Abnormal Uterine Bleeding – Currae Hospitals
Today, We are going to talk about a very common topic, for which we see the patients in the OPD, that is abnormal uterine bleeding. Now, what is abnormal uterine bleeding? Abnormal uterine bleeding is when there is an abnormality in the duration of the cycle, the menstrual cycle, amount of flow and the cycle length.
To know what is abnormal, you should know what is normal first. So, what is a normal menstrual cycle? There’s a lot of doubts in the people like, you know, when they start, what is the normal menstrual cycle has to be? A normal menstrual cycle lasts somewhere between 4 to 6 days, the cycle length that is the duration of the cycle should be between 21 days to 35 days, and the blood loss should not be more than 30 to 35 cc. Now, when it is abnormal is when the cycle length, the length of the cycle is less than 21 days or above 35 days, if the bleeding is above 80 cc, i.e. more than 80 cc of blood loss, and the duration is more than 7 days. So, this is basically what we call as an abnormal uterine bleeding.
Now, there are a few terms which you must be noticing it when you come to an OPD or when the doctors discuss your case, i.e. dysmenorrhoea. In the day-to-day life, you know, you must be listening to terms like dysmenorrhoea. What is dysmenorrhoea? Dysmenorrhoea is painful menses or painful menstrual cycle, same way, polymenorrhea is when the cycle length is short, i.e., it is you get menses in less than 3 weeks. Menorrhagia is other term which usually we hear is when the flow is more, i.e. more than 80 cc of blood loss or more than 7 days of bleeding. Amenorrhea that means there is no periods at all. And metrorrhagia, i.e. in between periods when you get bleeding, that is these are the common terms which I used.
Now, what are the causes of abnormal uterine bleeding? We always think that now, according to the age, the causes of bleeding have been divided. A young girl, i.e., she is in her puberty can come with menorrhagia. Menorrhagia means heavy flow or abnormal uterine bleeding. Puberty menorrhagia what we call as… so, these girls basically have got a history of early menarche that means they start their periods less than 10 years of age or they have got precocious puberty that is early puberty, so their management is accordingly. The second thing is when it is in the adolescence that means they get their periods at the normal age, mean when they menarche that is around 12 to 14 years of age, but they have heavy periods. Now, why, what are the causes? What we suspect is that either they are anovulatory cycles, i.e., because the hormonal axis is not yet developed, so these girls deal a lot, or the other causes are any coagulation defect. Some girls have got or some families have got genetic history of, you know, bleeding dyscrasias, so these patients have to be treated accordingly.
The other age group is again the reproductive age group. So, in reproductive age group, they can be abnormal uterine bleeding as a cause of complication of pregnancy, like either abortions or ectopic or other conditions like either fibroids or adenomyosis, polyp, and dysfunctional uterine bleeding, i.e., an abnormal hormonal cycle.
In perimenopausal age group that means around 40 to 60 years of age, again, the patient presents to us with abnormal uterine bleeding. So, in these patients, what we suspect is, first of all, a dysfunctional uterine bleeding, i.e., hormonal imbalance or endometrial hyperplasia that means the endometrium formation is more. Other conditions like either fibroid or adenomyosis, polyps, and even carcinoma to that matter.
In postmenopausal ladies, again once the menses are stopped, we are not supposed to bleed. At least when we label the patient as menopause that means 1 year there is no period and then again she starts bleeding that is a matter to be worried about. These patients have to be definitely assessed with regards to their endometrial hyperplasia, carcinoma, polyp, so and dysfunctional uterine bleeding.
And last but not the least, is iatrogenic that means some factor which is causing problem introduced by yourself. For example, if you have Copper T or an intrauterine device which can cause an abnormal uterine bleeding. For example, now the festive season is coming up, so most of the ladies come to our OPD, we want to postpone our periods, so some medicines that is oral and injectable steroids; or inbuilt medications like psychotropic drugs or patients who are already on medications, they also can present with abnormal uterine bleeding.
Now, what is the commonest cause of abnormal uterine bleeding, that is DUB, dysfunctional uterine bleeding. Now, what is the DUB? DUB is a bleeding condition when there is no organic pathology involved. Organic pathology, as in there is no fibroid, polyp, or any other inbuilt cause which is involved. There is just a hormonal imbalance. There is no iatrogenic factors like any Copper T or any medicines, which are on, or any other, other hormonal problems like thyroid, you know pituitary causes and all that. So, commonest causes are hormonal imbalance that is DUB. Now, in DUB, in 90% of the patients, it is either anovulatory cycle that is where the oestrogen which is the hormone, which supports the whole menstrual cycle, is produced in excess and there is no progesterone support to it. In such patients what happens, the patient starts bleeding and she continues to bleed because there is no support of progesterone which is there. And the other 10% have got ovulatory cycles, where they have excess of progesterone, where the progesterone is irregularly supplied in their body and that causes irregular bleeding or excessive bleeding because of irregular shedding of the endometrium.
The other causes are thyroid disorders, which is again one of the causes for abnormal uterine bleeding where the patient does not even realize whether the patient has thyroid or not, unless a blood test is done. When the patient comes to our OPD that is the first time when a thyroid has been sent and it comes to a very high level. Only correcting the thyroid can make her periods normal. So, that is thyroid or pituitary conditions.
Secondly, the most most most common is PCOD. Nowadays, 20% of our OPD patients come with complaints of PCOD. They usually present with complaints of amenorrhea that is no periods at all for 3 to 4 months, but once they start bleeding, they bleed a lot. They bleed for 15 days, 20 days continuously at stretch, which is not good. Now, PCOD that is polycystic ovarian disease is a condition where there is a hormonal imbalance in the patient and these patients have anovulatory cycles. So, these patients usually present with the symptoms of obesity that is excessive weight, more than the BMI. They have features of acne, hirsutism, and irregular cycles. Obesity, one more major factor for periods becoming irregular and with heavy bleeding in between, like they have amenorrhea of 3 to 4 months and then they again present with… when they start bleeding, they bleed, profusely they bleed. So, obesity also has to be controlled. I will be talking about the management later.
Now, when the patient comes to the OPD, first of all, we have to do an examination, a general examination, which includes weight, as I said, obesity is one of the factors for heavy periods. We have to check her BMI. What is her BMI? If she is in the high BMI then accordingly lifestyle modification has to be advised. Similarly patients with PCOD, when they come, they have to be counselled about weight loss, about lifestyle modifications, about maintaining a healthy lifestyle, losing weight. Acne, hirsutism is for cosmetic reasons, but for the Gynaec point of view, we have to monitor their weight.
Other features like thyroid problem or any other blood tests, blood tests have to be sent, of the patient. Haemogram , to know their basic CBC that is the basic haemoglobin of the patient. A proper history is the most important thing. When the patient comes to our OPD, they have got a very vague complaint, that I bleed every month but I bleed for a longer period of time. Now, the history what the patient presents is very subjective. For a patient, bleeding for 2 days, maybe she is bleeding for 2 days but maybe she is using maybe 8 to 10 pads in a day. When I take the history of the patient, I just don’t go by the days of bleeding because we Indians have usually take it for granted that it’s good to bleed. No, it is not good to bleed. We don’t have to have a heavy flow or passage of clots because that invariably makes us anaemic. So, when a patient comes in the OPD with saying 2 days of bleeding, I have to definitely ask her about the amount of pad she is using every day, how much is the bleeding, how many pads does she use, does she pass clots or not, how many days does she bleed. So that gives me a basic idea about how much is the blood loss of the patient. The external feature of the patient, she might be looking pale, she might be white as, you know, she must be just pale, too pale, but she says that no, that much, that is a regular menstrual cycle. So, a Haemogram that is a CBC tells me about how much is the blood loss that she is having.
Similarly, with the sonography, sonography usually tells me… after examination, history, investigations; after the CBC, a thyroid profile; in young girls of PCOD, maybe a hormonal profile, and a prolactin level, and a sonography. A sonography tells me about her inbuilt pathology, if any, like a fibroid or a polyp or any other adenomyosis, which is the cause of bleeding. See, if the cause is known, the treatment of the cause is most important.
Similarly, after sonography, there are other procedures like hysteroscopy. Once the cause is detected like a polyp or a fibroid. A hysteroscopy can be both, it can be either a diagnostic hysteroscopy where a scope is introduced through the vagina into the uterine cavity and we have a generalized look, whether there is a polyp involved or any adenomyosis and a submucous fibroid which is causing a bleeding. Similarly, if the cause is ruled out that is there is no clinical cause then we can treat her only with hormonal medicines. At the same time, hysteroscopy also helps us to treat the cause. For example, when we do a hysteroscopy, there is a polyp which is there, we can immediately remove it. If there is a fibroid, we can immediately remove it and send it for testing.
Other things are endometrial biopsy. Whenever we take a patient for hysteroscopy, it is always associated with a hysteroscopy-guided endometrial biopsy because in patients who are perimenopausal or who are postmenopausal, a biopsy always is sent for histopathological examination and it gives us the result whether there is a carcinoma or just a hyperplasia. So our line of management changes accordingly.
Now, if there is some other pathology which is involved, the treatment options I will be going ahead with, first of all, just general haematinic which are given to increase the haemoglobin of the patient because a pale patient or a patient who has bled a lot generally has complains of weakness or you know loss of interest in doing daily activities. So, these patients definitely have to be prescribed with haematinics. A patient with PCOD has to be explained about lifestyle management. Whatever the patient comes, we have to treat what is bothering her more. Most of the patients, when they come, they are not worried about their period, how much is the flow of the period, they are just wanting that it just becomes regular [ki bus regular ho jaye]. They have to be treated according to what is their requirement at that time. If she is a young girl, she is in her puberty and she is bleeding a lot, so right now, the concern for the parents is to control the bleeding. Once all the tests are done and there is no problem, we have to treat her. If she has a coagulating disorder then we have to treat her accordingly. Same thing is with adolescent girls, if she is bleeding continuously, we just can’t leave her like that, we will have to support her with progesterone. So, the hormonal management comes into play where we put her on hormones and we have to control, at the same time, give her something to build up her haemoglobin, so that because these are young girls, they are growing girls.
Same way, in a patient who are in the reproductive age group, if she has complaints of bleeding, first of all, rule out the cause like any iatrogenic cause like a Copper T or a medicine what she has taken, for example, an I-Pill or any other hormonal medicines to postpone the periods, so that has to be removed, regularize her cycle. If she is in the reproductive age group, not wanting for a pregnancy but wanting regular cycles, we can even put her on hormonal medicines that is oestrogen-progesterone combination all birth control pills. Same way, if the patient is bleeding continuously that is an anovulatory cycle where there is a constant oestrogen supply which is there, we have to support it with progesterones. Now, progesterones can either be given in a continuous manner or in a cyclical manner.
If a patient in a postmenopausal age group comes with complaints, we do an endometrial biopsy, there is only hyperplasia, we can wait or advice for a hysterectomy. Same way, we rule out any carcinoma because if there is any carcinoma then the line of management is an extensive surgery. If a patient comes with complaints of fibroid or polyp or adenomyosis on a sonography then the fibroid has to be removed, now that we can do it either laparoscopically or hysteroscopically, which has got a very good patient compliance and much faster recovery.
If the patient is a young girl, family complete, but still she is bleeding, we cannot do a hysterectomy for this patient. So, in such patients, we advise them for progesterone intrauterine device that is Mirena or levonorgestrel IUCD, which gives continuous release of progesterone and that regularizes your cycle. So just an intrauterine device, a progesterone supportive intrauterine device which can be inserted and the bleeding can be controlled, that will give a dual protection, she will have contraceptive help also as well as her uterus is conserved.
If she is in the elderly age group, if the patient is about 45-50 and the family is complete, she is bleeding. On the endometrial biopsy, there is only hyperplasia and she is not wanting to keep her uterus then in such patients, we advise them for a hysterectomy, which can be done again either laparoscopically or an open hysterectomy.
So, whenever we treat a patient, it has to be what the patient wants, it has to be depending upon what is the cause which is causing the abnormal uterine bleeding. If there is just hormonal imbalance, just supporting her in that time or just regularizing her cycles with maybe 1 or 2 cycles of hormones can make her bleeding regular. If there is a thyroid problem, treat her with the thyroid medicines; she does not need any hormones, only correcting the thyroid can make her periods regular. At the same time, if the cause is removed, like a fibroid, polyp or adenomyosis. So, you always treat a patient what she wants, whether it all depends upon what is her lifestyle, what is her reproductive… whether she is in the reproductive age group, what is her family, what does she want.