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Normal menstrual bleeding ranges from 2 to 7 days. Abnormal uterine bleeding refers to alterations in quantity, duration or frequency.
Causes:
- Structural: Polyps, Fibroids, Adenomyosis, Malignancy.
- Nonstructural: Coagulopathy, Ovulatory dysfunction, Endometrial abnormality, Iatrogenic.
- Drugs: Heparin, Warfarin, Cupper T (IUCD).
- Infections:
- Systemic: Hyperthyroidism, Liver diseases.
Clinical Features:
- Oligomenorrhea: an increase in length of time between menses. 35-90 days period.
- Polymenorrhea: frequent menstruation (less than 21 days cycle)
- Menorrhagia: increase in amount of flow (more than 80ml blood loss per menstruation or flow lasting more than 8 days).
- Metrorrhagia: bleeding between periods.
- Menometrorrhagia: excessive and irregular bleeding.
Investigations and work-up:
- Compelete blood count, platelet count, PT/INR, PTT: assess anemia, von-Wilibrand disease, and factor XI deficiency.
- B-hcg: rule out pregnancy.
- Wet mount and KOH preparation, Gonorrhea/chlamydia probe: for infections and cervical bleedings.
- Thyroid function test and prolactin levels: to rule out systemic causes like hyperthyroidism and hyperprolactinemia.
- Ultrasonography: for structural causes.
- Endometrial biopsy indications:
- Thickness of endometrium >4mm in postmenopausal woman.
- Patient with >35 years of age with risk factors for endometrial hyperplasia (obesity, diabetes mellitus).
Treatment and Management:
Acute heavy bleedings:
1st line hormonal management of Abnormal uterine bleeding is progesterone. Progesterone stabilizes the endometrium in most physiological way.
1st line management of severe abnormal uterine bleeding is estrogen. It forms the new glands and replaces previous endometrium. High doses of estrogen stabilizes the endometrium lining and stops bleeding.
Progesterone stabilizes the endometrium. Progesterone given but; if bleeding does not stop due to already disintrigated glands. Intravenous estrogen is given and it forms new glands and replaces previous ones. But estrogen makes larger glands and when they get shaded there is more bleeding. Estrogen withdrawal bleeding is more severe than progesterone withdrawal bleeding.
Transition to combined oral contraceptives or progestin when bleeding is stabilized.
Ovulatory bleedings:
- NSAIDS, tranexemic acid for pain and bleeding control.
- In hemodynamically stable patients, oral contraceptive pills, progestin or progestin IUD.
Anovulatory bleedings:
- Combined hormonal contraception, progestin IUD.
- Goal is to convert proliferative endometrium to secretory endometrium.
Surgical management:
If medical management fails.
- D & C
- Therapeutic curratage.
- Hemostatic curratage.
- Hysteroscopic directed uterine biopsies.
- Uterine artery embolization with polyvinyl alcohol particles, if the cause of menorrhagia is fibroid.
- Microwave/ Thermal ablation of endometrial lining.
- Trans-cervical resection of endometrium (burning uterine lining and forming scar).
- Hysterectomy: in females with whom:
- Hormonal treatment fails.
- No longer desire fertility.
- Symptomatic anemia.
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References:
- Williams Gynecology, Fourth Edition.
- DC Dutta’s Textbook of Gynecology, 9th Edition.
