Abnormal Uterine Bleeding

Alternative names :- Bleeding between periods; Intermenstrual bleeding; Spotting; Metrorrhagia

Abnormal uterine bleeding refers to abnormal endometrial bleeding without recognizable organic lesions. Abnormal uterine bleeding is the indication for almost 25% of gynecologic surgical procedures. Although prognosis varies with the cause, correction of hormonal imbalance or structural abnormality usually corrects the problem.

What causes Abnormal uterine bleeding?

Abnormal uterine bleeding usually results from an imbalance in the hormonal-endometrial relationship in which persistent and unopposed stimulation of the endometrium by estrogen occurs. When progesterone secretion is absent but estrogen secretion continues, the endometrium proliferates and become hypervascular. When ovulation doesn't occur, the endometrium is randomly broken down, and exposed vascular channels cause prolonged and excessive bleeding. In most cases of abnormal uterine bleeding, the endometrium shows no pathologic changes. However, in chronic unopposed estrogen stimulation (as from a hormone-producing ovarian tumor), the endometrium may show hyperplastic or malignant changes.

Disorders that cause sustained high estrogen levels include:

• polycystic ovary syndrome
• obesity (because enzymes present in peripheral adipose tissue convert the androgen androstenedione to estrogen precursors)
• immaturity of the hypothalamicpituitary-ovarian mechanism (postpubertal teenagers)
• anovulation (women in their late 30s or early 40s).

Other causes of abnormal uterine bleeding include:

• trauma (foreign object insertion or direct trauma)
• endometriosis
• coagulopathy, such as thrombocytopenia or leukemia (rare)
• drug-induced coagulopathy.

Signs and symptoms of Abnormal uterine bleeding

Abnormal uterine bleeding usually occurs as:

• metrorrhagia (episodes of vaginal bleeding between menses)
• hypermenorrhea (heavy or prolonged menses longer than 8 days, also known incorrectly as menorrhagia)
• chronic polymenorrhea (menstrual cycle less than 18 days) or oligomenorrhea (infrequent menses)
• fatigue due to anemia
• oligomenorrhea and infertility due to anovulation.

Possible complications of abnormal uterine bleeding include iron deficiency anemia caused by blood loss of more than 1.6L over a short time, hemorrhagic shock or right-sided heart failure (rare), and endometrial adenocarcinoma due to chronic estrogen stimulation.

Diagnosis information

Abnormal uterine bleeding may be caused by anovulation. Diagnosis of anovulation is based on:

• history of abnormal bleeding, bleeding in response to a brief course of progesterone, absence of ovulatory cycle body temperature changes, and low serum progesterone levels
• diagnostic studies ruling out other causes of excessive vaginal bleeding, such as organic, systemic, psychogenic. and endocrine causes, including certain cancers, polyps, pregnancy, and infection
• dilatation and curettage (D&C) or office endometrial biopsy to rule out endometrial hyperplasia and cancer in women over age 35
• hemoglobin levels and hematocrit to determine the need for blood transfusion or iron supplementation.

Treatment of Abnormal uterine bleeding

Possible treatment of abnormal uterine bleeding includes:

• high-dose estrogen-progestogen combination therapy (hormonal contraceptives) to control endometrial growth and reestablish a normal cyclic pattern of menstruation (usually given four times daily for 5 to 7 days even though bleeding usually stops in 12 to 24 hours; drug choice and dosage determined by patient's age and cause of bleeding); maintenance therapy with lower dose combination hormonal contraceptives.
• endometrial biopsy to rule out endometrial adenocarcinoma (patients age 35 and older)
• progestogen therapy (alternative for many women, such as those susceptible to such adverse effects of estrogen as thrombophlebitis)
• I. V. estrogen followed by progesterone or combination hormonal contraceptives if the patient is young (more likely to be anovulatory) and severely anemic (if oral drug therapy is ineffective)
• D&C (short-lived treatment and not clinically useful, but an important diagnostic tool) with hysteroscopy as a useful adjunct
• iron supplementation or transfusions of packed cells or whole blood, as indicated, due to anemia caused by recurrent or excessive bleeding
• explaining the importance of following the prescribed hormonal therapy and describing the D&C or endometrial biopsy procedure and purpose (if ordered)
• stressing the need for regular checkups to assess the effectiveness of treatment.

Special considerations and Prevention

• If a patient complains of abnormal bleeding, tell her to record the dates of the bleeding and the number of pads.
• She saturates per day to help assess the pattern and the amount of bleeding. Instruct the patient not to use tampons.
• Because aspirin may prolong bleeding, it should be avoided if possible.
• Instruct the patient to report abnormal bleeding immediately to help rule out major hemorrhagic disorders such as those that occur in abnormal pregnancy.
• To prevent abnormal bleeding due to organic causes and for early detection of malignancy, encourage the patient to have a Papanicolaou test and a pelvic examination annually.
• Bed rest is recommended if bleeding is heavy.
• Offer reassurance and support. The patient may be particularly anxious about excessive or frequent blood loss and passage of clots. Suggest that she minimize blood flow by avoiding strenuous activity and lying down with her feet elevated.