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Abnormal Uterine Bleeding in Thepremenopausal Period

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Abnormal Uterine Bleeding in Thepremenopausal Period 9 Abnormal Uterine Bleeding in the Premenopausal Period Heleen van Beekhuizen INTRODUCTION • Metrorrhagia: bleeding at irregular intervals. • Intermenstrual blood loss (IBL): irregular blood loss Abnormal uterine bleeding (AUB) is a very fre- during a normal menstrual cycle. quent symptom in women. The prevalence of AUB is estimated at 12% in the general population Chronic abnormal uterine bleeding and increases with age, reaching 24% in those aged 36–40 years. When it is a single episode of irregular Chronic AUB is defined by the International Fed- blood loss in non-pregnant women, it is most of eration of Gynecology and Obstetrics (FIGO) as the time harmless, but it can also be a first sign of bleeding from the uterine corpus that is abnormal serious pathology such as cancer of the cervix. For in volume, regularity, and/or timing, and has been this reason it is important to do a full gynecological present for the majority of the past 6 months in history, a speculum examination and a vaginal non-pregnant women. exam ination in all women with AUB. For practical purposes it is important to rule out Acute abnormal uterine bleeding (unrecognized) pregnancy problems or infection in Acute AUB is defined as an episode of heavy bleed- AUB of short duration. A longer duration of AUB ing in non-pregnant women that, in the opinion of points to more structural abnormalities like fibroids, the clinician, is of sufficient quantity to require im- polyps or malignancies. mediate intervention to prevent further blood loss. This chapter will describe the problems and Acute AUB may present in the context of exist ing how to establish the diagnosis. A flow chart for chronic AUB or might occur without such a history. abnormal uterine bleeding will be introduced. In Chapter 20 appropriate treatment of abnormal CAUSES OF UTERINE BLEEDING uterine bleeding will be explained. For bleeding after the menopause, please see Chapter 10. FIGO have developed a classification system for AUB (Table 1)2. Definition • Polyps and pendiculated fibroids: (generally) benign growths of uterine muscle (fibroids) or endo- Terms like menorrhagia, metrorrhagia, meno- metrium (polyps). metrorrhagia should be abolished as their defini- • Adenomyosis: the role of adenomyosis in AUB is tions differ from region to region. It is better to not clear yet. Adenomyosis describes the pres- speak of ‘abnormal uterine bleeding’: ence of endometrial tissue in the myometrium. • A normal cycle is between 24 and 35 days with a The sonographic appearance of adenomyosis is period of <7 days. The main menstrual blood partly related to the absolute presence of endo- flow during a period is 35 ml with 65% of metrial tissue in the myometrium and partly due women losing <60 ml each period. to the related myometrial hypertrophy2. • Menorrhagia: regular cycle but blood loss >80 ml • Leiomyoma (fibroids): benign growths of the per cycle1. myo metrium (see Chapter 19). 91 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS Table 1 FIGO classification syst em of abnormal uterine likely to progress to endometrial cancer (in bleeding. PALM refers to structural abnormalities causing about 25–40%) and should be treated surgic- the abnormal bleeding, COEIN are non-structural causes ally. When no atypia is present conservative ® P Polyps C Coagulopathy treatment with Mirena intrauterine device (IUD) or cyclic progestogens (medroxy- A Adenomyosis O Ovulatory dysfunctions progesterone acetate (10 mg/day for 12–14 L Leiomyoma E Endometrial days in the luteal phase of the cycle for 3 months), and repeated sampling is justified. M Malignancy or I Iatrogenic N Cervical ectopia or ectropion can cause spot- hyperplasia N Not yet classified ting and postcoital bleeding (often in young women or pill users). N Infections: Sexually transmitted infections (STIs) like chlamydia, urogenital schistoso- miasis or genital tuberculosis. • Malignancies: especially cervical and uterine can- • Iatrogenic causes of AUB are: cer (endometrial cancer or sarcoma, see Chapter N Anticonceptives like combined oral contra- 29) or hyperplasia. Granulosa cell tumors (see ceptives, IUDs. Chapter 28) of the ovaries produce estrogen and N Tricyclic antidepressants like amitriptyline cause endometrial hyperplasia and AUB and may cause AUB. postmenopausal vaginal bleeding. • (Unrecognized) pregnancy (complications) like mis- • Coagulopathy: abnormal bleeding tendencies are carriage, ectopic pregnancy and molar preg- present in around 13% of women with heavy nancy can cause bleeding and are sometimes menstrual bleeding. mistaken for AUB. • Ovarian dysfunction (formerly dysfunctional uterine bleeding or DUB). The term ovarian dysfunction HISTORY TAKING (OD) is used when hormonal imbalance is present. Common groups affected by OD are: • Duration of complaints (primary/secondary, N Young girls and perimenopausal women: how many months/years). Primary AUB starts both groups have anovulatory cycles (cycles from the first period, secondary AUB starts later without an ovulation). In long-term ano- in the reproductive period. vulation unopposed estrogen stimulation • Duration of periods and regularity of the cycle. (with lack of progesterone) stimulates the • Fever, discharge and abdominal pain can be a endo metrium to become hyperplastic. For sign of STI. Cervical cancer is often accompa- menstrual cycle see Chapter 16 on subfertility. nied by foul-smelling discharge and ectopic N Patients with obesity or extreme weight loss. pregnancy by pain! In obesity peripheral fat tissue produces estro- • Swelling in the abdomen is a symptom of gen and morbidly obese women have a high fibroids and ovarian masses but also of unrecog- level of estrogen that disturbs the menstrual nized pregnancy. Ask about fetal movements! cycle. Weight loss and emaceration can lead to • Easy bleeding tendency. Some women have in- anovulatory cycles and cause irregular periods herited bleeding disorders. They often have a • Endometrial causes of AUB are: history of prolonged bleeding during surgery, N A primary disorder of mechanisms regulating trauma or childbirth. It is difficult in low- local endometrial ‘hemostasis’ itself: endo- resource settings to establish the exact diagnosis metrial hemostasis is a very complex process but you can treat heavy periods in these women and local hormonal imbalance in the prosta- the same as in women without bleeding dis- glandin mechanism can cause AUB. orders (see Chapter 20)3,4. Make women with N Endometrial hyperplasia is a precursor to inherited bleeding disorders aware that it is endo metrial cancer and is classified as simplex import ant to deliver in a hospital with blood or complex and with or without atypia. The transfusion possibilities! presenting symptom is most often AUB. • Endocrine disorders like polycystic ovary syn- Endo metrial hyperplasia with atypia is most drome (POC) (see Chapter 16 on subfertility), 92 Abnormal Uterine Bleeding in the Premenopausal Period hypothyroidism, hyperthyroidism and hyper- prolactinemia. Signs of hypothyroidism are irregu lar periods with weight gain, lethargy, obstipation, hair loss (especially at the eyebrows) and a dry skin. Signs of hyperthyroidism are sweating, menorrhagia, palpitations, weight loss, irritability and tremor. Signs of hyperprolactin- emia are bilateral galactorrhea (milk from the nipples), amenorrhea, anovulation and (when caused by macroadenoma) headache and disturb- ance of visual fields (see Chapter 16). • Use of contraceptives: many women using pro- gesterone contraceptives such as Depo-Provera®, Implanon® and levonogestrel (LNG) IUD (Mirena®) have irregular blood loss5. Also many women with prolonged combined oral contra- ceptive use can face a period of spotting and postcoital bleeding. • Sexual history: STIs? Sexual abuse? Is pregnancy possible? • Dates of the two last periods and duration of Figure 1 A fibroid in the uterine cavity after bleeding. Are blood clots present during the hysterectomy period or flooding? • IBL: in chlamydia often IBL (spotting) occurs. If possible perform a test for pre-stadia of cervi- cal cancer like a human papillomavirus (HPV) test EXAMINATION or a visual inspection with acetic acid (VIA), see Chapter 26. • Signs of anemia. • PVE: fibroids, pelvic masses, cervical motion • Signs of pregnancy: abdominal distention, blue, tenderness (Figure 1). soft cervix, bigger breasts and nipples. If in doubt: do a pregnancy test. Most of the time you can make the diagnosis and • Obesity or emaciation. treat the patient after history taking and physical • Speculum examination: to establish that blood examination and you do not need (to refer for) loss is from the uterus (and not from the cervix extra investigations. Remember it is important to or vagina) and to look for signs and symptoms rule out curable life-threatening diseases like ecto- of: pic pregnancy, cervical cancer and STIs as soon as N Cervical carcinoma (see Chapter 26 on cervi- possible. If you do not have facilities for extra cal cancer)? An abnormal cervix can also be investi gations and tests and your history taking and seen in genital schistosomiasis. physical examination were reassuring you can start N Vaginal discharge? treatment (see Chapter 20) and review the patient N Cervicitis (see Chapter 17 on STI)? after 2 months. If she is well and irregular blood N Cervical ectopia/ectropion? This can be loss has stopped, there is no need for additional caused by Chlamydia but is also physiological testing. If at review the patient still has irregular in young fertile women and under OC. After
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