate bleeding. Many women are able to tolerate progesterone -- especially natural progesterone -- better than birth control pills.

Some women do not tolerate or do not respond to hormone manipulation. For these women, surgery may be a better option. An outpatient procedure called endometrial ablation can control bleeding in up to 80 percent of women. There are several ways of doing an endometrial ablation, but the basic idea is that the uterine lining is burned away. For especially bothersome cases -- especially if there is a structural problem like fibroids, or if all other options have been unsuccessful -- a hysterectomy may be the best choice.

Your wife's doctor should be able to discuss all these options with her. If her doctor is unfamiliar with these, or if the local hospital is unable to provide these services, she may wish to seek a second opinion from another gynecologist.