Abnormal Uterine Bleeding

Abnormal Uterine Bleeding

Lecture From: Dr. Shilpi, Rajshahi Medical College, Bangladesh

Normal uterine bleeding is defined as cyclic menstruation every 21-35 days that lasts fewer than 8days with 20-80ml of blood loss. For practical purposes, any patient who complains of a change in her previously established menstrual pattern may be considered to have abnormal uterine bleeding.

Polymenorrhoea is uterine bleeding at the interval of fewer than 21days.

Oligomenorrhoea is uterine bleeding at the interval of more than 35days.

Menorrhagia is excessive bleeding at regular intervals.

Metrorrhagia is bleeding at irregular intervals.

Menometrorrhagia is heavy irregular bleeding.

Intermenstrual bleeding is bleeding between regular intervals.

The causes of abnormal uterine bleeding may be categorized as either

Organic or

Non-organic /Dysfunctional uterine bleeding: when an organic cause cannot be found.

Organic

Organic cause can be further classified as

Reproductive tract disease:

–        Complication of pregnancy(ectopic pregnancy,incomplete abortion),

–        Benign disease-fibroid, polyp, infections, endometrial hyperplasia. 

–        Malignancy-endometrial, cervical cancer

–        Trauma or foreign body.

Systemic diseases:

–        coagulation disorders

–        Endocrinopathies—Hypothyroidism, Hyperprolactinaemia, PCOS

–        Liver disease, Renal disease

–        Obesity

Iatrogenic/pharmacologic causes

–        Psychotropic medication

–        Hormonal contraceptive/replacement therapy

Nonorganic

Dysfunctional uterine bleeding

An-ovulation

Ovulation

Evaluation

To determine the causes of a patient’s abnormal uterine bleeding, a complete work up must be performed, including

• History,
• Physical examination,
• Laboratory evaluation, possible imaging studies  and tissue sampling.

History

Onset, duration, frequency, amount and pattern of bleeding. In addition degree of   associated pain, vaginal discharge, fever, nausea and vomiting should be clarified.

Other sources of bleeding such as bleeding from GI tract, or urinary tract, should be ruled out.

For women of childbearing age, sexual and contraceptive history should be explored to help determine likely hood of pregnancy.

Menopausal symptoms should be explored in appropriate patients.

Any change in diet, weight and exercise are relevant.

Patient’s age, parity, hormonal contraception or hormone replacement history, past medical history, gynecologic and obstetric history and medication regimen are pertinent to the evaluation.

Family history of disease including gynecologic cancer or bleeding disorder should be discussed

Physical Examination

First ensure that patient is hemodynamically stable. If the patient does not require immediate resuscitative intervention, attention should be directed to abdomen and pelvis.

Abdominal examination determines the patient has an acute or surgical abdomen that requires urgent surgical intervention.

Inspection of the vaginal vault can determine the degree of current bleeding, the source of bleeding, discharge suggest of infection, trauma, lesion, polyp, tissue or masses.

Bimanual examination:  To determine  the status of internal os, the presence of cervical motion tenderness, the presence of any palpable mass or lesion, size and contour of uterus and adnexa, the presence of any tenderness on manipulation of any pelvic organ. Finally , more specific physical findings can be associated with abnormal uterine bleeding caused by systemic diseases.

Laboratory Studies

Diagnosis & Treatment

Benign reproductive tract diseases

COMPLICATION OF PREGNANCY:

• ectopic pregnancy,
• Threatened, inevitable, incomplete or missed abortion.

Investigation:

• Urinary β-hCG level
• A quantitive β-hCG level
• USG

TREATMENT: 

conservative management(ectopic pregnancy, Threatened),

• D&C

• Abdominal surgery