Abnormal Uterine Bleeding in Pre-Menopausal Women

 Definitions 

Heavy menstrual bleeding

Excessive menstrual blood loss which interferes with the woman’s physical, emotional, social, and material quality of life, and which can occur alone or in combination with other symptoms.

Prolonged menstrual bleeding

Describes menstrual blood loss which exceeds 8 days in duration

Shortened menstrual bleeding

Menstrual bleeding less than 3 days in duration.

Intermenstrual

Irregular episodes of bleeding, often light and short,occurring between otherwise fairly normal menstrual periods.

Post-coital

Bleeding post-intercourse.

Post-menopausal bleeding

Bleeding occurring more than one year after the acknowledged menopause.

PALM-COEIN Classification of AUB

Structural causes                                                                             

polyps

Adenomyosis                                    

Leiomyomas

– Submucosal

– Other

Malignancy and

hyperplasia

   Non-structural causes

Coagulopathy

Ovulatory dysfunction

Endometrial (primary disorder of mechanismsregulating local endometrial “hemostasis”)

Iatrogenic

Not yet specified

Determining the amount, frequency, and regularity of bleeding, the presence of post-coital or intermenstrual bleeding, and any dysmeno -rrhea or premenstrual symptoms can help to distinguish anovulatory from ovulatory bleeding or to suggest anatomic causes such as cervical pathology or endometrial polyps.

Ovulatory AUB is usually regular and is often associated with premenstrual symptoms and dysmenorrhea.

Anovulatory bleeding, which is more common near menarche and the perimenopause, is often irregular, heavy, and prolonged. It is more likely to be associated with endometrial hyperplasia and cancer.

Further history should include the following:

• symptoms suggestive of anemia (i.e. light-headedness, shortness of breath with activity)

• sexual and reproductive history (i.e. contraception, risk for pregnancy and sexually transmitted infections, desire for future pregnancy, infertility, cervical screening)

• impact on social and sexual functioning and quality oflife

• symptoms suggestive of systemic causes of bleeding such as hypothyroidism, hyperprolactinemia, coagulation disorders, polycystic ovary syndrome, adrenal or hypothalamic disorders, and

• associated symptoms such as vaginal discharge or odour, pelvic pain or pressure.

A family history of inherited coagulation disorders, PCOS, or endometrial or colon cancer should also be sought

any co-morbid conditions, such as hormonally dependent tumours, thromboembolic disease, or cardiovascular problems that would influence treatment options.

list of medications including over-the-counter and natural/herbal remedies that may interfere with ovulation or otherwise be associated with bleeding should be obtained

Medications that can be associated with abnormal uterine bleeding

Anticoagulants

Antidepressants (selective serotonin reuptake inhibitors and

tricyclics)

Hormonal contraceptives

Tamoxifen

Antipsychotics (first generation and risperidone)

Corticosteroids

Herbs: ginseng, chasteberry, danshen

Physical assessment

General assessment

Vital signs

Weight/BMI

Thyroid exam

Skin exam (pallor, bruising, striae, hirsutism, petechiae)

Abdominal exam (mass, hepatosplenomegaly

Gynecological assessment

Inspection: vulva, vagina, cervix, anus, and urethra

Bimanual examination of uterus and adnexal structures

Rectal examination if bleeding from rectum suspected or risk of concomitant pathology

Testing: Pap smear, cervical cultures if risk for sexually transmitted infection.

Investigations

Full  blood count is recommended if there is a history of heavy bleeding.

There is no evidence that routinely measuring serum ferritin adds information that will affectmanagement if the FBC is normal.

If there is any chance of pregnancy, it should be ruled out through serum β-hCG.

Thyroid stimulating hormone(TSH) levels should be measured only if there are other symptoms or findings suggestive of thyroid disease.

Testing for coagulation disorders should be considered in women who have a history of heavy bleeding starting at menarche, a history of postpartum hemorrhage or hemorrhage with dental extraction, evidence of other bleeding problems, or a family history suggesting acoagulation disorder.

 There is no evidence that measurement of serum gonadotropins,   estradiol, or progesterone levels is helpful in the management of AUB.

IMAGING 

Imaging studies in cases of AUB may be indicated when:

• examination suggests structural causes for bleeding,

• conservative management has failed, or

• there is a risk of malignancy

Transvaginal sonography

allows detailed assessment of anatomical abnormalities of the uterus and endometrium.In addition, pathologies of the myometrium, cervix,

tubes, and ovaries may be assessed. This investigative modality may assist in the diagnosis of endometrial  polyps, adenomyosis, leiomyomas, uterine anomalies, and generalized endometrial thickening associated with hyperplasia and malignancy

Saline infusion sonohysterography

It involves the introduction of 5 to 15 mL of saline into the uterine cavity during transvaginal sonography and improves the diagnosis of intrauterine pathology. Especially in cases of uterine polyps and fibroids, SIS allows for greater discrimination of location and relationship to the uterine cavity. As a result, SIS can also obviate the need for MRI in the diagnosis and management of uterine anomalies.

MRI

MRI is rarely used to assess the endometrium in patients who have menorrhagia. It may be helpful to map the exact location of fibroids in planning surgery and prior to therapeutic embolization for fibroids. It may also be useful in assessing the endometrium when transvaginal ultrasound or instrumentation of the uterus (i.e congenital anomalies) cannot be performed.

Hysteroscopy

Hysteroscopic evaluation for abnormal uterine bleeding is an option providing direct visualization of cavitary pathology and facilitating directed biopsy.

Endometrial Biopsy

1.  Indications for endometrial biopsy in women with abnormal uterine bleeding

• Age > 40

• Risk factors for endometrial cancer (see Table 2.4)

• Failure of medical treatment

• Significant intermenstrual bleeding

Methods of endometrial biopsy

Pippel biopsy - Office endometrial biopsy is a minimally invasive

option for endometrial evaluation in women at risk of malignancy.

The sample detects over 90% of endometrial cancers.27 The sample

is blind and therefore will miss a focal lesion.

Hysterescopic directed biopsy – more accurate .

Dilatation and Curettage

Dilatation and curettage is no longer the standard of care

for the initial assessment of the endometrium. It is a blind

procedure, with sampling errors

The following characteristically cause heavy regular menses:

a) Endometrial carcinoma

b) Adenomyosis

c) Cervical carcinoma

d) Endometriosis

e) Granulosa cell tumour of the ovary          

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