Anovulatory Bleed

Definition - What does Anovulatory Bleed mean?

An anovulatory bleed is bleeding that occurs in the absence of ovulation. This lack of ovulation interferes with the normal menstrual cycle because there is then no luteal phase. Because of the luteinizing hormone (LH) surge, the formation of corpus luteum, and production of progesterone are features of the luteal phase, these will be absent in anovulatory bleeding. The ovarian follicles, however, continue to produce estrogen, which stimulates the uterine lining (endometrium).

Anovulatory bleeding occurs in 50% of women over the age of 40 years and in teenagers around their start of menstrual periods. The absence of ovulation leads to infertility.

FertilitySmarts explains Anovulatory Bleed

In a normal menstrual cycle, ovulation stimulates the production of progesterone. In an anovulatory cycle, inadequate progesterone levels lead to heavy bleeding. The inability of estrogen to support a growing endometrium on its own causes the uterine lining to shed.

The following causes can trigger anovulatory bleeding:

  • Hypothalamic-pituitary-ovarian axis defect - mostly affects teenagers and causes breakthrough bleeding
  • Polycystic ovary syndrome (Most common cause of anovulation)
  • Obesity
  • Eating disorder (like anorexia nervosa)
  • Intense exercise (Female athlete triad)
  • Psychological stress
  • Thyroid problems
  • Diabetes mellitus
  • Increased prolactin levels
  • Medications like anti-seizure medications, antipsychotics

The majority of women with anovulatory bleeding may experience irregular and infrequent menstrual periods while others may have heavy periods. This is because high levels of unopposed estrogen cause the cessation of menses (amenorrhea) and the sudden withdrawal of estrogen triggers heavy withdrawal bleeding. This can be mistaken for a normal heavy period.

Unopposed estrogen production causes excessive endometrial proliferation, increasing the risk of endometrial cancer. Anovulation also interferes with a woman’s reproductive potential.

In women showing symptoms of anovulatory bleeding, a doctor will perform an ultrasound scan and relevant blood tests. Women who fall in the following categories are candidates for an endometrial biopsy:

  • Women with recurrent anovulatory cycles
  • Women before the age of menopause either with increased bleeding volume and/or duration of bleeding, bleeding more often than every 21 days, bleeding after sex, or who bleed between the periods.
  • Teenagers whose bleeding is spaced at intervals of more than 3 months or who have greater than 3 years of irregular cycles
  • Women above the age of 35 years suspected of having anovulatory bleeding
  • Women who do not respond to medical therapy

The treatment of anovulatory bleeding includes hormonal therapy with contraceptive pills, cyclic progesterone, or progesterone-releasing intrauterine device (like Mirena). Women who are unresponsive to medical therapy or who continue to have breakthrough bleeding may choose to undergo the surgical removal of the uterus (hysterectomy).

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