Abnormal uterine bleeding

Abnormal uterine bleeding is any menstrual bleeding from the uterus that is 1) abnormal in volume (excessive duration or heavy flow), 2) regularity, 3) timing (delayed or frequent) or 4) is non-menstrual.

Photo of attractive glamour woman 20s wearing straw hat holding menses calendar isolated over pink background in studioDescription

Abnormal uterine bleeding is bleeding from the uterus, which doesn’t remind normal menstruation. It was estimated that abnormal uterine bleeding affects approximately 9-14% of women of reproductive age. There are a lot of possible causes for this condition each of which has also other signs and symptoms except the abnormal bleeding.

Definitions

  • Heavy menstrual bleeding is an excessive menstrual blood loss that affects a woman’s body and the quality of life. The period which lasts longer than 7 days or when the blood loss is greater than 80 ml meets the criteria of heavy menstrual bleeding.
  • Intermenstrual bleeding is bleeding detected in-between the periods.
  • Postmenopausal bleeding – any uterine bleeding in a woman in menopause.
  • Postcoital bleeding – the genital bleeding, which occurs right after or shortly after the sexual intercourse.

Causes and classification

  1. Structural abnormalities
  • Polyps (AUB-P)
  • Adenoma (AUB-A)
  • Leiomyoma (AUB-L)
  • Malignant hyperplasia (AUB-M)
  1. Non-structural causes
  • Coagulopathy (AUB-C)
  • Ovulatory dysfunction (AUB-O)
  • Endometrial (AUB-E)
  • Iatrogenic (AUB-I)
  • Non-classified (AUB-N): chronic endometritis, arteriovenous malformations, myometrial hypertrophy

According to PALM-COEIN classification by the International Federation of Gynaecology and Obstetrics (FIGO)

Symptoms

  • The amount of blood may vary drastically – from light spotting to heavy life-threatening bleeding.
  • The bleeding may occur in different phases of the menstrual cycle.
  • The periods occur irregularly. Sometimes they occur frequently (the menstrual cycle lasts <21 days – polymenorrhea) and sometimes – relatively seldom (the cycle lasts >35 days or the period happens once in several months – oligomenorrhea).
  • An excessive amount of blood during the menstruation or its prolonged duration (>7 days).

Other symptoms may include one or several of the following:

  • Dysmenorrhea (painful menstruation);
  • Fatigue;
  • Pallor;
  • Dyspareunia (painful sexual intercourse);
  • Acne;
  • Hirsutism;
  • Obesity;
  • Anovulation and infertility;
  • Hot flashes;
  • Mood swings;
  • Petechial rash, ecchymosis or purpura;

Abnormal uterine bleeding due to ovulatory dysfunction

This type of abnormal uterine bleeding was previously referred to as dysfunctional uterine bleeding.

AUB may be diagnosed when there is no other detectable organic, systemic and iatrogenic cause of the condition. It is considered that AUB-O occurs as the result of hormonal imbalance in the hypothalamo-pituitary-ovarian axis.

Diagnosis

To verify a diagnosis and find the underlying cause of the abnormal uterine bleeding numerous laboratory and instrumental tests should be performed.

A complete blood count (CBC) is recommended to estimate anemia and detect possible inflammation. Bleeding time, platelet count, prothrombin time, and partial thromboplastin time should be done if any coagulopathy is suspected. Human chorionic gonadotropin should be evaluated if pregnancy is suspected.

Ultrasonography is obligatory to evaluate the uterus, adnexa, and endometrial thickness. Doppler ultrasonography may also be performed to estimate the blood flow in the uterus and detect any vascular abnormalities. If any intrauterine abnormalities are considered hysteroscopy along with biopsy should be done.

Treatment

The treatment of abnormal uterine bleeding depends on the underlying disorder.  Usually, oral contraceptives, gonadotropin-releasing hormone agonists, estrogen and progesterone are used to stop and avoid the bleeding.

Surgical treatment is required when medical therapy is not able to stop the bleeding or the amount of blood is too large. The surgical measures include:

  • Dilation and curettage – scraping and scooping of the endometrium– the lining of the uterus;
  • Hysterectomy – surgical removal of the uterus. This procedure is indicated when all the efforts to stop the bleeding fail;
  • Endometrial ablation – surgical destruction or removal of the endometrium;

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