Understanding Abnormal Uterine Bleeding
Abnormal uterine bleeding (AUB) refers to any unusual bleeding from the uterus that differs in frequency, duration, or amount from normal menstrual bleeding. It's a common gynaecological concern that can have various causes that require medical evaluation and treatment.
We consider the following factors to quantify the bleeding:
Duration: How long does the bleeding last? Prolonged bleeding may involve bleeding for more than seven days during a menstrual cycle.
Frequency: How often does the bleeding occur? Frequent bleeding may involve menstrual cycles shorter than 21 days or bleeding between periods.
Amount: How much blood is lost during the bleeding episode? Excessive bleeding may involve soaking through pads or tampons every hour with or without blood clots.
Heavy Menstrual bleeding (HMB) also known as menorrhagia is the most common presentation of abnormal uterine bleeding affecting 25% of pre-menopausal women. Heavy menstrual bleeding refers to heavy cyclical bleeding (Intermenstrual and postcoital bleeding require separate investigation)
Common Causes of Abnormal Uterine Bleeding
Several factors can contribute to abnormal uterine bleeding, including:
Pregnancy-related bleeding should be excluded before considering other causes.
Hormonal Imbalance: Fluctuations in hormone levels, such as oestrogen and progesterone, can disrupt the normal menstrual cycle and lead to irregular bleeding.
Polycystic Ovary Syndrome (PCOS): Characterised by irregular periods, ovarian cysts, and elevated androgen levels.
Structural causes, such as:
Uterine Fibroids: Noncancerous growths in the uterus can cause heavy or prolonged menstrual bleeding.
Endometrial Polyps: Benign growths in the lining of the uterus that can cause abnormal bleeding.
Endometrial Hyperplasia: Thickening of the uterine lining due to hormonal imbalance or other factors, leading to irregular bleeding.
Endometrial Cancer: Cancer of the lining of the uterus, which may cause abnormal bleeding, especially in postmenopausal women.
Non Structural causes;
Disorders of blood clotting mechanisms - Abnormal haemostasis within the endometrium (excess local fibrinolysis or prostaglandin production) is the most common functional cause of heavy menstrual bleeding, occuring in 50% of cases, but is a diagnosis of exclusion.
Iatrogenic (caused by medical treatment) include; long acting contraception device, anticoagulation therapy, tamoxifen and other hormonal therapies.
Ovulatory dysfunction is most often due to polycystic ovarian syndrome other causes include hypothyroidism.
Investigation of Abnormal Uterine Bleeding
When evaluating abnormal uterine bleeding, healthcare providers may recommend the following:
Thorough history including general health, symptoms, menstrual history, sexual and reproductive history, medication history and family history.
Pelvic Examination: A physical examination to assess the uterus, ovaries, and other pelvic structures for any abnormalities. This might involve visualisation of the vulva, vagina and cervix and an internal bi-manual pelvic exam and swabs or cervical screening as indicated.
Pathology tests: BHCG, full blood count, iron studies, thyroid studies and consider check coagulation studies and hormonal testing.
Transvaginal Ultrasound: performed on day 5-10 of the menstrual cycle to assess possible structural causes.
We may consider further testing if clinical risk or poor response to initial treatment. Including:
Endometrial Biopsy: A procedure to obtain a small tissue sample from the lining of the uterus, particularly if cancer or precancerous changes are suspected.
Hysteroscopy: A procedure that allows for direct visualisation of the inside of the uterus by a gynaecologist.
Management Options
Treatment for abnormal uterine bleeding depends on the underlying cause and may include:
Hormonal Therapy: Hormonal medications, such as contraceptive pills or hormone-releasing intrauterine devices (IUDs), can help regulate the menstrual cycle and reduce bleeding.
Levonorgestrel-releasing intra-uterine system (LNG-IUS) such as a Mirena is the most effective medical management option.
Non-hormonal options include: Tranexamic acid to reduce blood loss and Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) such as ibuprofen, which can help reduce bleeding and alleviate pain.
Surgical Interventions: In some cases, surgical procedures such as endometrial ablation, myomectomy (removal of fibroids), or hysterectomy (removal of the uterus) may be necessary, especially if conservative treatments are ineffective or if there are concerns about cancer. When surgical options are being considered, the least invasive procedure appropriate should be offered.
Acute Severe bleeding requires immediate intervention to prevent excessive blood loss. In the case where you are soaking through pads or tampons every hour for a few consecutive hours this is a time to seek urgent medical care. Rarely can be catastrophic, resulting in severe anaemia and shock.
Informed choice and shared decision-making
The long-term goal of managing HMB is to ensure that women with HMB:
Offered the least invasive and most effective treatment appropriate to their clinical needs
have the opportunity to make an informed choice from the range of treatments suitable to their individual situation.
When to see a specialist Gynaecologist?
If heavy menstrual bleeding has not settled after 6 months of management
Surgical condition such as polyp of fibroid
Needing fertility specialist care and consideration
Concurrent painful periods suggestive of conditions such as endometriosis
Increased risk or findings suggestive of endometrial cancer
Intermenstrual and Post-coital bleeding
Intermenstrual bleeding (IMB) is vaginal bleeding at any time other than during normal menstruation or following intercourse. Post-coital bleeding (PCB) is vaginal bleeding after intercourse. These are sympotms which in most cases are not related to serious disease, but conditions such as chlamydial infection or cervical cancer should be ruled out in women with persistent abnormal bleeding.
IMB is common, especially in women using hormonal contraception or hormonal therapies. PCB is regarded as a cardinal symptom of cervical cancer and the commonest presenting symptom for Chlamydia.
Genital tract malignancy is an uncommon cause of abnormal bleeding at any age, and is rare in young women, but must be considered in all patients.
Women at risk of sexually transmitted infection should have appropriate tests performed. Women with persistent IMB or PCB should have a cervical screening co-test (HPV and LBC), a transvaginal ultrasound and referral to a gynaecologist.
Conclusion
Abnormal uterine bleeding is a common womens health concern that can have various causes and may require medical evaluation and treatment. If you experience any changes in your menstrual bleeding pattern or have concerns about abnormal uterine bleeding, don't hesitate to consult with your healthcare provider. Early diagnosis and appropriate management can help alleviate symptoms and improve your overall quality of life.
Resources for further reading
https://www.jeanhailes.org.au/uploads/09_HP-tools/Heavy_menstrual_bleeding_tool.pdf