ABNORMAL UTERINE BLEEDING – Types, Causes and Risk Factors, Clinical Manifestations, Diagnostic Evaluations and Management
ABNORMAL UTERINE BLEEDING – Types, Causes and Risk Factors, Clinical Manifestations, Diagnostic Evaluations and Management
Abnormal uterine bleeding is one of the most common gynecologic problems that occur most frequently in women at the beginning and end of their reproductive lives. It can occur at any age and has many causes. About half the cases occur in women over 45 years of age and about one fifth occur in women under age 20. Abnormal uterine bleeding may be heavier or longer than usual or occur at unexpected times. Some are easily treated, while others are more serious.
Bleeding in any of the following situations is abnormal. Bleeding between periods, bleeding after sex, spotting anytime in the menstrual cycle, bleeding heavier or for more days than normal and bleeding after menopause
TYPES OF ABNORMAL UTERINE BLEEDING
Types of abnormal uterine bleeding (also called dysfunctional uterine bleeding) include:
- Polymenorrhea: Frequent, regular periods that occur less than every 21 days
- Hypermenorrhea: Excessively heavy bleeding during a normal-length period
- Menorrhagia: Prolonged or excessive bleeding lasting longer than a week that occurs at regular intervals
- Metrorrhagia: Periods that occur at irregular intervals, or frequent bleeding of various amounts, though not heavy.
- Menometrorrhagia: Frequent, excessive, and prolonged bleeding that occurs at irregular intervals.
- Postmenopausal bleeding: any bleeding that occurs more than 6 months after the last normal menstrual period of menopause.
MENORRHAGIA
Menorrhagia is the most common type of abnormal uterine bleeding characterized by heavy and prolonged menstrual bleeding. In some cases, bleeding may be so severe and relentless that daily activities become interrupted. A normal menstrual cycle is 21-35 days in duration, with bleeding lasting an average of 5 days and total blood flow between 25 and 80 ml. A blood loss of greater than 80 ml or lasting longer than 7 days constitutes menorrhagia (also called Hypermenorrhea)
Depending upon the cause, it may be associated with abnormally painful periods (dysmenorrhea)
CAUSES AND RISK FACTORS
In some cases, the cause of heavy menstrual bleeding is unknown, but a number of conditions may cause menorrhagia. These include imbalance of hormones (estrogen and progesterone), fibroids (benign uterine tumors), pelvic infection, endometrial disorder, intrauterine device, hypothyroidism, pregnancy, ovarian cyst or tumor and other hormonal causes.
- Hormonal Imbalance: In a normal menstrual cycle, a balance between the hormones estrogen and progesterone regulates the buildup of the lining of the uterus (endometrium), which is shed during menstruation. If a hormonal imbalance occurs, the endometrium develops in excess and eventually sheds by way of heavy menstrual bleeding.
- Dysfunction of the ovaries: Lack of ovulation (anovulation) may cause hormonal imbalance and result in menorrhagia. Girls are especially prone to anovulatory cycles in the first year and a half after they have their first menstrual period (menarche). Women ages 40 to 50 are at increased risk of hormonal changes that lead to anovulatory cycles
- Uterine fibroids: These noncancerous (benign) tumors of the uterus appear during your childbearing years. Uterine fibroids may cause heavier than normal or prolonged menstrual bleeding.
- Polyps: Small, benign growths on the lining of the uterine wall (uterine polyps) may cause heavy or prolonged menstrual bleeding. Polyps of the uterus most commonly occur in women of reproductive age as the result of high hormone levels.
- Adenomyosis: This condition occurs when glands from the endometrium become embedded in the uterine muscle, often causing heavy bleeding and pain. Adenomyosis is most likely to develop if you are a middle-aged woman who has had many children.
- Intrauterine device (IUD): Menorrhagia is a well-known side effect of using a nonhormonal intrauterine device for birth control. When a IUD is the cause of excessive menstrual bleeding, you may need to remove it.
- Pregnancy complications: A single, heavy, later period may be due to a miscarriage. If bleeding occurs at the usual time of menstruation, however, miscarriage is unlikely to be the cause. An ectopic pregnancy – implantation of a fertilized egg within the fallopian tube instead of the uterus – also may cause menorrhagia.
- Cancer: Rarely, uterine cancer ovarian cancer and cervical cancer can cause excessive menstrual bleeding.
- Inherited bleeding disorders: Some blood coagulation disorders – such as von Willebrand’s disease, a condition in which an important blood-clotting factor is deficient or impaired – can cause abnormal menstrual bleeding. Other coagulation disorders: thrombocytopenia, platelet disorders and leukemia can cause abnormal menstrual bleeding.
- Medications: Certain drugs, including anti-inflammatory medications (aspirin) and anticoagulants can contribute to heavy or prolonged menstrual bleeding. Improper use of hormone medications also can cause menorrhagia.
- Other medical conditions: A number of other medical conditions, including pelvic inflammatory disease (PID), thyroid problems (Hypothyroidism), endometriosis, and liver or kidney disease, may cause menorrhagia.
CLINCIAL MANIFESTATIONS
Menorrhagia refers to losing about 5 ½ tablespoons (81 milliliters) or more of blood during menstrual cycle. The signs and symptoms of menorrhagia may include:
- Menstrual flow that soaks through one or more sanitary pads or tampons every hour for several consecutive hours
- The need to use double sanitary protection to control menstrual flow
- The need to change sanitary protection during the night
- Menstrual periods lasting longer than seven days
- Menstrual flow that includes large blood clots
- Heavy menstrual flow that interferes with regular lifestyle
- Tiredness, fatigue or shortness of breath (symptoms of anemia)
DIAGNOSTIC EVALUATIONS
- Pelvic and rectal examination
- Pap smear
- Blood tests
- Pelvic ultrasound scan is the first line diagnostic tool for identifying structural abnormalities.
- Sonohysterogram
- Endometrial biopsy to exclude endometrial cancer or atypical hyperplasia
- Dilation and curettage (D and C)
- Hysteroscopy
MANAGEMENT
Drug therapy for menorrhagia may include:
- Iron supplements: If the condition is accompanied by anemia, doctor may recommend that patient take iron supplements regularly. If iron levels are low but patient is not yet anemic, may be started on iron supplements rather than waiting until patient become anemic.
- Nonsteroidal anti-inflammatory drugs: NSAIDs, such as ibuprofen (Advil, Motrin, others), help reduce menstrual blood loss. NSAIDs have the added benefit of relieving painful menstrual cramps (dysmenorrhea)
- Oral contraceptives: Aside from providing effective birth control, oral contraceptives can help regulate menstrual cycles and reduce episodes of excessive or prolonged menstrual bleeding
- Oral progesterone: When taken for 10 or more days of each menstrual cycle, the hormone progesterone can help correct hormonal imbalance and reduce menorrhagia
- Hormonal IUD (mirena): This type of intrauterine device releases a type of progestin called levonorgestrel, which makes the uterine lining thin and decreases menstrual blood flow and cramping.
- Patient may need surgical treatment for menorrhagia if drug therapy is unsuccessful.
Treatment options include:
- Dilation and curettage (D and C): In this procedure, doctor opens (dilates) cervix and then scrapes or suctions tissue from the lining of uterus to reduce menstrual bleeding. Although this procedure is common and often treats menorrhagia successfully, patient may need additional D and C procedures if menorrhagia recurs.
- Operative hysteroscopy: This procedure uses a tiny tube with a light (hysteroscope) to view uterine cavity and can aid in the surgical removal of a polyp that may be causing excessive menstrual bleeding.
- Endometrial ablation: using a variety of techniques, doctor permanently destroys the entire lining of uterus (endometrium). After endometrial ablation, most women have little or no menstrual flow. Endometrial ablation reduces ability to become pregnant
- Endometrial resection: This surgical procedure uses an electrosurgical wire loop to remove the lining of the uterus. Both endometrial ablation and endometrial resection benefit women who have very heavy menstrual bleeding. Like endometrial ablation, this procedure reduces ability to become pregnant
- Hysterectomy: Surgical removal of the uterus and cervix is a permanent procedure that causes sterility and cessation of menstrual periods. Hysterectomy is performed under anesthesia and requires hospitalization. Additional removal of the ovaries (bilateral oophorectomy) may cause premature menopause in younger women.