Dealing with Abnormal Vaginal Bleeding: A Minimally Invasive Approach

Assia StepanianWith this article, it is with great pleasure that I introduce to you my beginning series of editorials to discuss minimally invasive approaches to women’s health. We will begin by addressing a condition that I see affecting many women tremendously: abnormal vaginal bleeding. It creates anemia, associated fatigue, and if left unattended, can be life threatening.

What are the main objectives of treatment? Safety and quality of life. If pregnancy is present, urgent attention is needed. For young ladies, the possibility of experiencing a blood clotting disorder, presence of ovarian cysts, or potential hormonal disbalance (along with other concerns) must be taken into consideration. Further in reproductive years, such bleeding can signal uterine fibroids, adenomyosis (glands of the uterus within the muscle of the uterus), uterine polyps, cervical or vaginal problems and overgrowth of the lining of the uterus that can lead to malignancy.

For some, you may not realize the heaviness of your bleeding, so we always check your hemoglobin at the time of annual visits. Initial evaluation for vaginal bleeding (in addition to history and examination) includes a pain free Transvaginal (TV) ultrasound that can be performed during a first visit. This ultrasound results in a n abundance of information on the structure of your uterus, the endometrial lining and cervix, and confirms the normal architecture of the ovaries.

From here, it is determined whether or not a biopsy needs to be performed, noninvasive approaches are applicable or minimally invasive procedures or outpatient surgeries must be performed. There are many options in medicine to help you, and they each start with listening to what is happening in your life now, and what course can be taken to move you back to the joys of life easily, freely and fully.

Be brave and believe that everything will be OK.
With much love,
Assia Stepanian

P. S. In my September post I will be sharing my thoughts on Urinary Incontinence and pelvic organ prolapse.

The Cause, Symptoms, and Treatments of Endometriosis

The Cause

The lining of a woman’s uterus, the endometrium, is made up of special cells that are perfect for the functions of menstruation and pregnancy. When these special cells and their supportive structures (endometrial tissue) grow outside of the uterus endometriosis develops. When these cells and their supportive structures grow within the body of the uterus the condition is called adenomyosis.

Endometrial tissue reacts to hormonal changes. That’s why women bleed during menstruation and can support a growing fetus during pregnancy. The endometrial tissue that grows outside of the uterus or within the muscular structures of the uterus reacts to hormones as well, causing internal bleeding during menstruation and scarring once menstruation stops. Depending on where these growths form, they can cause pain, infertility, bowel problems, even adhesions that bind organs together. Furthermore, under rare conditions, endometriosis can grow into any surgical scars, the diaphragm, the lung – in one extreme case, we diagnosed endometriosis of an eye.

Endometriosis affects many women, behaves quite aggressively at times, causes an infinite number of problems – both emotional and physical – grows anywhere it wants to in a human body, and yet it is not cancer. It’s no surprise that this condition was called a “mystery of the century,” although this mystery involves way more than one century of extensive scientific work.

The Symptoms

  • Chronic pelvic pain that gets worse during menstruation
  • Pain during intercourse
  • Increased menstrual pain
  • Infertility
  • Painful urination and/or bowel movements
  • Nausea
  • It can lead to silent (asymptomatic) kidney damage as a result of ureteral obstruction.
  • Fatigue, chronic stress, and emotional disturbances
  • Frequent yeast infections

If you have any of these symptoms, your physician may suspect endometriosis. While endometriosis can be suspected based on the symptoms alone, if a cyst or deep endometriotic nodules are detected, a transvaginal ultrasound or MRI may need to be perfumed to evaluate the extent of the condition and the state of the surrounding organs and structures. The only definitive way to diagnose the condition, however, is through laparoscopy, a minimally invasive surgical procedure that allows your gynecologist to look inside your body with a thin camera inserted through a 1-1.5 cm incision in your abdomen. Through this outpatient procedure, the size, location, and extent of endometrial growth can be determined and treatment can take place.

The Treatment

Endometriosis may be treated with medication, surgery, or both, depending on the extent of the problem, the amount of pain it causes, and whether or not the patient is able, and desires, to have children.

At times we feel that treatment of endometriosis involves treatment of a couple. When good communication is established to address the problem, a cooperative treatment plan can begin. In this way, the entire family feels attended and cared for and the healing can begin in earnest.

Depending on the age, extent and location of endometriosis, and in consideration of the reproductive needs of a woman, we select medical or surgical approaches. Various hormonal regimens may be prescribed to suppress the mechanism that leads to pain, to suppress the growth of endometriotic lesions and reduce the formation of new ones, and as a result, to prevent the formation of new adhesions. Neither treatment will eradicate current growths or adhesions, however.

Another option is minimally invasive laparoscopic/endoscopic surgery that focuses on removal of endometriotic growths and adhesions. This option applies to women who consider pregnancy in the near future and cannot have intercourse due to pelvic pain. It also applies to women who experience pain that does not respond to hormonal medications or non-medical approaches. We remove these lesions, or perform separation or removal of the adhesions, using a contact nd:Yag laser scalpel that allows for a precise dissection with minimal blood loss. Additionally, Laparoscopy allows for a inspection of the tissue under magnification, enhancing our ability to detect all lesions and to select a specific surgical strategy.

We reserve hysterectomy for women who have completed their reproductive function and in whose case we highly suspect adenomyosis. We very rarely recommend removal of ovaries or tubes based on lack of pain reduction. If pain does not respond to excision or Lupron, there might be additional cause of pain not diagnosed previously.

If you think you have endometriosis

If you suffer from any of the symptoms of endometriosis, please make an appointment with Dr. Stepanian.

At Academia of Women’s Health and Endoscopic Surgery, we have extensive experience with the diagnosis and treatment of endometriosis. We focus on your goals with a holistic, minimally invasive approach. We treat the whole person, considering mental, emotional, and social factors as well as the symptoms of your problem.

  • Do you want to stop pain in a specific area?
  • Do you want to eliminate the pain you feel during sexual intimacy?
  • Do you want to have children?

By prioritizing and focusing on your goals, we make sure that your treatment is precisely what you need to live a healthy, fulfilling life.

Pelvic Pain: The Academia Approach

A woman’s pelvis carries an abundant array of organs, each with its own pathways of nerves. A problem with any of these organs can be translated by its nerves as pain.

Causes of Pelvic Pain

A woman’s pelvis carries structures representing urinary, gastrointestinal, genital, musculo-skeletal, lymphatic, vascular, and nervous systems. The pelvis carries the weight of the entire torso and upper body. It also carries the entire history of a woman’s sexuality, often resulting in muscular tenderness and psychological stress. Women who have been sexually abused have a much greater risk of pelvic pain. As you can see from this image, there are many pathways for the development of pelvic pain.

Diagnosing Pelvic Pain

Pelvic pain receives highly individualized treatment at Academia. Diagnosis begins with a complete exploration of a woman’s personal and medical history, including endometriosis, infections, sexuality, surgeries that might have resulted in scarring, as well as an investigation of any malformations. When speaking with a woman with pelvic pain we map her symptoms to the potential organs/systems involved and orient our further evaluation toward areas that appear involved. Since any of a complex array of organs and nerves may be involved, physical examination and testing may include various forms of evaluation, including psychological, medical, radiographic, sonographic, and even endoscopic (laparoscopic or hysteroscopic). Our goal is to make a complex problem simple and identify specific areas of the woman as a whole that need support and treatment.

Treating Pelvic Pain

At Academia, approaches range from holistic to surgical. When necessary, our associates specializing in other branches of medicine may be involved. Our commitment is to treat a patient with pelvic pain without the use of narcotics. We prefer to identify and address the problem that led to its development and chronicity.

Depending on the cause, your treatment may include well-balanced approaches that are entirely non-invasive and can balance your body and mind, and enhance your sense of well-being:

  • Teaching you how to relieve emotional stress
  • Teaching you site-specific exercises to strengthen and relax pelvic muscles
  • Counseling, biofeedback, and/or cognitive behavioral therapy
  • Dietary changes
  • Acupuncture
  • More specific physical therapy
  • General body exercises

The above techniques can be used by themselves or in combination with any of the approaches below:


  • Addressing a non-gynecologic condition with the specialist in the field involved
  • Oral contraceptives or progestins to suppress ovulation and decrease menstrual flow and associated inflammatory response
  • Other medications that affect the organs and tissues of the pelvis, starting with vaginal/vulvar creams, and following with medications that control interstitial cystitis


  • Vulvar and vaginal surgery as needed
  • Laparoscopic, hysteroscopic, and robotic approaches (endoscopic surgery) to treat pregnancy outside of the uterine body, adhesions, ovarian cysts, hydrosalpinx, endometriosis, uterine fibroids, adenomyosis, pelvic floor disorders, malformation and other problems.

Our goal is to improve your quality of life by addressing the source of pain medically or with minimally invasive surgical techniques, such as laparoscopy, and to eliminate the need for narcotic medications.

If you are suffering from chronic pelvic pain, please give Academia a call or make an appointment via this website (see Patient Portal). Pelvic pain should be treated as soon as possible. Not merely to avoid greater problems, but, just as important, to ensure that your day-to-day life is as wonderful and carefree as it should be.

Special Advice to Young Women & Men Reengaging in Sexual Activity

Please Avoid Infections! They are completely avoidable!

  • A large percentage of pelvic pain is caused by sexually transmitted infections (STD), especially in younger women who have become sexually active. The best way to avoid such infections is to practice safe sex. Avoid sexual contact with men or women who have symptoms or who have multiple sex partners and may have been exposed to a STD. Having more than one sex partner at a time increases the risk of STDs. Always use a condom even when using other methods of contraception. Of course, the only sure way to avoid a STD Is is to abstain from sexual contact.
  • See your doctor as soon as you notice frequent pelvic pain. The longer you wait, the more difficult it will be to solve the problem.
  • Keep a calendar of your menstrual cycle, including any pain you feel during the month. You can download free mobile apps, like iPeriod Free (among others), to help you keep track. Bring it with you to your doctor.

A Special Note to Men:

Please take care of your health. If you notice pain during sex, during urination, or any other discomfort in the area of your sex organs, see your doctor as soon as you can. You will be protecting your own health as well as the health of the woman you love.

Vaginal Bleeding and Heavy Menstruations

Excessive vaginal bleeding during menstruation or vaginal bleeding between periods signifies a possible problem in a woman’s reproductive system. Abnormal bleeding should be diagnosed and solved as soon as possible, not only because it could be a symptom of a serious condition, but because the bleeding itself could cause further problems.

Safety First

At Academia, our first task is to check for, and control, anemia.

Frequent or abnormally heavy blood loss can result in a significant loss in red blood cells. Red blood cells carry oxygen and iron through the body, and dispose of carbon dioxide. Therefore, women who have become anemic can suffer from constant fatigue, dizziness, lightheadedness, and/or fainting spells, as well as an increased risk of heart problems.

Finding the Cause

Many gynecologic and non-gynecologic conditions can result in abnormal vaginal bleeding. We talk with the patient to explore her personal and medical history for clues. Have there been any recent changes in medications? Does bleeding occur during or after sexual intercourse? Is the patient ovulating regularly? Is she a teenager who has always had heavy periods? Is she menstruating at regular intervals? Has her menstrual flow decreased? Is she pregnant? Does she have a sexually transmitted disease?

Possible causes of abnormal vaginal bleeding include:

  • Complications of early pregnancy
  • Problems related to the use of hormones (contraceptives or hormone replacement therapy)
  • Polyps (small benign growths)
  • Endometrial Hyperplasia (overgrowth of the lining of the uterus, called endometrium)
  • Fibroids (non-cancerous growth of uterine smooth muscle tissue)
  • Adenomyosis (growth of uterine lining outside of the uterus)
  • Endometrial cancer (unusual, and more frequent in women over 40)
  • Cervical and vaginal cancers or other pathology
  • Hypothyroidism (underactive thyroid) or hyperthyroidism (overactive thyroid)
  • Inherited clotting or platelet disorders, or misbalance in medications affecting those
  • Infections involving the uterus
  • Hormonal transitions seen in adolescence and perimenopause
  • Psychological stress

To find the source of the problem, I addition to attentive review of histories, our evaluation may include:

  • A thorough physical examination
  • A pregnancy test when indicated
  • Evaluation of the kidney, thyroid, and liver functions, testing for sexually transmitted disease, and hormonal function
  • Cervical evaluation with pap smear, colposcopy , or biopsy as needed
  • A high resolution ultrasound examination to check for uterine fibroids, adenomyosis, or endometrial problems
  • Endometrial sampling – taking a sample and testing a small piece of tissue from the inner lining of the uterus
  • Hysteroscopy – a minimally invasive surgical technique used to see inside the uterus and treat the problems originating in the uterine cavity


Depending on the cause of abnormal vaginal bleeding and patients reproductive and life goals, treatment may vary. At Academia, treatment options include:

  • Adjustment of current hormonal medications or initiation of new ones
  • Prescription of antibiotics to eliminate suspected infection
  • Hysteroscopic surgery in office and outpatient
  • Endometrial ablation – a minimally invasive procedure that removes the uterine lining
  • Laparoscopy or robotic surgery– a minimally invasive surgical technique used to remove uterine fibroids, or other benign growths
  • Laparoscopy or robotic surgery for hysterectomy (4 types of laparoscopic/outpatient hysterectomy can be performed by our team)
  • Other holistic, hormonal, and minimally invasive surgical techniques

One Final Note

Depending on the diagnosis, the cause of abnormal vaginal bleeding can lead to serious disease, including uterine cancer, if left untreated. If you suffer from heavy vaginal bleeding or spotting, please see your doctor – the sooner the better.

Of course, you are warmly invited to make an appointment with Dr. Assia Stepanian at Academia of Women’s Health & Endoscopic Surgery. We are uniquely equipped to diagnose and treat all forms of gynecologic problems. Our offices are remarkably beautiful and comfortable, and our approach is compassionate, holistic, complete, and minimally invasive.

Endometrial Pathology (Hyperplasia and Endometrial Polyps)

The Cause

The endometrium is the sheet of cells that grows monthly to line the uterus. Normally, women naturally expel these endometrial cells during menstruation. In some women, however, the growth of cells becomes excessive, resulting either in flat or protruding growths, called endometrial polyps, or in a thickening of the endometrium, called endometrial hyperplasia. Hyperplasia can lead to cancer if not treated. These conditions may occur when a woman’s hormone levels are out of balance as her endocrine glands produce too much estrogen and not enough progesterone-like hormones that would normally work to counteract estrogen’s tissue-producing properties.


Endometrial hyperplasia and polyps can cause excessive bleeding during menstruation and/or vaginal bleeding between periods. They can also cause pelvic pain and sensitivity during and after intercourse and at other times during the month.


At Academia, we perform trans-vaginal ultrasound to evaluate the cause of bleeding. Unless the uterine lining is extremely thin, we take a sample of the endometrium and perform a biopsy.


We treat hyperplasia medically or with minimally invasive surgery, depending on the reproductive goals and general medical condition of a patient. If endometrial hyperplasia is not found and a polyp is suspected, we perform diagnostic hysteroscopy in the office which can be extended to a hysteroscopic polypectomy (removal of the polyp) at the same time as needed. If more extensive therapy is indicated, hospital surgery may be necessary using minimally invasive techniques.

If you are suffering from chronic pelvic pain or abnormal vaginal bleeding, please give Academia a call or make an appointment via this website (see Patient Portal). These symptoms should be diagnosed and treated as soon as possible – not merely to avoid greater problems, but, just as important, to ensure that your day-to-day life is as wonderful and carefree as it should be.

MRKH: when the uterus and vagina do not develop.

MRKH stands for Mayer–Rokitansky–Küster–Hauser syndrome. Other names for this condition are müllerian aplasia and müllerian agenesis. MRKH occurs in one out of every 4,000–10,000 females.

MRKH is caused when the channels that normally form the fallopian tubes, uterus, cervix, and the upper two-thirds of the vagina do not get formed for various reasons. Other symptoms may include hearing loss and kidney and/or spinal problems (see illustration). There are variations in which of these organs are affected, but the ovaries, formed separately, are usually normal. Patients with MRKH have normal breast development, normal secondary sexual body proportions, body hair, and hymenal tissue.

MRKH may not become evident until a woman reaches puberty and menstruations do not occur (primary amenorrhea).  If the first menstrual cycle has not occurred within three years of the onset of breast development, it is important to consult a gynecologist for further evaluation.

Before any treatment is recommended, however, it is important to consult a highly specialized gynecologist, one who is thoroughly trained in the management of müllerian anomalies and the potential problems that they may be associated with, to undergo as thorough an evaluation as possible. Academia’s Dr. Assia Stepanian is one such specialist.

Women who are born with MRKH can, and should, be treated. Their two major concerns are usually sexual intimacy and the inability to have children. In most cases, proper treatment can alleviate both of these concerns.

MRKH does not rule out the ability of a woman to have children since her ovaries are not affected. While she will never become pregnant or carry her own child, assisted reproductive techniques, including surrogate motherhood, may be used to enable a woman with MRKH to have her own, normal baby.

What’s more, sexual intimacy can be greatly improved, even for women well beyond their teenage years, through the construction of a neovagina. In 90% of cases, women are able to achieve anatomic and functional success through a non-surgical technique called vaginal dilation.

There are, however, benefits to the surgical technique practiced by Academia’s Dr. Assia Stepanian. While vaginal dilation can be a long, sometimes painful, process, this minimally invasive surgical technique is the only type of surgery for vaginal agenesis that forms the neovagina of average size and width immediately without the need of grafts, tractional devices, or the formation of scars. Postoperative narcotics are used only minimally, no therapeutic dilation is required, and blood loss is usually minimal.

Dr. Stepanian is a daughter of L.V. Adamyan, the innovator of this surgical technique, and has learned this and other procedures from her mother firsthand. Over the years, Dr. Stepanian has performed this surgery both in Russia and in the U.S. She has presented at multiple international congresses and universities, and was elected to perform this surgery live at AAGL‘s International Congress. She is a co-author of multiple publications on the subject, including new classification of Müllerian Anomalies based on experiences with over 1,400 patients.

At Academia of Women’s Health & Endoscopic Surgery, we are highly specialized in müllerian anomalies, and we welcome women of all ages to come to us for a consultation to establish a plan for thorough, complex, and complete evaluation. We can recommend and perform a variety of successful treatment options. We can also provide much-needed comfort, understanding, and emotional guidance for women (often teens) and their families.

What is the best way to treat the symptoms of menopause?

Once a woman has experienced the absence of her period for twelve straight months, the functioning of her ovaries has decreased enough to cause the cessation of menstruation. This is called menopause, and all women, usually beyond their fifties and sometimes earlier in life, will experience it.

The cessation of menstruation requires no treatment whatsoever. The symptoms of menopause, however, can be severe and may include hot flashes, vaginal dryness, sleep disturbances, mood swings, and loss of bone density. These symptoms can – and in my opinion should – be treated, especially when one takes into account that these years can be the most fulfilling years in a woman’s life – years that signify the beginning of a new and most mature era in her journey and development.

There are many forms of treatment, including hormone replacement therapy, low-dose antidepressants, drugs such as Gabapentin that can reduce hot flashes, bisphosphonates, SERMs, and other medications as well as specially designed physical therapy to prevent or reduce the loss of bone density, and vaginal estrogen and other supplements for the relief of vaginal dryness.

The most effective of these treatments is hormone replacement therapy, including “bioidentical hormones,” often mentioned by my patients, which can replace the hormones that the body stops producing once the ovaries reduce their function. Hormone replacement therapy can treat virtually all the symptoms of menopause. It can also, however, increase the risk of certain serious conditions for some women. The most thorough way to determine if the benefits outweigh the risks is to talk to your gynecologist.

Before we prescribe any treatment for menopausal patients, we discuss their current symptoms and establish how significantly these symptoms affect their quality of life. We look carefully into family history and medical history, and we discuss the risk factors involved both if therapy is started and if it is avoided. The options that provide the greatest benefit and least amount of risk are chosen on an individual basis.

Gynecologists are aware of various aspects involved in the management of hormone replacement therapy. Your gynecologist may also confer with your other physicians to ensure that everyone is aware of, and agrees with, the approved treatment.

If you are experiencing menopause, or if you believe you are transitioning into menopause, please make an appointment and share your concerns with your gynecologist. After all, you deserve to enjoy your mature years as deeply and completely as possible.

When should a girl start seeing a gynecologist?

The American College of Obstetricians and Gynecologists recommends that a girl first see a gynecologist between the ages of 13 and 15, once her menstrual cycle has begun. If a parent is interested in their daughter receiving the HPV vaccine, then an earlier visit is recommended.

It is especially vital for a young woman to see a gynecologist if she:
• has any concerns or questions about pain or discomfort in her vagina, lower abdomen, or when she urinates
• has a vaginal discharge or odor
• is concerned that she might have a STD (or that her partner might have one)
• has periods that are very irregular — even after the first year or two — or if they are overly long or painful

When we see a teenager for her first gynecologic examination, we are most concerned with her comfort and her trust. We want her visit to be enlightening and relaxed. A pelvic examination during the first year may not be necessary.

We talk about how she feels as she becomes a woman, about her overall health, about any concerns she has, and about her sexuality and any sexual activity she has had or is planning to have. We answer her questions and help her to feel cared for and understood. Such open discussion also helps us to know if a pelvic exam is necessary.

We find that young patients actually look forward to our annual discussions. That is so important, because yearly visits to a gynecologist are so essential to a woman’s physical and emotional health.