Abnormal Uterine Bleeding

Abnormal Uterine Bleeding

 

Abnormal uterine bleeding (AUB) is defined as any bleeding that sig­nificantly deviates from the usual menstrual pattern. Normal menstrua­tion varies among women in the amount and duration of blood flow and by the intervals between menstrual cycles. The average range of intervals between cycles is 21 and 35 days; the duration of normal menses is 3 to 7 days; blood lost during a normal cycle varies from 25 to 80 mL

 

Etiology

 

  1. Uterine bleeding can be divided into two major categories: organic and dysfunctional.
  2. Dysfunctional uterine bleeding (DUB) is abnormal bleeding from the uterine endometrium that is unrelated to anatomic lesions of the uterus.
    1. In perimenopausal women, hypothalamic-pituitary dysfunction results in less predictable ovulation.
    2. Without adequate progesterone, the endometrium becomes unsta­ble and fragile.
    3. Anovulatory bleeding can often be diagnosed by the patient’s history of erratic bleeding that is painless and unpredictable in volume.
    4. If endometrial proliferation or hyperplasia without atypia is found on endometrial biopsy, progestin-based medical management is indicated with follow-up evaluation after 3 to 4 months.
  3. Organic causes can be subdivided into systemic disease and reproduc­tive tract disease.
    1. Endometrial polyps and uterine fibroids are very common causes of anatomic conditions causing AUB in the perimenopausal period.
    2. Endometrial atrophy is the most common cause of postmenopausal bleeding.
    3. All postmenopausal bleeding is considered abnormal and needs evaluation.

 

 

Definitions of Abnormal Bleeding

 

  1. Amenorrhea: Absence or abnormal cessation of the menses
  2. Hypermenorrhea: Menorrhagia, prolonged or profuse menses
  3. Hypomenorrhea: A diminution of the flow or a shortening of the duration of menstruation

 

  1. Menorrhagia: Excessively profuse or prolonged menstruation
  2. Metrorrhea: Irregular, acyclic bleeding from the uterus, particularly between periods
  3. Menometrorrhagia: Irregular or excessive bleeding during menstrua­tion and between menstrual periods
  4. Oligomenorrhea: Scanty menstruation; menses occurring at intervals greater than 35 days
  5. Polymenorrhea: The occurrence of menstrual cycles of greater than usual frequency—usually at intervals less than 21 days

 

 

Diagnosis

 

  1. History.
    1. Frequency, duration, and amount of bleeding
    2. Current pregnancy?
    3. Contraceptive history
    4. Systemic diseases (Box 8-1)
    5. List of medications
    6. Any recent surgical or gynecologic surgery

 

 

BOX 8-1 Systemic Diseases That Can Cause Abnormal  Bleeding
         1.Blood Dyscrasia

Thrombocytopenia purpura

von Willebrand’s disease

Leukemia

Increased fibrinolysin (endometrium)

  2. Hepatic Disease

Impaired synthesis of coagulation factors

Impaired metabolism of sex steroids (i.e., estrogen)

Impaired synthesis of sex hormone—binding globulin

   3 .Renal Disease
 Impaired excretion of estrogens

Obesity

    4. Iatrogenic Causes

Anticoagulants, digitals, oral contraceptives (breakthrough bleed­ing), aspirin, intrauterine device (IUD)

   5. Endocrine
 Hypothyroidism or hyperthyroidism

Diabetes mellitus

 

 

  1. Physical examination.

 

  1. A complete physical examination, including a careful pelvic examina­tion, should be performed. There are many anatomic causes of nonuterine bleeding (Box 8-2) and anatomic uterine abnormalities (Box 8-3).

 

 

  1. Examination should include the following:
    • Thyroid
    • Breasts

 

 

 BOX 8-2 Anatomic Causes of Nonuterine Bleeding
Cervix
Neoplasia (polyps or carcinoma)
 Cervicitis
 Ectropion and eversion
 Ulceration
 Condylomatous lesions
 Endometriosis
 Vagina
 Neoplasia (carcinoma, sarcoma)
 Adenosis
 Trauma
 Foreign body
 Atrophic vaginitis
 Infection (vaginitis)
 Condylomas
 Vulva
Trauma
 Infections or inflammations
 Neoplasia
 Condylomas
 Dystrophy
 Varices
 Urinary Tract
 Urethral caruncle
 Urethral diverticulum
 Hematuria
 Gastrointestmal Tract
 Hemorrhoids
 Anal fissure
 Colorectal lesions

 

 BOX 8-3 Anatomic Uterine Abnormalities
1. Endometrial hyperplasia
2. Endometrial or cervical carcinoma
 3. Leiomyomas
4. Polyps: endometrial and endocervical
 5. Infections: endometritis, cervicitis, vaginitis
 6. Foreign bodies (e.g., IUD, tampon)
 7. Pregnancy abnormalities
 8. Estrogen-producing ovarian tumors
 9. Medications: hormone replacement therapy, oral contraceptives
(OCs)
J

 

 

  • Liver
  • Presence or absence of ecchymotic lesions on the skin
  • Obesity
  • Hirsutism
  • Inspection of vulva and vagina
  • Inspection and palpation of cervix and uterus
  • Determination of the size and shape of uterus

(10) Palpation of adnexa for mass and to check for ovarian pathology

 

 

  1. Diagnostic studies: Some of the following may be indicated depending on the history and findings on physical exam.
    1. Hemoglobin and hematocrit
    2. Serum iron level and serum ferritin level
    3. Chemistry profile including liver function tests
    4. Serum human chorionic gonadotropin (HCG)
    5. Thyroid profile
    6. Coagulation profile
    7. Luteal phase progesterone
    8. Prolactin, follicle-stimulating hormone (FSH), luteinizing hor­mone (LH)
    9. Serum androgens
    10. Stool for occult blood
    11. Urinalysis for hematuria
    12. Papanicolaou smear
    13. Pelvic ultrasound; include measurement of endometrial thickness
    14. Hysterogram or hysteroscopy
    15. Endometrial sampling

 

 Management

In most patients, abnormal uterine bleeding is a recurrent problem and long-term management depends on correct diagnosis for treatment

(see Box 8-3). Systemic and anatomic causes should be managed with their specific treatments.

 

 

MEDICAL THERAPY

  1. Estrogen-progestin contraceptives

 

  1. Oral contraceptives containing low doses of estrogen (<35 ug ethinyl estradiol)

 

  • First-line therapy for healthy, nonsmoking perimenopausal women with AUB
  • Variable effectiveness for women with fibroids

 

  1. Vaginal ring releasing etonogestrel and ethinyl estradiol

 

  1. Continuous progestin-only contraceptives

 

  1. Depot injection of medroxyprogesterone acetate (Depo-Provera)
  2. Levonorgesterol intrauterine device (1UD) (Mirena)

 

  1. Postmenopausal estrogen plus progestin therapy (EPT) (with sufficient progestin sufficient to inhibit ovulation)

 

  1. 17beta estradiol 1 mg plus 0.5 mg Norethindrone acetate (Activella)
  2. Ethinyl estradiol 5 (am plus 1 mg Norethindrone acetate (Femhrt)

 

  1. Other therapies
    1. Cyclic oral progestogen alone
    2. Parenteral estrogen
    3. Danazol
    4. Gonadotropin-releasing hormone (GnRH) agonists such as leupro- lide acetate (Lupron)

 

 

 

SURGICAL THERAPY

  1. Dilation and curettage (D&.C)
    1. This surgical procedure is now considered obsolete for the treat­ment of AUB because it can miss localized disease such as polyps.
    2. D&C does not completely remove intracavitary tissue.
  2. Endometrial ablation
    1. Endometrial histologic evaluation should take place before endo­metrial ablation.
    2. Some approaches do not involve visualization of the endometrial cavity and may not effectively treat AUB caused by anatomic lesions such as submucous fibroids or polyps.
  3. Hysterectomy
    1. Used to be the only definitive treatment for AUB.
    2. Postoperative complication rate is approximately 30%.

 

 

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