ABNORMAL VAGINAL BLEEDING

•	Patterns of abnormal flow.
•	Organic causes. 
•	Dysfunctional uterine bleeding.
•	Approach.
•	Investigations.
•	Management.

Patterns of abnormal flow

1.	The average menses lasts for 3 – 7 days with a mean of blood loss of 35ml.

2.	Menorrhagia: excessive and / or prolonged menstrual flow (80 ml > 7days) occurring at normal intervals.

3.	Polymenorrhoea: frequent regular periods at shorter intervals of < 21 days.

4.	Metrorrhagia: irregular intervals of excessive and / or prolonged uterine bleeding. 

5.	Oligomenorrhoea: menses at intervals of > 35 days. 

Organic causes

1.	Pregnancy complications:

a.	Threatened, incomplete and inevitable abortion.

b.	Ectopic pregnancy.

c.	Trophoblastic diseases.

2.	Fibroids:

a.	Common cause of heavy periods.

b.	Submucosal: heavy periods, may be irregular with intermenstrual bleeding and dysmenorrhoea.

c.	Intramural: usually painless heavy periods.

d.	Subserous: may be very large with no abnormal bleeding.

3.	Adenomyosis:

a.	Presence of endometrial tissue embedded within the myometrium.

b.	It is a common cause of heavy and painful menstrual bleeding.

c.	Ultrasound scan shows enlarged uterus and coarse myometrium.

4.	Endocervical polyps: cause intermenstrual bleeding due to erratic and irregular shedding of the endometrium.

5.	IUCD: 

a.	Associated with an alteration in menstrual flow in many women.

b.	Periods may become heavier and longer in duration.

c.	Newer generation progesterone-releasing IUCDs actually reduce blood loss and may be used as a form of therapy.

6.	Pelvic inflammatory disease:

a.	May cause heavy or erratic menstrual bleeding due to a local endometrial inflammatory response.

b.	Severe pelvic infection may affect ovarian function and secondarily lead to abnormal menstrual bleeding.

7.	Tumors:

a.	Cervical / endometrial cancer: classically causes post-coital or post-menopausal bleeding.

b.	Granulosa-thecal cell tumors.

8.	Trauma to the lower genital tract.

9.	Endocrine disorders:

a,	Hyper – or hypothyroidism.

b.	Diabetes mellitus.

c.	Adrenal disease.

d.	Prolactin disorders.

10.	Blood disorders: 

a.	von Willebrand’s disease.

b.	Idiopathic thrombocytopenic purpura.

11.	Liver disorders may interfere with the metabolism of estrogen.

12.	Renal disease may alter the excretion of estrogen and progesterone.

13.	Drugs:

a.	OCP / HRT.

b.	Tamoxifen.

c.	Warfarn, heparin and aspirin.

Dysfunctional uterine bleeding

1.	Definition: abnormal uterine bleeding not due to organic causes of the genital tract.

2.	Mostly associated with anovulation.

3.	Anovulatory DUB:

a.	This tends to occur in women at the extremes of reproductive age and is typified by an irregular cycle.

b.	It is more common in obese women.

c.	Pubertal: immaturity of the HPO axis.

d.	Perimenopausal: failure of ovary to respond to gonadotrophins.

4.	Ovulatory DUB:

a.	Corpus luteum insufficiency: premenstrual spotting with menorrhagia.

b.	Prolonged action of CL: menorrhagia with postmenopausal spotting.

Approach

1.	History:

a.	Detailed menstrual history:

i.	regularity of cycle: duration and interval.

ii.	flow volume: quantify number of pads used then and now.

iii.	PCB / IMB.

iv.	associated pain, discomfort, bloatedness.

b.	Evidence of systemic disease:

i.	endocrine: symptoms of thyroid diseases.

ii.	blood dyscrasia: history of easy bleeding.

c.	medical history: exclude history of breast and genital tract cancers. 

d	Drug history: exclude use of OCP< HRT, warfarin.

e	Psychological state. 

2.	Clinical examination:

a.	Signs of anaemia.

b.	Stigmata of endocrine dysfunction.

c.	Evidence of any bleeding tendency.

d.	Assessment of mental state.

e.	Abdominal examination.

f.	Speculum and PV examination.

g.	PR examination. 

3.	Different approaches need to be adopted for different age groups:

a.	For an adolescent, uterine bleeding is almost always dysfunctional in origin though one may have to exclude pregnancy, an ovarian tumor or tuberculous endometritis.

b.	For an adult between 20 to 40 years of age:

i.	first exclude the abnormal bleeding as a complication of pregnancy.

ii.	questions must be asked concerning the use of oral contraceptive pills and if patient has completed her family.

c.	For peri-menopausal and post-menopausal bleeding: abnormal bleeding is due to genital tract cancer until proven otherwise. 

Investigations

1.	Haematological:

a.	Hb level: to assess degree of anaemia.

b.	Serum iron and ferritin.

c.	Coagulation profile: PT / PTT: for bleeding disorders. 

d.	Cases of persistent and unexplained DUB should have a PBF, platelet count and tourniquet test to exclude idiopathic thrombocytopenic purpura. 

2.	Urine HCG: to exclude pregnancy.

3.	Gynaecological endocrine tests:

a.	Limited use in DUB.

b.	Indicates occurrence of ovulation and sufficiency of CL.

c.	Basal body temperature.

d.	Vaginal smear and examination of cervical mucus.

e.	Serum progesterone: a level greater than 30 nmol/L is indicative of ovulation.

4.	Endocrine tests:

a.	Thyroid and adrenal function tests.

b.	Serum androgens: may be elevated in patients with polycystic ovarian syndrome.

c.	Prolactin: hyperprolactinaemia may result in anovulation, which can cause DUB.

5.	Examination under anaesthesia and D&C:

a.	Recommendations for age group:

Age	D&C	
20 & below	Only if bleeding persist or is severe or organic causes suspected.	
20 – 40	May be deferred up to 3 months if bleeding is moderate and these is no suspicion of organic disease.	
40 & above	Mandatory in all cases. 	

b.	Best time for curretage is second half of cycle 5 – 6 days before menstruation.

c.	To exclude uterine pathology:

i.	incomplete abortion.

ii.	endometrial polyp.

iii.	fibroid.

iv.	carcinoma.

6.	Others:

a.	Transvaginal ultrasound: diagnose fibroids, adenomyosis and polycystic ovaries.

b.	Endometrial biopsy: evaluate DUB in women > 35 years of age.

c.	Hysteroscopy: allows visualization of entire uterine cavity and directed biopsy.

d.	Hystero-salpingography: diagnosis of uterine polyps and malformations.

e.	Laparoscopy: diagnosis of PID, ovarian tumor. 

Management

1.	Acute DUB:

a.	I/M progestogen.

b.	Oral progestogen such as norethisterone 5mg 3 – 4 times / day for 10 days.

c.	Bleeding should stop within 48 hours.

2.	Hormonal preparations:

a.	Cyclic progestogen:

i.	converts proliferation to secretory endometrium.

ii.	not useful for ovulatory cycles.

iii.	norethisterone 5 – 10 mg tds for 21 days (on day 5 of cycle) for 3 cycles. 

b.	Combined oral contraceptives for younger patients who also require contraception.

c.	HRT for peri-menopausal women.

d.	Danazol:

i.	a derivative of testosterone that acts on the HPO axis and endometrium as a competitive inhibitor of sex steroids.

ii.	effective treatment for heavy menstrual bleeding and may reduce blood loss up to 60%.

iii.	androgenic side effects: weight gain, hirsutism, acne and voice changes.

e.	GnRH agonists like buserelin and naferelin induce a medical menopause by suppressing gonadotrophin output.

f.	Mirena:

i.	very effective at controlling heavy menstrual bleeding.

ii.	progestogen released directly from the coil act locally on the endometrium. 

3.	Iron and folate supplements.

4.	Antifibrinolytics; tranexamic acid.

5.	NSAIDS: mefenamic acid is used for women with heavy and / or painful periods. 

6.	Surgery:

a.	Usually reserved for patients in whom medical treatments have failed.

b.	Dilatation and curretage in an acute situation can reduce haemorrhage in 75 – 80% of cases.

c.	Endometrial resection and ablation:

i.	involves the resection or ablation of the endometrium so that a layer of fibrous tissue replaces it.

ii.	techniques used: diathermy, laser, radiofrequency-induced ablation. 

d.	Hysterectomy for:

i.	refractory cases.

ii.	patient is over 45 years of age.

iii.	there is co-existent ovarian pathology.

iv.	there is a family history of ovarian, breast or bowel cancer.

v.	history of severe pelvic pain.