Abnormal Uterine Bleeding - A Synopsis

Introduction

Abnormal uterine bleeding refers to irregularities and abnormalities in the menstrual cycle. The condition may occur for several reasons, including; hormonal imbalances, abnormal structures of the uterus, thyroid disorders, polycystic ovary syndrome, cancer, medications, etc. The symptoms of abnormal uterine bleeding depend on the menstrual cycle's duration, frequency, and regularity, along with the amount of blood flow and length of the cycle. Abnormal uterine bleeding may also occur due to other systemic diseases and hormonal imbalances. The diagnosis of the condition is made with the help of blood examinations and imaging tests.

Moreover, the treatment modalities for abnormal uterine bleeding depend on the underlying cause of the disease, desire for fertility, age of the patient, etc. Finally, the treatment is done with the help of medications and surgical procedures.

What Is Abnormal Uterine Bleeding?

Abnormal uterine bleeding includes variations in flow, volume, time and duration, intensity, and frequency of blood flow. Moreover, these abnormal uterine bleeding are not associated with pregnancy. Mentioned below is the broadly accepted standard biological range of various parameters for menstrual flow, and any variation in these parameters can be considered abnormal uterine bleeding. These parameters are:

• The menstrual cycle length should be between 24 and 38 days. The length of the menstrual cycle is counted from the first day of the period to the first of the following period. The menstrual cycle consists of the follicular, ovulation, and luteal phases.

• A typical menstrual cycle.

• It should last from five to nine days.

• Blood loss should be between 5 and 80 millimeters (mm) during each menstrual cycle.

What Are the Types of Abnormal Uterine Bleeding?

Abnormal uterine bleeding is further classified into the following subtypes:

1. Acute Abnormal Uterine Bleeding: Excessive and abrupt uterine bleeding that should be immediately treated to prevent excessive blood loss. Acute abnormal uterine bleeding may manifest on its own or in addition to chronic abnormal uterine bleeding.

2. Chronic Abnormal Uterine Bleeding: Irregular menstrual bleeding for over six months is termed chronic abnormal uterine bleeding.

What Causes Abnormal Uterine Bleeding?

There are numerous medical disorders and other factors that might cause abnormal uterine bleeding:

1. Hormonal Imbalances:

• Anovulation: Anovulation is when the egg or the ovum does not release from the ovaries during a menstrual cycle. It is one of the common causes of infertility in women.

• Thyroid Disease: Thyroid disorders like hypothyroidism (underactive thyroid gland) and hyperthyroidism (overactive thyroid gland) are common causes of abnormal uterine bleeding. Hypothyroidism is the more prevalent cause of abnormal uterine bleeding.

• Polycystic Ovarian Syndrome: It is a common condition occurring due to hormonal disorder, and it is characterized by enlarged ovaries with multiple cysts (fluid-filled sacs) on the outer edge and the ovaries failing to release an egg.

2. Structural Abnormalities of the Uterus:

• Polyps: Uterine polyps are non-cancerous growths affixed to the uterus's internal wall and protruding into the uterus cavity. Uterine polyps develop as a result of endometrial cell overgrowth.

• Fibroids: Benign (non-cancerous) uterine growths known as uterine fibroids. These fibroids frequently manifest themselves in women of reproductive age.

• Adenomyosis: Endometrial tissue, which ordinarily lines the uterus, develops into the muscular uterine wall, causing adenomyosis.

3. Precancer and Cancer:

• Uterine Cancer: Uterine cancer is a type of cancer growing inside the uterus; it usually begins in the endometrial layer of the uterus.

• Cervical Cancer: Cervical cancer affects the cells of the cervix (the part of the uterus that connects to the vagina).

• Vaginal Cancer: It is cancer affecting the cells of the vagina.

• Ovarian Cancer: A cell growth that develops in the ovaries is called ovarian cancer. Often, ovarian cancer is not discovered until it has spread to the pelvis and stomach.

• Endometrial Hyperplasia: In endometrial hyperplasia, the endometrium (the lining of the uterus) becomes unusually thick because of hyperplasia (having too many cells). Endometrial hyperplasia is not cancer but can increase the risk of developing endometrial cancer.

4. Infections:

• Trichomoniasis: A common sexually transmitted disease caused by a parasitic protozoan.

• Cervicitis: Inflammation or swelling in the lower part of the uterus that connects to the vagina.

• Chlamydia: It is a bacterial infection spreading through sexual intercourse or sexual fluids.

• Gonorrhea: A common sexually transmitted infection caused by bacterial infection. This condition can cause infertility.

• Vaginitis: Vaginitis is defined as vaginal inflammation, which can cause discharge, itchiness, and pain. An infection or a shift in the balance of vaginal bacteria is the cause.

5. Medications: Some common medicines and drugs like blood thinners, hormone replacement drugs, breast cancer-treating drugs, intrauterine devices, birth control pills, etc., can cause abnormal uterine bleeding;

6. Other Conditions: Other conditions associated with abnormal uterine bleeding are liver diseases, kidney diseases, platelet disorders, etc. However, they are rare.

How Common Is Abnormal Uterine Bleeding?

• The incidence of abnormal uterine bleeding among reproductive-aged women is approximately three to thirty percent globally.

• The condition is more common during perimenopause (nearing menopause or cessation of periods) and menarche (onset of periods) time.

• Since many women do not seek treatment for their symptoms, it is challenging to estimate the exact prevalence.

What Are the Symptoms of Abnormal Uterine Bleeding?

Signs and symptoms of abnormal uterine bleeding can differ among individuals. However, some of the common symptoms include the following:

• The frequency of periods does not occur between 24 to 38 days. Menstrual cycles are either very frequent (less than 24 days) or infrequent (more than 38 days).

• The duration of the period may be less than four days or more than eight days.

• The volume of blood flow occurring during each menstrual cycle does not fall in the normal range.

• Menorrhagia (excessive bleeding during period).

• Bleeding at unusual times, like between two menstrual cycles, after sexual intercourse, etc.

• Unusually long periods.

• Irregular menstrual cycles.

• Weight loss.

• Pain.

• Vaginal discharge.

• Symptoms of anemia (reduced red blood cells).

• Symptoms of bleeding disorders.

• Symptoms of endocrine disorders.

How Is Abnormal Uterine Bleeding Diagnosed?

The diagnosis of abnormal uterine bleeding includes:

• Menstrual History: It is important to know the patient's menstrual history to determine the possible cause and treatment of abnormal uterine bleeding. The time of commencement of periods, last period date, frequency, duration, blood flow, and regularity of the period should be noted.

• Sexual and Reproductive History: The patient’s frequency and type of delivery, fertility status, history of sexually transmitted infection, etc., should be known.

• Systemic Symptoms: The presence of any kind of systemic or associated symptom will help in determining the underlying cause of abnormal uterine bleeding. Signs like weight loss, mood swings, hot flashes, anemia, bowel symptoms, etc., should be noticed.

• Medical and Family History: Medical and family history will help determine the cause of abnormal uterine bleeding.

• Pregnancy Test: A pregnancy urine test should be done because heavy and abnormal bleeding can occur in case of miscarriages.

• Blood Examinations: Several blood examinations, including complete blood count, coagulation panel, serum ferritin, gonadotropins, prolactin, thyroid function test, liver function test, kidney function test, blood glucose level, etc., are done.

• Imaging Tests: Ultrasound or transvaginal ultrasound of the pelvic region may be done. The healthcare provider can perform imaging tests to look for any growths in the reproductive organs that might be the source of abnormal uterine bleeding. Transvaginal ultrasonography does not expose the patient to radiation and can identify ovarian abnormalities, endometrial thickness, adenomyosis, uterus size and form, and the presence of fibroids. Therefore, a crucial diagnostic procedure should be obtained as soon as abnormal uterine bleeding is diagnosed. In addition, magnetic resonance imaging (MRI) offers precise pictures that can be helpful for surgical planning.

• Hysteroscopic Examination: This examination looks for polyps, fibroids, or malignancy (cancer) indications.

• Biopsy: Even though endometrial tissue sampling may not be required for all patients, it is recommended for those at a high risk of developing hyperplasia or cancer. An endometrial biopsy is regarded as the first-line diagnostic procedure in women with abnormal uterine bleeding and who are 45 years of age or older.

How Is Abnormal Uterine Bleeding Treated?

Treatment for abnormal uterine bleeding is based on several variables, including the cause, the patient's desire to conceive, the patient's overall health, and the presence of other associated complications. Therefore, each patient's treatment should be unique and personalized based on these variables. Hence, the treatment of abnormal uterine bleeding includes:

• Medication: Medications for treating abnormal uterine bleeding include birth control pills, Progestin, nonsteroidal anti-inflammatory drugs (NSAIDs), gonadotropin-releasing hormone agonists, gonadotropin-releasing hormone antagonists, etc.

• Surgery: Hysteroscopy (a procedure performed to view the inner part of the uterus) will help in removing abnormal structures present in the uterus. Uterine artery embolizations stop the blood flow to fibroids and make them shrink. Myomectomy is the surgical procedure of removing uterine fibroids, and endometrial ablation is a procedure that helps in destroying the uterus lining to treat abnormal uterine bleeding. These procedures are performed to treat this condition.

• Cancer Treatment: Radiation or chemotherapy may be required for advanced cancer stages.

Conclusion

Although the prognosis of abnormal uterine bleeding relies on the cause, the prognosis is often good. The treatment of abnormal uterine bleeding should help improve the patient's quality of life and consider present and future fertility goals as well as other comorbid medical conditions that could affect treatment or symptoms. The primary objective of diagnosing and treating abnormal uterine bleeding is to rule out the presence of severe diseases like cancer. Moreover, chronic abnormal uterine bleeding can cause complications like anemia, infertility, and endometrial cancer. In addition, acute abnormal uterine bleeding can cause severe anemia, low blood pressure, shock, and death, if left untreated.