What is Abnormal Uterine Bleeding?
Abnormal uterine bleeding, or AUB, is a term used to describe any unusual patterns in a woman’s menstrual cycle when she is not pregnant. These unusual patterns could be in frequency, regularity, duration, or the amount of blood loss. Around one in three women may experience this abnormal bleeding during their lifespan. It’s most commonly noted when a woman starts menstruating and when she is nearing menopause. A typical menstrual cycle takes place every 24 to 38 days and lasts for 2 to 7 days, with a blood loss of 5 to 80 milliliters. Any changes to these factors could be labeled as AUB.
Older terms like oligomenorrhea, menorrhagia, and dysfunctional uterine bleeding are now being replaced by simpler language to describe AUB. The International Federation of Obstetrics and Gynecology (FIGO) updated these terms in 2007, 2011, and 2018, providing more precise definitions and acronyms for common causes of abnormal bleeding. These improved descriptions help in identifying chronic abnormal bleeding that doesn’t relate to pregnancy.
In 2018, another update added intermenstrual bleeding and gave a definition for irregular bleeding as anything outside the 75th percentile.
We can also classify AUB into two categories, acute and chronic. Acute AUB is a severe bleeding episode requiring immediate medical intervention to prevent more blood loss. It can happen independently, or can be superimposed on chronic AUB, which is defined as irregular menstrual bleeding for most of the previous 6 months.
What Causes Abnormal Uterine Bleeding?
The International Federation of Obstetrics and Gynecology (FIGO) came up with a handy way to categorize causes of abnormal bleeding from the uterus, using the acronym PALM-COEIN. The “PALM” section refers to physical or structural problems, while “COEI” covers non-physical issues, and “N” is for ailments that don’t fit into either category.
The acronym stands for:
* P: Polyp
* A: Adenomyosis
* L: Leiomyoma
* M: Malignancy and hyperplasia
* C: Coagulopathy
* O: Ovulatory dysfunction
* E: Endometrial disorders
* I: Iatrogenic (caused by medical treatment)
* N: Not otherwise classified
Any combination of these issues could cause abnormal bleeding from the uterus. Some physical conditions, like polyps or leiomyomas, may not cause any symptoms and may not be the main cause of abnormal bleeding.
In the 2018 revision of the system, bleeding caused by blood-thinning medication was reclassified from a blood clotting problem to a treatment-related issue.
The “not otherwise classified” category encompasses conditions like pelvic inflammatory disease, chronic liver disease, and cervicitis.
Other rare causes of abnormal bleeding that don’t fit into the main categories include arterial abnormalities, muscle overgrowth in the uterus, and inflammation of the uterine lining.
Risk Factors and Frequency for Abnormal Uterine Bleeding
Abnormal uterine bleeding is a condition that impacts a significant number of women worldwide, particularly those at reproductive age. The condition affects anywhere from 3% to 30% of these women, with cases being more common around the times of their first and last periods. Often, research focuses on heavy menstrual bleeding, but the range of abnormal bleeding includes irregular periods and bleeding between periods. If these types are taken into account, up to 35% of women or more may experience this issue.
- Abnormal uterine bleeding affects 3-30% of women of reproductive age worldwide.
- This condition is most common around the first and last menstrual periods.
- The condition’s estimation includes heavy, irregular, and intermenstrual bleeding.
- When these types are included, up to 35% or more women may be affected.
- Many women do not seek treatment for their symptoms.
- Diagnosis can be complicated as it involves both noticeable and unnoticeable symptoms, making it hard to establish the exact number of cases.
Signs and Symptoms of Abnormal Uterine Bleeding
When a patient has any issues related to menstruation, it’s important for the healthcare provider to ask for a detailed history. This includes:
- Menstrual history, which covers age at first period, date of last period, and specifics about cycle frequency, regularity, duration, and flow.
- Information regarding changes of sanitary products each day, presence and size of clots, need to change products during sleep, and sensations of “flooding”.
- Notable issues such as bleeding in between periods or after sexual intercourse.
- Information related to pregnancy and childbirth.
- Any issues with fertility and contraception currently in use.
- Past instances of sexually transmitted infections and history regarding Pap smears.
- Presence of other symptoms such as weight loss, pain, changes in discharge, issues with bowel or bladder, signs of anemia, and signs or history of bleeding disorders.
- Information about other medical conditions, current medications, and family history involving coagulopathies, cancer, endocrine disorders.
- Social history including use of tobacco, alcohol, or drugs, information about occupation, and the impact of symptoms on their quality of life.
- Surgeries undergone in the past.
In addition to taking this detailed history, the healthcare provider should conduct a thorough physical examination. This will encompass:
- Vital signs like blood pressure and body mass index.
- Signs of paleness in the skin and mucous membranes.
- Signs of endocrine disorders such as examination of the thyroid, abnormal or excessive hair growth, signs of Cushing syndrome like atypical fat distribution and stretch marks.
- Signs of coagulation disorders like bruising or petechiae (small red or purple spots).
- An abdominal examination to check for any abnormal masses.
- A pelvic exam, which may include Pap smear or screening for sexually transmitted infections, if required.
Testing for Abnormal Uterine Bleeding
Lab tests for irregular uterine bleeding might include a pregnancy test, blood count, tests for iron levels, blood clotting, thyroid function, hormones associated with fertility, and a hormone called prolactin.
Imaging tests might involve a special kind of ultrasound called a transvaginal ultrasound, an MRI, or hysteroscopy. The transvaginal ultrasound doesn’t involve radiation, and it can give useful images of the size and shape of the uterus, fibroids, a condition called adenomyosis, the thickness of the uterine lining, and anything unusual about the ovaries. It’s a vital tool that should be used early when investigating abnormal uterine bleeding. An MRI gives even more detailed images that can help with surgical planning, but it’s more costly and not the first choice for patients with abnormal bleeding. A hysteroscopy or sonohysterography could be done if polyps are seen, ultrasound images are unclear, or fibroids are seen on the inner wall of the uterus. These are more invasive procedures but can often be done in a regular doctor’s office.
A tissue sample of the inner lining of the uterus may not be needed for all women with unusual bleeding. But it should be considered for women at a high risk for abnormal growths or cancer. This tissue sample, which is called an endometrial biopsy, is usually the first test done for women with abnormal bleeding who are 45 years and older. It should also be considered for women younger than 45 who have been exposed to higher levels of the hormone estrogen, like women who are obese, have polycystic ovarian syndrome, have not responded to treatment, or who have ongoing bleeding.
Treatment Options for Abnormal Uterine Bleeding
Treatment for abnormal uterine bleeding (AUB), which is unusual bleeding from the uterus, depends on various factors. These can include the cause of the AUB, if the patient wants to have children, their overall health condition, and any other existing health issues. The treatment plan needs to be personalized, taking all of these into account. Traditionally, medical treatments are the first choice for AUB.
During acute AUB, hormone treatments are often used. These include intravenous (IV) equine estrogen, combination oral contraceptive pills, and oral progestins. Tranexamic acid is also an option as it helps stop bleeding. A Foley bulb can be used to put pressure on the bleeding area – this is a mechanical solution. The patient’s overall health condition needs constant monitoring to make sure they are stable. They might also need IV fluids and blood products to replace lost volume. Desmopressin can be given in various ways (intranasally, subcutaneously, or intravenously) for AUB caused by a blood clotting disorder known as von Willebrand disease. Some patients might need a procedure called dilation and curettage.
Treatment options for chronic AUB depend on its cause, as explained by the PALM-COEIN acronym:
– Polyps: These can be removed surgically.
– Adenomyosis: Hysterectomy is usually performed to treat adenomyosis, sometimes adenomyomectomy is used.
– Leiomyomas (Fibroids): Medical or surgical treatments are considered, depending on if the patient wants to have children, her overall health condition, symptoms, and if the uterine cavity is distorted. Surgical options can include uterine artery embolization, endometrial ablation, or hysterectomy. Medical options can include a levonorgestrel-releasing intrauterine device (IUD), GnRH agonists, systemic progestins, and tranexamic acid with non-steroidal anti-inflammatory drugs (NSAIDs).
– Malignancy or hyperplasia: Treatment options can include surgery and/or additional treatments depending on the stage, high dose progestins when surgery is not possible, or palliative therapy like radiotherapy.
– Coagulopathies: These can be treated with tranexamic acid or desmopressin (DDAVP).
– Ovulatory Dysfunction: Lifestyle changes can be suggested for women with obesity, PCOS, or other conditions where anovulatory cycles are suspected. Any related endocrine disorders should be controlled by suitable medications.
– Endometrial Disorders: These don’t have a specific treatment, as their mechanisms are not clearly understood.
– Iatrogenic Causes: Treatment can depend on the drug causing AUB. If a contraception method is suspected to cause AUB, alternatives may be used. If other medications can’t be stopped and they’re causing AUB, similar alternative methods can be used to control the bleeding.
There are some other causes of AUB such as endometritis, which can be treated with antibiotics, and AVMs (Arteriovenous Malformations), which can be treated with a procedure called embolization. The treatment of AUB always needs to be tailored to the individual patient’s needs and overall health condition.
What else can Abnormal Uterine Bleeding be?
When a woman experiences unusual bleeding from the uterus, there could be a number of possible causes. It’s crucial to note that bleeding might also come from the urinary or digestive systems, therefore, these possibilities need to be checked and ruled out first.
From there, doctors need to consider various reasons for irregular bleeding based on where in the body the bleeding might be happening:
- On the outside of the genitals (vulva): This could be due to harmless or harmful growths.
- In the vagina: Possible reasons include harmless growths, sexually transmitted infections, inflammation of the vagina, harmful growths, injury, or foreign objects.
- In the narrow passage forming the lower end of the uterus (cervix): This could be due to harmless growths, sexually transmitted infections, or harmful growths.
- In the tubes connecting the ovaries to the womb (fallopian tubes) and ovaries: This could be due to a disease of the female reproductive organs (pelvic inflammatory disease), or harmful growths.
- In the urinary tract: This could be due to infections, or harmful growths.
- In the digestive tract: This could be due to a disease where the body’s immune system attacks parts of the digestive system (inflammatory bowel disease), or Behçet syndrome, a rare disorder causing inflammation in blood vessels.
- Complications during pregnancy: This could be due to a miscarriage, a pregnancy occurring outside the womb (ectopic pregnancy), or a condition where the placenta covers the cervix (placenta previa).
- In the uterus: Numerous causes include those represented by the medical acronym PALM-COEIN.
Each of these possibilities requires a closer look and different tests to confirm or rule out.
What to expect with Abnormal Uterine Bleeding
The outlook for abnormal uterine bleeding is usually good, but it can vary depending on the cause. The main aim of evaluating and treating chronic abnormal uterine bleeding is to rule out serious conditions like cancer and enhance the patient’s quality of life, considering present and future fertility goals and other health conditions that could affect treatment or symptoms. The outcome also differs based on whether you receive medical or surgical treatment.
Medications that aren’t hormonal, such as anti-fibrinolytic and non-steroidal anti-inflammatory drugs, can decrease menstrual blood loss by up to 50%. Oral contraceptive pills can also be helpful, although we need more data from randomized trials to confirm this. For those whose primary symptom is heavy menstrual bleeding, an intrauterine device (IUD) that releases levonorgestrel has proven superior to other drugs and also improves quality of life.
Injectable progestogens and GnRH agonists can stop periods in up to 50% and 90% of women, respectively, nonetheless, injectable progestogens may cause breakthrough bleeding as a side effect, and GnRH agonists usually aren’t used for more than six months due to the side effects of producing a low estrogen state.
Talking about surgical techniques, studies have shown that endometrial ablation (a process that destroys the uterine lining) controls bleeding more effectively four months after surgery, but after five years, there’s no difference when compared to medical treatment. When compared head-to-head, hysterectomy performed better than a levonorgestrel-releasing IUD after one year. Beyond that, quality of life was the same after five and ten years, but many women who got the IUD ended up having a hysterectomy within ten years.
Possible Complications When Diagnosed with Abnormal Uterine Bleeding
Chronic abnormal uterine bleeding can lead to several problems. These include anemia, infertility, and endometrial cancer. If not treated immediately, severe cases of acute abnormal uterine bleeding can cause severe anemia, low blood pressure, shock, and even death.
Common complications of chronic abnormal uterine bleeding are:
- Anemia
- Infertility
- Endometrial cancer
- Severe anemia caused by acute abnormal uterine bleeding
- Low blood pressure caused by acute abnormal uterine bleeding
- Shock caused by acute abnormal uterine bleeding
- Death caused by acute abnormal uterine bleeding
Preventing Abnormal Uterine Bleeding
Across the globe, many women do not inform their doctors about abnormal bleeding during their menstrual cycle. Therefore, it’s vital to create a comfortable, open dialogue about menstruation. Family doctors should regularly ask women about the details of their last period, whether it was regular, their wishes regarding having children, their method of birth control, and their sexual health.
If abnormal bleeding is identified during these routine check-ups, the doctor can investigate further with more detailed questions, physical exams, and medical tests. They can also schedule the necessary medical consultations.
It is also essential that women with abnormal menstrual bleeding are given guidance on any lifestyle changes they may need to make, the various treatment options available to them, and to let them know when it might be necessary to seek immediate medical attention.
