Abnormal Uterine Bleeding

What is abnormal vaginal bleeding?

Abnormal vaginal bleeding is also called abnormal uterine bleeding. It is defined as bleeding from the uterus that is irregular in duration,regularity, volume or frequency when the patient is not pregnant according to FIGO (International Federation of Gynecology and Obstetrics).

There may be acute or chronic blood loss. In acute blood loss, when there is a high quantity of bleeding, emergency intervention is necessary. In this case the patient may have low blood pressure and emergency volume replacement or even blood transfusion may be needed. An effective treatment strategy should be chosen immediately, which may require surgery.

What are the causes of abnormal vaginal bleeding?

There is an acronym used to classify etiologies of abnormal uterine bleeding defined by FIGO and ACOG (American College of Obstetrics and Gynecology). PALM-COEIN stands for:

• Polyp
• Adenomyosis
• Leiomyoma
• Malignancy and hyperplasia
• Coagulopathy
• Ovulatory disfunction
• Endometrial
• Iatrogenic (medication caused)
• Not otherwise classified.

PALM is a summary of structural causes of abnormal uterine bleeding whereas COEIN is a summary of non-structural causes.

What is endometrial polyp?

Emdometrial polyps are benign structures found on the inner lining of uterine cavity. They are a common cause of intermenstrual bleeding. They may be removed by hysteroscopic polypectomy.

What is Adenomyosis?

It is a chronic disease of the uterus that presents with abnormal vaginal bleeding and pain. The uterus is enlarged and tender on examination. Endometrial tissues are found within the uterine muscle walls and they are the cause of bleeding and pain. The only certain diagnostic way for this condition is pathological examination of the uterus after surgical removal.

What is leiomyoma?

Fibroids or leiomyomas are benign uterine masses found in the muscular wall, cavity or outside the uterus. Their growth is dependant on estrogen and are the most common causes of abnormal bleeding in reproductive age group. They may also cause pain and pressure on neighbouring organs.

What are the endometrial causes of abnormal vaginal bleeding?

Endometrial hyperplasia and endometritis are the pathologies related to the endometrium (inner lining of the uterus) that cause abnormal vaginal bleeding.

Endometrial hyperplasia is the abnormal thickening of the endometrium due to chronic hormonal disorders. It can be diagnosed by endometrial sampling (dilatation and curettage)and can most commonly be treated medically (by oral, systemic or intrauterine administarion of progestins).

Endometritis is the acute or chronic inflammation of the endometrium. It can be diagnosed by endometrial sampling (dilatation and curettage) and can most commonly be treated medically by antibiotics.

What is Coagulopathy?

In general coagulopathy term is used to describe congenital or acquired hematological disorders of coagulation so that there is an increased tendency to bleed. Patients in this group may have heavy menstrual bleeding since their first period. They may also have frequent bruising, nose and gum bleeding, bleeding associated with dental treatments.

• Von Willebrandt disease-congenital clotting disorder,
• Hemophilia- congenital clotting disorder,
• Platelet function disorders,
• Leukemia,
• Liver function disorders,
• Anti-coagulant medications,
• Chemoterapeutic medications.

What are the diagnostic tests for abnormal Uterine Bleeding?

All patients must be tested for pregnancy before proceeding with other tests. Then they may be tested for coagulopathies,complete blood count, liver function, thyroid hormones,sepsis or leukemia.

Endometrial tissue sampling should be performed as the next step in management.

Pelvic or transvaginal ultrasound is a useful diagnostic tool for the diagnosis of structural causes of vaginal bleeding.

How is the treatment of abnormal vaginal bleeding?

Treatment may be medical or surgical. Medical management should be the initial treatment for all patients, if clinically appropriate.

For patients without coagulopathy medical treatment options are:

• Intravenous conjugated equine estrogen
• Combined oral contraceptives
• Oral progestins
• Tranexamic acid
• Intrauterine baloon tamponade
• Levonorgestrel intrauterine system (hormonal IUD)

Surgery may be necessary when the bleeding is severe, when there are contraindications to medical treatment or the patient is unresponsive to medical treatment.

Surgical management options can be summarised as:

• Dilatation and curettage
• Endometrial ablation
• Uterine artery embolisation
• Polypectomy (hysteroscopic)
• Myomectomy
• Hysterectomy

What is Dilatation and Curettage?

It is both a diagnostic and therapeutic procedure. The patient may be under local or general anesthesia. Special equipment called laminaria are used to dilate the cervix. Inner lining of the uterus (endometrium) may either be suctioned or removed with curettes and it is sent to pathology laboratory for evaluation.

What is Endometrial Ablation?

It is reserved for patients when other treatments have been ineffective or contraindicated. Endometrial sampling must be done before this procedure to rule out endometrial cancer. It should not be applied to patients who desire to have children in the future. The cervix may need to be dilated before the procedure and a handpiece for he endometrial ablation device is inserted into the uterus to destroy all uterine inner lining by energy.

What is Uterine artery Embolisation?

It is a minimally invasive procedure designed to treat uterine fibroids and to stop abnormal uterine bleeding. The patient is sedated before the procedure. Under the guidance of X-ray visualisation, special catheters are inserted through the groin and guided to the uterine arteries, then blocking agents are given through these catheters to decrease blood flow to the uterus. This decreases uterine bleeding and causes the fibroids to shrink by cutting their blood supply.

Uterine artey embolisation is usually performed as an outpatient procedure,which means the patient can be discharged on the same day after surgery.

What is hysteroscopic polypectomy?

Hysteroscope is a tube with a light and camera, that can be inserted through the cervix to visualize uterine cavity. Endometrial polyps and fibroids may be removed using special equipment through the cervix. It is usually performed as an outpatient procedure,which means the patient can be discharged on the same day after surgery.

What is myomectomy?

It is the removal of uterine fibroids by a surgical procedure. Surgery can be performed as open surgery (laparotomy) or closed surgery (laporoscopy or hysteroscopy).

Fibroids are the most comon cause of hysterectomy in USA. Patient who wish to retain fertility and opt for preservation of their uterus are candiates for myomectomy.

Not all uterine fibroids need to be surgically treated. Patients with severe bleeding, pain and pressure on neighbouring organs that are unresponsive to medical management need to be treated by myomectomy.

What is hysterectomy?

It is the removal of the uterus using several surgical techniques. Patients with abnormal vaginal bleeding unresponsive to medical management may be treated by removal of the uterus if they do not plan to become pregnant in the future. Hysterectomy will not affect sexual life in an adverse way. The only function of the uterus is chilbearing.

It can be performed using several techniques:

• Open surgery (Laporotomy)
• Vaginal hysterectomy
• Laporoscopy assisted vaginal hysterectomy
• Robotic hysterectomy.