General Gynaecology

Menstrual Disorders

 

Abnormal uterine bleeding can be caused by many different conditions. Most conditions that cause abnormal uterine bleeding can occur at any age, but some are more likely to occur at a particular time in a woman's life.

Abnormal uterine bleeding in young girls- Bleeding before menarche is abnormal and needs to be investigated. Most often this is due to trauma, irritation of the genital area, foreign body or even sexual abuse

Adolescents —Irregular bleeding is common during this time and often resolves by itself. If bleeding is heavy this needs to be investigated.

Premenopausal women — Many different conditions can cause abnormal bleeding in women between adolescence and menopause. Most of these are due to hormonal changes that could be related to ovulation or lack of ovulation and sometimes also due to hormonal birth control methods.

Other common reasons include uterine fibroids, uterine adenomyosis, or endometrial polyps. Fibroids are benign masses in the muscle layer of the uterus (myometrium), while adenomyosis is a condition in which the lining of the uterus (endometrium) grows into the myometrium. Endometrial polyps are fleshy (usually benign) growths of tissue which project into the uterine cavity.

Other causes of abnormal uterine bleeding in premenopausal women include:

  • Pregnancy

  • Cancer or precancer of the cervix or the endometrium (lining of the uterus)

  • Infection or inflammation of the cervix or endometrium

  • Blood clotting or thinning disorders

  • Medical illnesses such as hypothyroidism, liver disease, or chronic renal disease

Women in the menopausal transition — This is a time in a woman’s life when they are more likely to experience abnormal uterine bleeding. This is often due to irregular ovulation and leading to thickening and breakdown of the lining of the womb. Abnormal bleeding can also be due to precancerous changes or cancer of the womb, polyps, fibroids or infection or even pregnancy. Further evaluation is needed in women with persistent irregular menstrual cycles or an episode of profuse bleeding.

Menopausal women — Bleeding after attaining menopause (12 months of no periods) is abnormal and should be investigated.

Causes of abnormal bleeding during menopause include:

  • Atrophy or excessive thinning of the tissue lining the vagina and uterus, caused by low hormone levels

  • Cancer or precancerous changes (hyperplasia) of the uterine lining (endometrium)

  • Polyps or fibroids

  • Infection of the uterus

  • Use of blood thinners or anticoagulants

How do we assess abnormal uterine bleeding?

  • We take a full clinical history and undertake a pelvic examination.

  • We may do vaginal swab tests or cervical screening test (pap smear) if this is necessary. 

  • Blood tests may be done to assess the severity of your blood loss(anaemia) and assess blood clotting. Other blood tests may be indicated based on clinical suspicion eg: thyroid tests or ovarian hormone status.

  • An transvaginal pelvic ultrasound scan (internal scan of your pelvic organs) is often ordered to assess for fibroids, adenomyosis and polyps.

  • Endometrial assessment is often indicated especially if you are in the perimenopausal or menopausal group. This may be a sample taken in the clinic using a thin sterile tube that is passed through the cervical canal at the time of pelvic examination (Pipelle biopsy).

  • Sometimes a hysteroscopy (insertion of a small telescope attached to a camera into the cavity of uterus) is necessary. This is often undertaken under anaesthetic and tissue samples are taken from the lining at the same time.

Treatment of abnormal uterine bleeding

The treatment of abnormal bleeding is based upon the underlying cause.

Combined oral contraceptive pills COC pills are often used to treat uterine bleeding that is due to hormonal changes or hormonal irregularities. This regulates the cycles and reduces the heaviness of blood flow making it easier to manage.

Nonsteroidal anti-inflammatory drugs (NSAIDs; eg, ibuprofen, mefenamic acid) may also be helpful in reducing blood loss and cramping.

Tranexamic acid-These tablets help blood to clot more easily and thereby reduces the heaviness of menses

Progesterone This is a hormone made by the ovary that stabilises the lining of the womb, hence effective in preventing or treating abnormal bleeding. This is given as tablets in the second half of the cycle- cyclical or continuously on a daily basis. This hormone can be given as an injection (Depo Provera) and implant (Implanon) or an intra uterine device (Mirena IUD). Mirena IUD is a very effective treatment for abnormal bleeding and some women stop having periods completely as a result of this. This change is completely reversible when IUD is removed.

Surgery This will depend on the cause of the bleeding. If fibroids and polyps are thought to be the cause, this may need to be removed.  Route of Fibroid removal will depend on size and site of the fibroid. Polyps are generally removed by the vaginal route using a camera with a telescope attached and sometimes using special devices to resect the polyp from its attachment.  (Hysteroscopic resection/ myosure)

Endometrial ablation is another option to women who have completed treatment. This uses heat energy to destroy the lining of the uterus. This is quite an effective treatment with around 80% of women finding relief of symptoms.

The most definitive surgical treatment for abnormal uterine bleeding is hysterectomy, or removal of the entire uterus. At the time of hysterectomy, the ovaries may be left in place or removed. Hysterectomy may be performed by conventional laparoscopy or robotic laparoscopy or through the vagina, or by an open incision on the abdomen.

https://ranzcog.edu.au/womens-health/patient-information-guides/patient-information-pamphlets