Heavy Unscheduled Bleeding - Causes and Treatment

Menstrual bleeding affects the quality of a woman’s life and has an impact on 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 elderly women.

Menorrhagia

This is the cause of around 20 % gynecologist referrals to hospitals where one in 20 ladies of reproductive age consults a GP 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 only greater than 80 ml per cycle), then they need investigations and treatment to prevent further complications like anemia, endometrial hyperplasia, and endometrial cancer.

Causes of Heavy Bleeding

1. Dysfunctional uterine bleeding (DUB)

This is without any uterine/pelvic pathology, an absence of pregnancy, or any medical or systemic disease.

It is a diagnosis of exclusion. Most women with heavy bleeding are classified as DUB. A woman of reproductive age can be treated easily even with superficial investigations and history.

DUB is abnormal bleeding due to the abnormal 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 use of oral contraceptive pills or after taking or skipping hormones

This bleeding/spotting actually causes a lot of stress as medications used for heavy bleeding themselves cause spotting and unscheduled bleeding as a side effect.

4. Medical disorders

Endocrine problems, thyroid abnormalities (hypothyroidism), bleeding disorders (Von Willebrand), thrombocytopenia, coagulation disorders, Cushing syndrome.

Dysmenorrhea

Pain during menses (dysmenorrhea) is unacceptably painful menses, mainly in the first two days of bleeding.

1. Idiopathic: mostly 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.

2. Secondary: due to underlying cause or pathology. Could be fibroids, intrauterine contraceptive devices, cervical or uterine pathology, pelvic inflammatory disease, previous surgery (with or without postoperative adhesion), endometriosis, adenomyosis, congenital abnormalities of the pelvis, Asherman syndrome, etc.

Diagnosis

1. A detailed history (gynecological, medical, drug, obstetrical, hormonal, contraceptive or drug intake).
2. Examination (generalized and local) - Sometimes, hysteroscopic and laparoscopic examinations help a lot to exclude pathologies.
3. Complete blood count is the main test to check for anemia and platelets 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 any other local pathology.
8. Endometrial biopsy in women with irregular/continuous/heavy/unscheduled/erratic menses and aged around 40 years. 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.

Treatment

For management of any of the above-mentioned conditions, the patient‘s wish and convenience are the most important factor.

• Painful menses can be treated by treating the cause and pain as well with proper analgesia.

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

Medical treatments for heavy, irregular/unscheduled bleeding:

1. Prostaglandin synthesis inhibitors: for example Mefenamic acid (Ponstan) intake during bleeding reduce 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: Traxenamic acid, if taken during bleeding can reduce bleeding by upto 50 %, especially in case of DUB and IUCD related unscheduled/irregular bleeding. It is suggested while waiting for the laboratory results or when the cause is still unknown.
3. Progestogen: cyclically given in specific days of menstrual period and then to stop for five days for withdrawal bleed. This way, it not only regulates the cycles but also reduces unscheduled bleeding.
4. Combined oral contraceptive pills: normally oral contraceptives are given for three cycles cyclically to regulate cycles and reduce unscheduled or/and painful bleeding in patients with low-risk factors like youngsters, thin ladies without any chronic disease like obesity, hypertension, diabetes, migraines, history of venous thromboembolism or systemic lupus erythematosus. Combined oral contraceptives have multiple side effects like mood variations, high blood pressure, unscheduled bleeding, migraines, stroke, breast and endometrial cancer, etc. It reduces the bleeding by around 40 % and painful menses as well.
5. Mirena (intrauterine hormone-releasing device) can be safely used for three years if not having any side effects. It reduces period bleeding gradually in a span of six months. Women who use this get scanty periods and 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: can reduce menstrual bleeding, and even stop it, but it gives postmenopausal symptoms. It can give bone pain in three months and bone loss if used more than six to 12 months. It is mostly used in severe painful periods that did not respond to any other medical treatment.
7. Vitamin B and Magnesium supplementation are also advised for painful menses.

Surgical treatments for heavy unscheduled bleeding

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

1. Endometrial ablation: Advised to patients who have already completed family, need contraception and sterilization, does not want to remove uterus or not fit for surgery. It is a short-term procedure. 30 % of the patients are satisfied with the procedure (destruction of endometrium down to 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 procedure as most patients get benefitted temporarily as 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: advised to patients who did not respond to any treatment, completed family, fit for surgery, elderly patient with atypical endometrial hyperplasia (biopsy proved). Normally, patients are advised to remove ovaries and tubes as well especially in patients aged more than 40 to 45 years with proven atypical endometrial hyperplasia due to high risk of ovarian cancer in the future. Before surgery, the patient needs to be assessed by anesthesia for complications during surgery and risk factors for venous thromboembolism during and post procedure.

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

For more information consult a menstrual disorders specialist online --> https://www.icliniq.com/ask-a-doctor-online/obstetrician-and-gynaecologist/menstrual-disorders