Heavy Unscheduled Bleeding - Causes and Treatment

Introduction:

Menstrual bleeding affects the quality of a woman's life and impacts her physically, emotionally, and socially, with or without mild to severe signs and symptoms, and it needs attention. Mostly longer, anovulatory cycles have been observed at and after puberty, whereas frequent and short interval cycles are seen in older women.

What Is Menorrhagia?

Menorrhagia is the cause of around 20 % of gynecologist referrals to hospitals where one in 20 ladies of reproductive age consults a GP (general practitioner) with heavy bleeding. 20 % of ladies have a hysterectomy (removal of the uterus) before 60 years of age due to heavy bleeding.

If periods are unacceptably heavy with or without symptoms, that is, there may or may not be clotting and flooding (not necessarily more significant than 80 ml per cycle), then they need investigations and treatment to prevent further complications like anemia, endometrial hyperplasia, and endometrial cancer.

What Are the Causes of Heavy Bleeding?

1. Dysfunctional Uterine Bleeding (DUB) -Most women with heavy bleeding are classified as DUB. This is without any uterine or pelvic pathology, an absence of pregnancy, or any medical or systemic disease. It is a diagnosis of exclusion. A woman of reproductive age can be treated easily, even with superficial investigations and history. DUB is abnormal bleeding due to the odds ratio of prostaglandin and inflammatory mediators, causing excessive fibrinolysis, defective local factors, and defect in the endomyometrial junctional zone.
2. Local Pathology - Heavy prolonged cycles with or without clots could be due to some local pathology like submucous fibroid (can increase blood loss to 200 ml per cycle), adenomyosis, cervical pathology present or treated, pelvic infection, endometrial or uterine polyp, endometrial hyperplasia, etc.
3. Unscheduled Bleeding With the Use of Oral Contraceptive Pills or After Taking or Skipping Hormones - This bleeding or spotting causes a lot of stress as medications used for heavy bleeding themselves cause spotting and unscheduled bleeding as a side effect.
4. Medical Disorders - Medical disorders like endocrine problems, thyroid abnormalities (hypothyroidism), bleeding disorders (Von Willebrand), thrombocytopenia, coagulation disorders, and Cushing syndrome also cause uterine bleeding.

What Is Dysmenorrhea?

Pain during menses (dysmenorrhea) is unacceptable, mainly in the first two days of bleeding. The following are the causes of dysmenorrhea,

• Idiopathic: It occurs mainly in teenage girls, mostly in ovulatory cycles. It might be due to oversensitivity to prostaglandins and overproduction of inflammatory mediators, their local side effects, genetic, psychological causes, or neuropathic dysregulation.

• Secondary: It is due to an underlying cause or pathology. It could be fibroids, intrauterine contraceptive devices, cervical or uterine pathology, pelvic inflammatory disease, previous surgery (with or without postoperative adhesion), endometriosis, adenomyosis, congenital pelvic abnormalities, Asherman syndrome, etc.

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How Is Heavy Unscheduled Bleeding Diagnosed?

1. A detailed history (gynecological, medical, drug, obstetrical, hormonal, contraceptive, or drug intake).

2. Examination (generalized and local) - Sometimes, hysteroscopic and laparoscopic tests help a lot to exclude pathologies.

3. A complete blood count is a preliminary test to check for anemia and platelet count.

4. Thyroid function test.

5. Coagulation profile only indicated if having a history or symptoms.

6. Sexually transmitted disease screening in case of a history of infection only.

7. Transvaginal scan for endometrial thickness, polyp, fibroid, endometriosis, congenital abnormalities, or other local pathology.

8. Endometrial biopsy is taken in women aged 40 years with irregular, continuous, heavy, unscheduled, or erratic menses. The biopsy could be a Pipelle endometrial biopsy or hysteroscopic biopsy.

9. Laparoscopy is advised for women with severe, unbearable, painful periods with abnormal ultrasound findings, medical treatment failure, or along with suspected infertility.

What Is the Treatment for Heavy Unscheduled Bleeding?

For managing any of the conditions mentioned above, the patient's wish and convenience are crucial. Following are the treatment modalities:

A. Medical Treatments:

1. Prostaglandin Synthesis Inhibitors- For example, the intake of Mefenamic acid (Ponstan) during bleeding reduces bleeding by around 30 % to 40 %. Although it is helpful to reduce pain during periods, it can cause digestive system disturbances in 50 % of the patients.

2. Antifibrinolytics- Tranexamic acid, if taken during bleeding, can reduce bleeding by up to 50 %, especially in the case of DUB and IUCD related unscheduled or irregular bleeding. It is suggested while waiting for the laboratory results or when the cause is still unknown.

3. Progestogen- It is given cyclically on specific days of the menstrual period and then stopped for five days to get a withdrawal bleed. This way, it regulates the cycles and reduces unscheduled bleeding.

4. Combined Oral Contraceptive Pills- Normally, oral contraceptives are given for three cycles to regulate cycles and reduce unscheduled and painful bleeding in patients with low-risk factors like youngsters, slim ladies, and without any chronic conditions like obesity, hypertension, diabetes, migraines, history of venous thromboembolism, or systemic lupus erythematosus. It reduces the bleeding by around 40 % and treats painful menses. Combined oral contraceptives have multiple possible but rare side effects like mood variations, high blood pressure, unscheduled bleeding, migraines, stroke, breast, endometrial cancer, etc.

5. Mirena (Intrauterine Hormone-Releasing Device)- It can be safely used for three years without side effects. It reduces period bleeding gradually in six months. Women who use this get scanty periods, and a few of them get amenorrhea in six months. Initially, it can give symptoms of unscheduled bleeding, lower abdominal pain, breast tenderness, etc. Mirena is advised for patients with typical endometrial hyperplasia (diagnosed on biopsy) and patients who refused hysterectomy after proven atypical endometrial hyperplasia (having high risks of future endometrial cancer).

6. GnRH (Gonadotropin-Releasing Hormone) Analogs- It can reduce menstrual bleeding and even stop it, but it causes postmenopausal symptoms to occur. It can cause bone pain in three months and bone loss if used for more than 6 to 12 months. It is primarily used in severe painful periods that do not respond to other medical treatments.

7. Vitamin B and Magnesium Supplementation- These are also advised for painful menses.

8. Painful menses can be treated by treating the cause and pain with proper analgesia.

9. Anemia is to be treated by iron supplementation and an iron-rich diet.

B. Surgical Treatments:

If the patient does not respond to medical treatment, surgical treatment options are advised.

1. Endometrial Ablation- Advised to patients who have already completed giving birth to children, need contraception and sterilization, do not want to remove the uterus, or are not fit for surgery. It is a short-term procedure. 30 % of the patients are satisfied with the procedure (destruction of endometrium down to the basalis layer). Around 80 % of the patients will significantly improve. Chances of infection, uterine perforation, and failed procedure are there. But, the main drawback is the need for repeat procedures as most patients get benefitted temporarily compared to hysterectomy (permanent relief). The procedure needs general anesthesia and a short hospital stay. Many types of ablations are available like microwave, thermal, balloon, NovaSure, etc.

2. Hysterectomy- Hysterectomy is advised to patients who did not respond to any treatment, completed family, fit for surgery, and in elderly women with atypical endometrial hyperplasia (biopsy proved). Typically, patients are advised to remove ovaries and tubes, especially in patients aged more than 40 to 45 years with proven atypical endometrial hyperplasia due to a high risk of ovarian cancer in the future. Before surgery, the patient needs to be assessed by an anesthesiologist for complications during surgery and risk factors for venous thromboembolism during and post-procedure.

Conclusion:

In short, heavy, irregular, unscheduled painful vaginal bleeding needs to be investigated and treated according to the patient's need, wish, and convenience to improve the quality of life and to prevent long-term consequences like endometrial cancer.