Uterus prototype model.

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Abnormal Uterine Bleeding

Abnormal uterine bleeding, also known as dysfunctional uterine bleeding, is common for women of reproductive age. Bleeding in between menstrual periods is abnormal uterine bleeding.  Menorrhagia or heavy menstrual bleeding characterised by increased amount of blood lost during menstrual period. The normal menstrual period blood loss is around 80 to 120 millilitres, about five tablespoons. Excessive blood loss is, therefore, blood loss that requires a woman to change their pad every hour or less, as it gets soaked from the heavy flow.

If the amount of blood lost interferes with your lifestyle, it is abnormal and you should seek help. 

Abnormal uterine bleeding unrelated to pregnancy may be caused by a number of conditions and the causes differ with womens’ age.

Bleeding that occurs in very young girls before their first menstrual period is always abnormal. This type of bleeding is usually caused by trauma or foreign bodies such as toys, coins, a bit of toilet paper or some kind of irritation to the genital areas. It could also be caused by use of soap or lotions, bubble baths, or sometimes it’s just scratching from common things such as yeast infection. 

Adolescent girls who have started having menstrual periods abnormal uterine bleeding, heavy menstrual periods can be related to blood disorders or hormonal dysfunction. If the abnormal uterine bleeding persists for longer than a few months after the first menstrual period or its heavy, further evaluation is necessary.

In women of reproductive age, causes of abnormal uterine bleeding may be

  • uterine fibroids
  • uterine adenomyosis or endometriosis
  • polyps in the uterus
  • thickened endometrial lining
  • hormonal changes 
  • cancer of the cervix or uterus or sometimes even the ovaries
  • infection or inflammation in the cervix or the uterus due to sexually transmitted infections such as chlamydia 
  • bleeding disorders
  • hormonal birth control 

Medical illnesses that can cause abnormal uterine bleeding

  • Thyroid-dysfunction
  • Liver disease
  • Blood-thinning disorders
  • Platelet abnormalities

Rarely, blood disorders such as Von Willebrand disease or any other condition with similar symptoms, may cause very heavy uterine bleeding usually in adolescents. 

In women who are in menopausal transition, abnormal uterine bleeding can be commonly caused by thinning of vaginal skin and fragility of the vaginal skin so called vaginal atrophy of genito-urinary syndrome of menopause.

Cancer is something that we worry about if post-menopausal women, hence, we always investigate this bleeding.  Other less sinister causes of post-menopausal bleeding are polyps, fibroids, infections and blood-thinning issues.

Possible symptoms include:

  • You get your period more often than every 21 days 
  • Your period lasts longer than 7 days
  • Your bleeding is heavier than normal, as discussed above
  • You bleed in between your periods

The treatment for uterine bleeding would depend on the cause of the bleeding. The cause is identified through a patient’s history, clinical assessment, pelvic ultrasound, sometimes a hysteroscopy, STDs tests, endometrial biopsy to exclude cancer and diagnose any other abnormal cell changes in the uterine lining.

These tests will help your gynaecologist check for other causes of your symptoms and allow them to decide on the best treatment.

If someone has a medical condition such as thyroid dysfunction, liver disease or a blood-thinning disorder we would treat this particular condition to assist with the management of the abnormal uterine bleeding.

We can use medications to decrease the amount of blood loss during the menstrual period (tranexamic acid and brufen), but this treatment will not treat the cause of bleeding.

If someone has fibroids, the gynaecologist would treat the fibroids.

If the bleeding is related to adenomyosis or endometriosis of the uterus, we would treat that condition and the treatment will differ from woman to woman.

Bleeding caused by chlamydia or other infections will be treated with antibiotics.

Hormonal treatments include the contraceptive pill, the patch, ring, intrauterine device, injections, implant. Generally, hormonal contraceptive pills / devices decrease the amount of blood loss during menstruation. Taking the contraceptive pills or applying a patch continuously without using placebo pills or taking a break will stop you having menstrual periods altogether. Many women ask if it is healthy not to have a period at all. There’s nothing unhealthy about it. A hundred years ago, women only had a few menstrual periods in their lifetime because they were either pregnant or breastfeeding. Nowadays, we have a period every month, but this is only because we are not pregnant. Our bodies are designed to carry the pregnancy and breastfeed the babies. Menstrual cycle changes are part of the process necessary to conception. When we experience a menstrual period, it’s only because the pregnancy has not occurred. So I don’t think there is anything wrong with not having a period at reproductive age. Once you decide that you want to have a baby, you can change the use of your hormonal treatments to go back to having periods and trying to get pregnant. 

Mirena intrauterine devices can be another treatment option for heavy or irregular uterine bleeding. Mirena contains Levonorgestrel which is progesterone. It’s a little device that can be inserted in the uterus in the doctor’s office. It does not require any preparations for the procedure and the best time to insert the intrauterine device is during the menstrual period as the cervix is slightly open during that time.

Mirena intrauterine device is used to treat both heavy menstrual bleeding and abnormal uterine bleeding. The device can be used up to five years and the procedure to insert Mirena is quick. 

I pass the speculum in the vagina (in the same way for Pap smear). I use the antiseptic solution to clean the cervix.  I inject with a tiny needle numbing solution into the cervix to prevent pain during Mirena insertion. Then, I insert a Mirena device. I check the ultrasound to make sure that the positioning of the inserted device is correct.

It is extremely unlikely for an intrauterine device to move from the uterus into the tummy. It can be placed incorrectly, but we would pick that up during the ultrasound performed immediately after the insertion. 

There is a very remote possibility of the Mirena device falling out which could be due to structural abnormalities or just the shape of the uterus and if that happens, we will try to insert another one. I usually do not recommend two repetitive Mirena insertions if it has been inserted twice and both intra-uterine devices have fallen out.

On rare occasions, I would perform the Mirena insertion in the operating room under general anaesthesia. Usually for girls who have never been sexually active or if a woman chooses to have it done in the operating room.

After the insertion, women may experience a menstrual type of pain immediately following the procedure which may continue for a couple of days. Spotting and irregular bleeding is common for up to six weeks. If that continues beyond three months, we would investigate it and manage it accordingly. But what is most likely is that this device is not suitable for this particular woman and we would have to remove it, this is done quite easily in the office as well. 

The Mirena contraceptive intrauterine device stops menstrual bleeding in 70% of women completely. Twenty percent of women have periods similar or slightly lighter than before and ten percent of women may have irregular bleeding using Mirena IUD and we would consider removing it and using other treatments for such cases.

  • Hysteroscopy and D&C (dilatation and curettage)
  • Endometrial Ablation
  • Resection of uterine fibroids or polyp hysteroscopically
  • Removal of uterine fibroids (myomectomy) via laparoscopy (keyhole surgery) or laparotomy 
  • Hysterectomy via laparoscopy (keyhole surgery) or laparotomy or vaginally

See attached documentation for possible surgical procedures, depending on the gynaecologist’s diagnosis of the cause of the bleeding:

Hysterescopy

Hysterectomy

Endometrial Ablation