ABNORMAL UTERINE BLEEDING by Dr. KH Jagot (Obstetrician & Gynaecologist)

Abnormal uterine bleeding can have a significant impact on a woman’s life. It can limit daily activities and be unpredictable, resulting in anxiety and in some cases it may even prevent a woman from leaving her house.

What is abnormal uterine bleeding?
During her period a woman bleeds an average of 5 days in a 21 to 35 day cycle. Abnormal uterine bleeding is when a woman bleeds for too long or it is an extremely heavy flow. It may also be bleeding (or spotting) between monthly periods or bleeding after menopause.

What causes abnormal uterine bleeding?
There are many causes of abnormal uterine bleeding and these can be either structural abnormalities of the uterus or non-structural causes.
Structural causes include fibroids which are benign overgrowths of the muscle of the uterus or polyps which are benign overgrowths of the lining of the uterus or cervix. Adenomyosis, also a benign cause of abnormal uterine bleeding, is a condition wherein the lining of the uterus grows into the muscle of the uterus. Other important structural causes include cancer of the cervix, endometrium (lining of the uterus) or uterus.
The most common cause of non-structural abnormal uterine bleeding is due to hormonal imbalance. This is usually seen in teenagers at the start of their menstrual cycle and in woman approaching menopause. Polycystic ovarian syndrome is another cause of abnormal uterine bleeding due to hormonal imbalance. As a result of this hormonal imbalance, patients with polycystic ovarian syndrome do not ovulate causing them to skip their periods for months at a time followed by heavy prolonged bleeding. Other non-structural causes include problems with thyroid function, anorexia, excessive weight gain or obesity, emotional or physical stress, blood clotting deficienices, infection of the cervix or uterus and medication such as hormonal contraceptives.
Some woman may experience bleeding in early pregnancy and it is important to see an obstetrician to establish pregnancy well-being if this occurs. Any bleeding during menopause is abnormal and should be investigated.

How is abnormal uterine bleeding diagnosed?
Establishing the diagnosis starts with the history from the patient followed by a physical examination which includes an abdominal and pelvic exam, as well as a PAP smear if not recently done. A pelvic ultrasound is then done to view the uterus, the lining of the uterus and the ovaries to establish any structural causes. If indicated a sample of the lining of the womb (endometrial biopsy) can also be taken in the rooms to check for endometrial cancer.
If the patient could be pregnant it is important to do a pregnancy test. Blood tests such as a full blood count may be done by the doctor if anaemia is suspected as a result of heavy bleeding. Other hormonal blood tests may be necessary depending on history and examination findings.
Another test to view the lining of the uterus is a hysteroscopy where a thin tube with a camera is put into the uterus via the cervix. This test is not necessary in all cases.

How do you treat abnormal uterine bleeding?
Treatment options for abnormal uterine bleeding depend on the cause and on the woman’s fertility desires. First line therapy involves hormonal medication, anti-inflammatories and tranaxemic acid to control heavy bleeding. Other options (depending on cause) include an intra-uterine device or endometrial ablation (destroying the lining of the uterus).
Surgical options include a myomectomy (removal of fibroids) or polypectomy (removal of polyps). Uterine fibroid embolisation (blocking the blood supply to a fibroid) is sometimes an option which results in the shrinkage of a fibroid and decreased bleeding. A hysterectomy (removal of the uterus) is usually only considered when other treatments have failed or in the presence of cancer.
There are many options available to treat abnormal uterine bleeding therefore woman need not despair. It is important for a woman to seek medical assistance if she is experiencing abnormal uterine bleeding in order to establish a diagnosis and to find the correct treatment option which will lead to a better quality of life.