Patients with long-term hormonal suppression should visit their OB/GYNE to assess possible malignancies. Clinical microscopes are used by clinicians to examine tissue samples for malignancies and other pathologies and diseases.

For patients with underlying medical conditions, such as coagulopathies or a malignancy requiring chemotherapy, long-term therapeutic amenorrhea with menstrual suppression using the following regimens may be necessary as well as tissue sample biopsies using clinical microscopes:

1.    Progestins, such as oral norethindrone, norethindrone acetate, or medroxy¬progesterone acetate, on a continuous daily basis
2.    Continuous (noncyclic) combination regimens of oral estrogen and progestins
(birth control pills) that do not include a withdrawal bleeding-placebo week.
3.    Depot formulations of progestins (DMPA), with or without concurrent estrogens 4. Gonadotropin-releasing hormone (GnRH) analogs

The choice of regimen depends on any contraindications (such as active liver disease pre¬cluding the use of estrogens, or thrombocytopenia precluding intramuscular injections) and the clinician’s experience. Although the goal of these long-term suppressive therapies is amenorrhea, all of these regimens may be accompanied by breakthrough bleeding. They require regular follow-up visits and continued patient encouragement. When in doubt, tissue sampling and examination using clinical microscopes should be done. Occasional episodes of spotting and mild breakthrough bleeding that do not result in a lowered hemoglobin level may be managed expectantly. When breakthrough bleeding affects the hemoglobin level, it should be evaluated with respect to the underlying disease. For example, in a pa¬tient with underlying platelet dysfunction, breakthrough bleeding may reflect a lowered platelet count. Bleeding in a patient with hepatic disease may reflect worsening hepatic function. Supplemental estrogen can be helpful in the management of excessive break¬through bleeding that has no specific cause other than the hormonal therapy.

Beyond the first 1-2 years after menarche, menstrual cycles generally conform to a cycle length of 21-40 days, with duration of less than 7 days of menstrual flow. As a woman approaches menopause, cycle length becomes more irregular as more cycles become anovulatory. Although the most frequent cause of irregular bleeding is hormonal, other causes occur more often than during the adolescent years. Pregnancy-related bleeding (spontaneous abortion, ectopic pregnancy) should always be considered, and a pregnancy test should always be obtained as part of the evaluation of abnormal bleeding. Although a variety of terms have been used to describe abnormal menses, a complete description of the menstrual pattern may be more important than the use of the correct term.

Dysfunctional Uterine Bleeding

The term dysfunctional uterine bleeding has been used to describe abnormal bleeding for which no specific cause has been found. It most often implies a mechanism of anovulation, although not all bleeding that is out¬side the normal range (either in cycle length or duration) is anovulatory. The term is a diagnosis of exclusion, which is probably more confusing than enlightening.

Most anovulatory bleeding is a result of what has been termed “estrogen breakthrough.” In the absence of ovulation and the production of progesterone, the endometrium responds to estrogen stimulation with proliferation. This endometrial growth, as seen in clinical microscopes using tissue samples, without periodic shed¬ding results in eventual breakdown of the fragile endometrial tissue. Healing within the en¬dometrium is irregular and dysynchronous. Relatively low levels of estrogen stimulation will result in irregular and prolonged bleeding, whereas higher sustained levels result in episodes of amenorrhea followed by acute, heavy bleeding.