Abnormal Uterine Bleeding

Abnormal Uterine Bleeding is a common health complaint. Also called heavy periods or menorrhagia, its affects one in five women in India.

although it is usually defined as a total menstrual blood loss of more than / 80 millilitres during every period, this can be difficult to measure. Therefore, the diagnosis is made on the basis of other signs, such as:

• An unusual increase in menstrual blood loss
• Menstrual blood loss (excluding spot-ting) that lasts longer than seven days frequent flooding or menstrual loss , that is not contained by pads or tampons.
• Increase in the number of times you have to change pads or tampons (more than every four hours, or more than once during the night) .
• Passing of blood clots that are wider than three centimetres (a bit more than one inch); small stringy clots are common and normal.
• Iron deficiency of the blood (anaemia) caused by it.

As your experience may vary from the points listed above, talk to your doctor so you can better understand AUB.

Causes of Heavy Menstrual Bleeding .

Dysfunctional Uterine Bleeding.

If no abnormality of the uterus is found, then the condition is called "dysfunctional uterine bleeding". More than half of women with AUB have dysfunctional uterine bleeding. It is probably related to a problem with blood levels of female hormones that control menstruation, principally oestrogen and progesterone. During the menstrual cycle, levels of these hormones change constantly.

Although doctors know that hormonal changes can cause AUB, it is difficult to identify those changes in a woman and to know why they are causing problems. This is because:

• To accurately track hormone levels, blood samples would have to be taken daily (or more frequently), and the findings would not always be informative.
• It is difficult to measure the effects of hormones within the uterus where they interact in a complex environment of tissues, blood vessels and blood factors responsible for coagulation.

Fibroids

These are benign (non-cancerous) growths of the muscle and connective-tissue cells in the wall of the uterus. They are found in up to one in three women. Although fibroids are often found in women with AUB, most women with fibroids do not have AUB. In particular, small fibroids usually do not cause problems.

Endometrial polyps

These benign growths occur on the lining of the uterus. They may also lead to spotting between or after periods.

Endometrial hyperplasia.

This is a thickening of the lining of the uterus (endometrium) that leads to heavier bleeding.

Adenomyosis

This is an enlargement of the uterus caused by growth of the endometrium into the wall of the uterus.

Although the above conditions may cause, or be linked to, AUB, it is possi-ble that AUB may occur in the absence of physical abnormalities of the uterus.

Uncommon causes of AUB

• Thyroid imbalance.
• Contraceptive intra-uterine devices (IUD).
• Some liver or kidney conditions.
• Blood clotting disorders, including medication taken to treat or prevent blood clots elsewhere in the body.
• Endometrial cancer is a rare cancer that can cause heavy periods. However, it is more likely to cause bleeding between periods, blood-stained vaginal discharge, or post-menopausal bleeding.

DIAGNOSIS AND TESTS

The following tests may help find the cause of AUB:

• An internal vaginal examination to feel the size of the uterus. A routine Pap smear may be done at the same time.
• A blood test for haemoglobin levels. If haemoglobin is low, further tests may be needed.

An ultrasound scan to examine the lining of the uterus in women who have a higher risk of endometrial hyperplasia or uterine cancer. Ultrasound can also detect uterine fibroids, ovarian cysts and other pelvic abnormalities. The ultrasound probe is usually placed into the vagina to obtain a better view of the uterus and ovaries. In some cases, the probe may be placed on the abdomen.

Hysteroscopy

Hysteroscopy is a procedure to look inside the uterus using a thin telescope. It is done as an outpatient or inpatient procedure. At the time of hysteroscopy, a sample. of the cells that line the uterus can be taken for examination under a microscope. Hysteroscopy may be recommended particularly if an ultrasound has been performed and the results indicate an abnormality.

Curette

A curette is an instrument used to remove endometrium in a procedure called dilatation and curettage (or D&C). This is a minor surgical procedure done under local or general anaesthesia.

Pieces of the endometrium are examfined for abnormalities. If available, an ultrasound examination of the uterus may be done at the same time. Recent studies indicate that D&C does not appear to have any benefit in treating or curing AUB, so the procedure is less common.

If a piece of endometrium needs to be examined, your doctor may suggest an alternative called endometrial biopsy. This procedure to collect a small sample of tissue can be done quickly and easily in the doctor's surgery, especially for women who have delivered a baby through the birth canal.

Laparoscopy

: This procedure may be required if a woman with AUB also has pelvic pain, infertility or a condition affecting the ovaries.

Medical Treatments for Heavy Menstrual Bleeding

Some years ago, surgical removal of the uterus (hysterectomy) was the only effective treatment, but now medicines are also available.

It is important that you understand the impact that surgical and medical treatments may have on your life. For example, a hysterectomy or medications that reduce fertility are not suitable if you are trying to become pregnant.

The severity and duration of AUB must also be taken into account. For example, if a treatment were known to reduce bleeding by one-third, even this reduction may not be enough if your AUB is severe.

Other factors, such as family history, your response to medications, and your personal medical history (including pelvic pain or premenstrual syndrome) may influence your decision and your doctor's treatment recommendations.

Only you can determine how much the AUB is affecting you, and only you can decide what you are willing to try to relieve the problem.

While the choice of treatment is yours, your doctor's role is to help you to understand your treatment options and whether they are suitable for you.

The following medications often have an effect during the first cycle they are used. There may be further improvement with subsequent cycles.

Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are medications that reduce heavy bleeding. On average, NSAIDs reduce menstrual blood loss by about one-third. They also have the advantage of relieving painful periods and menstrual headaches. However, some women experience:

• Stomach upsets, nausea and diarrhoea.
• Headaches instead of ralief from headache.

The benefits and side effects of NSAIDs vary from woman to woman.

Oral contraceptive pill: The pill usually reduces menstrual blood loss by a little more than a third. It may bring relief to women with painful periods. However, side effects may include nausea, breast tenderness and headaches. It may not be suitable for women with risk factors for heart disease. The pill is not recommended for women older than 35 who smoke.

Oral progesterone (progestogen): Oral progesterone reduces blood loss if it is taken for 21 out of 28 days from day five to 25 of a woman's cycle. It has the added advantage of producing regular cycles. However, side' effects can include bloating, mood swings, pre-menstrual syndrome and irregular light bleeding.

Tranexamic acid: Tranexamic acid may reduce menstrual blood loss by about half. Tranexamic acid is a non-hormonal therapy that affects clotting mechanisms in the lining of the uterus. Tablets are taken only on the days that the woman has heavy bleeding. Nausea and diarrhoea are uncommon side effects.

Danazol: Danazol may reduce menstrual blood loss by about two-thirds and may cause some women to stop menstruating. Possible side effects include weight gain, acne, hirsutism (male-patterned hairiness), hair loss, and deepening or hoarse voice. Other treatments are usually tried first. Danazol is a banned drug for women in competitive sports.

Progestogen intrauterine device: Placed into the uterus via the cervix, this device steadily releases tiny amounts of progestogen. This keeps the endome-trium thin and inactive rather than increasing in thickness during the build-up to ovulation. As the lining of the uterus does not increase, menstrual bleeding is reduced.

Nearly all women will experience a large reduction in their blood loss (on average, a 94% decrease in blood flow). The treatment usually takes several months to achieve the desired effect. It appears to be the most effective drug treatment of AUB. Added benefits are reliable contraception and no need to take tablets.

A common side effect is irregular light bleeding in the initial months of therapy. It causes menstrual cramps in some women and, rarely, the device may be expelled. The device is typically effective for about five years.

Iron supplements for anaemia A woman who bleeds heavily during every period can become anaemic, which is a low concentration of red cells in the blood or not enough haemoglobin in red blood cells. Anaemia can cause signs and symptoms such as pale skin, shortness of breath, tiredness and heart palpitations.

Anaemia is usually treated with tablets containing iron. This does not treat the cause of AUB. Constipation can be a side effect of iron tablets.

Surgical Treatments for Abnormal Uterine Bleeding

Endometrial ablation: This is the surgical removal or destruc-tion of the lining of the uterus using a hysteroscope, an instrument that is inserted into the cavity of the uterus through the vagina and cervix.

The procedure is performed under general or local anaesthe-sia, and women are usually able to go home the same day. Its effectiveness is high. About 85 of every 100 patients report a significant improvement, and about 40 of these 100 women will have no periods. However, an improvement may not be long lasting for some women.

Endometrial ablation is not suitable for women with severely painful periods or chronic pelvic pain. The rate of major com-plications is between one and two in every 1,000 procedures.

Women planning to get pregnant in the future should not have endometrial ablation because the remaining endometrium may not be able to support a pregnancy; however, the procedure is not a contraceptive technique.

A newer technique uses low-intensity microwaves to heat and remove the endometrium. A probe is placed into the uterus through the vagina and moved throughout the uterus. Still being evaluated but becoming used more widely, this procedure is done under a local or general anaesthetic and takes several minutes.

Myomectomy : This is surgical removal of fibroids while retain-ing the uterus. Its precise effectiveness in reducing AUB has been a matter of debate.

Hysterectomy : : This is the removal of the uterus. The operation can be done in one of four ways.

• Abdominal hysterectomy — removal of the uterus through a cut in the abdomen.
• Vaginal hysterectomy — removal of the uterus through the opening of the vagina.
• Laparoscopically assisted vaginal hysterectomy — removal of the uterus through the vagina with small cuts in the abdomen to assist the surgeon.
• Laparoscopic hysterectomy — removal of the uterus through small cuts in the abdomen.

The surgical method chosen depends on a range of issues, including the nature of a woman's problem and her medical history. Hysterectomy is a major surgical procedure, and up to four in 10 patients may have some type of operative or post-operative complication. However, only a small percentage of these women will have severe or long-lasting complications. A decision to have a hysterectomy, other than for cancer or pre-cancer changes, needs to be carefully discussed. Some women may wish to seek a second opinion. Although few women with AUB regret their decision to undergo hysterectomy, it is important that you have enough information about possible complications to fully weigh up the benefits and risks of any surgical procedure that may be recommended.

For more information, see the College article Hysterectomy — A guide for women, available from your gynaecologist.

Frequently Asked Questions about Heavy Menstrual Bleeding

Q How common is AUB?

A: About one in five healthy women have excessive menstrual bleeding. The condition is treatable, with several effective treatment options being available.

Q I have been sterilised. Could this be the cause of my AUB?

A: No. At one time, it was thought that female sterilisation may increase menstrual blood loss. It is now thought that stopping the Pill causes the change in menstrual blood loss. Women on the combined oral contraceptive pill tend to have light periods. When 'the Pill is discontinued after sterilisation, the periods return to the blood loss that would have been experienced without the benefit of hormonal control. There is no difference in the bleeding pattern of women who have undergone sterilisation compared to women whose partners have had a vasectomy.

Q Should I have tests to find the causeof my AUB?

A: Tests can be important in helping to find out the cause. A blood count may be needed because AUB can cause anaemia, which can be corrected with iron tablets.

For women aged from their late teens through the 20s and 30s (and when obvious problems have been excluded), further investigation may be necessary only if:

• The woman is at risk of endometrial hyperilasia or endometrial cancer
• The bleeding is irregular or it fails to respond to medication

Q What would be a reasonable initial treatment for a teenager or young woman with AUB?

A: The combined oral contraceptive pill is usually an effective first choice for a younger woman, particularly if she also needs contraception. Teenagers with AUB may be having "anovulatory cycles", meaning that an egg is not being released each month.

Progestogens taken in the second half of the cycle may be effective and are often favored by parents with concerns about starting their young daughters on the contraceptive pill. Tranexamic acid taken on the days when the bleeding is heavy can also be a good first choice. When pain accompanies the heavy blood loss, a non-steroidal anti-inflammatory agent may be appropriate.

Q What are the risks of having a hysterectomy?

• The urinary tract (bladder and ureters) is close to the uterus and may be damaged.
• The bowel, which is normally separated from the uterus, can be attached to it as a consequence of infection, endometriosis or previous surgery. This increases the possibility of the bowel being damaged when the uterus is removed.
• Infection in the urinary tract is a possible complication that can be treated with antibiotics.
• Bladder symptoms are common following hysterectomy but usually settle with time.
• • Thromboembolism is a blood clot in the leg or lung. Although rare, this complication can be life threatening. For more information about hysterec-tomy and its benefits and risks, see the College patient education article Hysterectomy — A guide for women.

Q What if I am trying to get pregnant?

A: If you are trying to get pregnant, many of these therapies are not suitable. To plan treatment, it is important that you tell your doctor whether you intend to get pregnant. Your treatment can often be tailored to your needs.

Q Are alternative therapies effective in treating AUB?

A: There are anecdotal reports of alterna-tive and complementary therapies that have appeared to work for some women, but evidence in large or validated studies is lacking.

Costs

Dr Suyesha can advise you about coverage by public health insurance, private health insurance and out-of-pocket costs. You may want to ask for an estimate that lists the likely costs. This includes medical and hospital fees, and other items. Ask which costs can be claimed on private health insurance. Due to unexpected tests or treatments, the final account may vary from the estimate. It is better to discuss costs with your doctor before receiving tests and treatment, rather than afterwards.