Abnormal uterine bleeding

Posted On April 12, 2018

Abnormal uterine bleeding, heavy menstruation or intermenstrual bleeding are common problems faced by women.  Beside medical treatment, progesterone releasing intrauterine devices, hysteroscopy and many other modalities of treatment are available for this problem, before the last resort, hysterectomy.  Any change from the normal pattern gives rise to anxious moments. The reasons for abnormal bleeding varies according to the age of the patient.  In the years following the first menarche and in the years preceding menopause, there may be disorders of ovulation. Ovulation is the normal process of extrusion of ova in women). In the reproductive years, bleeding may occur in spite of normal ovulation.  Besides these hormonal abnormalities, tumours in the uterus or ovaries could cause excessive or irregular uterine bleeding.     In the following section, a few of the commonly faced situations are discussed.

Q:What is normal menstruation?

A: Normal menstruation means menstruation occurring once in 28-35 days,  the flow being   moderate in amount for the first 2-3 days and petering out to a complete stop in 7 days time.  Menstruation is a normal physiological event occurring in a woman in the reproductive years.  Normal menstruation occurring in normal quantities is reassuring to the woman, in spite of the small inconveniences experienced during the period.

Case example:A young 12 year old girl who has attained menarche (first menstruation) 6 months back comes with bleeding coming on every 15 days. 

The flow is not heavy, but it is bothersome and the girl is not able to concentrate in her studies. Does it need medical intervention?

A;Menstruation is a result of the combined efforts of the uterus, the ovaries and the brain.  In the first few years after mernarche, menstruation tends to be a bit irregular, because the body systems are yet to mature.  In due course of time it may mature and regular menstruation may ensue.  Meanwhile there may be signs of anaemia like inability to concentrate, etc.  Taking iron tablets with a good nutritious diet will help in tiding over the situation.  If the menstruation still does not become normal, taking oral contraceptive pills for 3 months will help.  As the flow is not very heavy, probably detailed investigations could be deferred.

Case example:If the same girl comes with heavy bleeding, what could be the reason?

A: If the bleeding is heavy, then the girl should be evaluated thoroughly.  An ultrasonography should be done to rule out any abnormalities in the uterus or ovaries.  A detailed blood test should be done to rule out any bleeding disorders or abnormalities in the blood cells. If there are any abnormalities detected, treatment should be given to cure the disease.    If every thing is normal, she may need treatment with heavy doses of hormone pills.

  Q: If a woman in the reproductive age group comes with heavy bleeding what could be the reason?

A: In the reproductive group the causes could be

  1. Pregnancy related problems.Hormonal imbalance.
  2. Ovarian cysts or uterine fibroids.
  3. Intrauterine device related problems
  4. Pelvic inflammatory disease.

Pregnancy related problems: In a woman in the reproductive age group, unintentional pregnancy and related problems should always be kept in mind.  It is commonly believed that pregnancy will occur only if a woman misses her periods.  But it is quite possible that even without missing her periods, a woman may be harbouring an abnormal pregnancy either in the uterus or even outside the uterus, which is then called an ectopic pregnancy.  Ectopic pregnancies are usually associated with pain in the abdomen.

  Intrauterine device related problems.

Patients using copper containing intrauterine contraceptive devices could have bleeding related to a foreign body reaction to the device.   Usually the first 2-3 months following insertion of the IUD is associated with irregular and excessive periods, but it settles on its own. If it is excessively heavy even after that, medical intervention may be necessary.

  As in all age groups, abnormal tumours in the uterus or ovaries should be ruled out.

Any infections in the uterus or nearby structures (Pelvic inflammatory disease) could also cause abnormal bleeding.  Clinical examination can rule out gross abnormalities.  Ultrasonography is a more accurate method of ruling out abnormalities in the pelvic organs.

In women with no structural or pregnancy related abnormalities, any bleeding is called dysfunctional uterine bleeding.  While in the post menarchal or premenopausal women, these abnormalities occur due to disorders in ovulation, in women in the reproductive age group, bleeding occurs in spite of normal ovulation. Quite often they can be cured by non-hormonal medical treatments.

Q:What are the abnormalities in menstruation are expected in the woman nearing menopause?
The menstrual irregularity at perimenopause is the result of physiologic reduction or depletion of healthy oocytes (ovarian eggs). The remaining oocytes of the ovary are of lesser competence and cannot sustain the normal hormone balance. In most women this menstrual dysfunction continues till menopause (complete cessation of menses). In the perimenopause period, the previously regular periods tend to become irregular with changes in intermenstrual lengths. The perimenopause is divided into two phases:
• Early perimenopause – The menstrual cycles may be short or prolonged.
• Late perimenopause – Characterized by lengthened intermenstrual periods, resulting in prolonged and irregular menstrual cycles. In some women, the menstrual bleeding may be prolonged and heavy requiring immediate medical attention.

  • Infrequent and delayed periods with normal or excessive and prolonged bleeding
    • Irregular and non-cyclic prolonged periods with scanty or excessive bleeding.

What are the treatment options for dysfunctional uterine bleeding in women who have completed child bearing?
In the woman nearing menopause, one has to rule out cancer of the lining of the uterus, called the endometrium. This is done by Ultrasonography in the early menstrual period, or by sampling the endometrium and sending it to a pathologist. Once this has been done, drugs are given to control the bleeding. Hormone preparations and non hormone preparations are used by doctors depending on the case, by doctors to control this situation. Sometimes, quick and permanent response to medical treatment is also an indication of the bleeding being benign in nature. Associated medical disorders like thyroid dysfunction, diabetes mellitus, pelvic infections should be ruled out. Iron-deficiency, anemia is a very common nutritional disorder in Indian women and menstrual dysfunction further aggravates this deficiency. Therefore, this needs to be treated simultaneously.

What are the other treatment options for women who continue to have abnormal bleeding?

  1. 1. D&C: In women who have completed childbearing, when medical treatment fails, a small procedure called D&C (Dilatation and curettage) may be done. It involves widening the opening of the uterus and putting in a curette and scraping the inner surface of the uterus. This inner lining of the uterus is called the endometrium. The endometrium which is thus taken out is submitted for testing in a pathological laboratory to make sure there is no malignancy in it. This procedure besides being diagnostic to rule out malignancy may also be curative. Bleeding may completely stop after this. D&C is usually done as a day care procedure and need not involve admission to the hospital.
  2. 2. Medicated intrauterine devices: Intra-uterine devices medicated with a hormone called progesterone are placed in the uterus. The advantage of this IUD is that it is a simple procedure and avoids the complications of surgical procedures. The disadvantage is that it is a bit costly (Around Rs.7500). Although the cost may seem to be a bit high for the average patient, it is certainly worth trying specially in cases where surgery or anaesthesia poses a risk to the patient.

3.Endometrial Ablatio
n: In dysfunctional uterine bleeding the irregular or excessive and prolonged bleeding is caused by irregular shedding of the inner lining of the uterus called the endometrium. This lining can be destroyed using many modalities like heat, electricity, laser, microwaves etc. These procedures could be a boon to the woman with DUB with risk of surgery or anaesthesia.

4.Thermal ablation:
 A rubber device is introduced into the uterus and a hot solution is passed into the rubber balloon. The heat of the solution is transmitted across the rubber balloon on to the lining of the uterus which is desiccated. . Most of them attain normal menstruation or decreased menstruation. Very few attain stoppage of menstruation. It is done as a day-care procedure and can be done under local anaesthesia and sedation or under mild general anaesthesia. Immediately following the procedure.   There may be uterine cramps which settles with antispasmodics. Some women may have profuse watery discharge for a month or so.

  1. Hysteroscopy: An instrument called hysteroscope is inserted into the uterus, The uterus is distended with fluid. Any small projections into the uterus called polyps can be removed using special equipments called resectoscopes. The endometrium can also be ablated using this instrument.
  2. Hysterectomy:If medical treatment and D&C fails, another option is removal of the uterus. Uterus being of normal size, can be removed through the vaginal route. Pain after surgery is minimal, and in uncomplicated cases the hospital stay may be limited to 3 or 4 days. Hysterectomy being a major surgery should be reserved for cases where all other means of controlling bleeding fails. Since vaginal hysterectomy is not a very morbid procedure,& there is a 100% possibility of cure, some doctors do not wait to try methods like medicated intrauterine devices or endometrial ablation before going in for hysterectomy. However, it must be remembered that hysterectomy is certainly associated with more complications compared to the non surgical treatment modalities. In India where there is no insurance cover for most patients, the cost of these procedures may seem prohibitive to some patients, and probably that is another reason why hysterectomy is preferred in many patients with dysfunctional uterine bleeding.