Abnormal Uterine Bleeding: Understanding Causes, Symptoms, and Treatment Options

Abnormal Uterine Bleeding (AUB) is a common gynaecological condition that affects women. 

AUB refers to any variation from normal menstrual patterns in terms of frequency, duration, or bleeding volume. It can be classified based on the nature of the bleeding, and it may be caused by a range of factors, from hormonal imbalances to structural issues in the uterus. AUB can occur in both premenopausal and postmenopausal women, though the causes and management may differ. 

This comprehensive guide will take you through the various aspects of abnormal uterine bleeding, including its causes, symptoms, diagnosis, and treatment options.

What is Abnormal Uterine Bleeding or Menometrorrhagia?

Abnormal uterine bleeding, also known as menometrorrhagia, refers to vaginal bleeding that occurs outside of a woman’s normal menstrual cycle or is heavier or longer than typical menstrual periods. This condition can significantly impact a woman’s quality of life and may be a sign of underlying health issues.

Classification of Abnormal Uterine Bleeding

AUB is often classified using the PALM-COEIN system, which categorises the causes of abnormal bleeding into structural and non-structural causes. 

PALM (structural causes): 

• Polyps: Benign, non-cancerous growths in the endometrium or cervix. 
• Adenomyosis: Endometrial tissue grows into the uterine muscle, causing heavy bleeding and pain. 
• Leiomyomas (Fibroids): Benign tumors of the uterus that can cause heavy or irregular bleeding. 
• Malignancy and hyperplasia: Includes endometrial cancer or precancerous changes (endometrial hyperplasia). 

COEIN (non-structural causes): 

• Coagulopathy: Blood clotting disorders like Von Willebrand disease or platelet dysfunction. 
• Ovulatory dysfunction: Conditions where ovulation does not occur regularly, leading to irregular bleeding. 
• Endometrial: Dysfunction in the endometrial lining due to inflammation, infection, or atrophy. 
• Iatrogenic: Caused by medications or devices (e.g., anticoagulants, intrauterine devices, or hormonal therapies). 
• Not yet classified: When the exact cause cannot be determined despite evaluation. 

How Common is Abnormal Uterine Bleeding?

Abnormal uterine bleeding is a relatively common condition, affecting approximately 10-30% of women of reproductive age. The prevalence increases with age, particularly as women approach menopause, says, Dr. Prashanth Ganesh.

Who Does It Affect?

Abnormal uterine bleeding can affect women of all ages, but it is most common in:

• Adolescents experiencing their first menstrual cycles
• Women approaching menopause (perimenopause)
• Women with certain medical conditions or taking specific medications

What are the most common symptoms associated with abnormal uterine bleeding?

The primary symptom of abnormal uterine bleeding is, as the name suggests, unusual vaginal bleeding. Other abnormal uterine bleeding symptoms are:

• Heavy bleeding during menstruation (soaking through a pad or tampon) for several consecutive hours
• Prolonged menstrual periods (lasting more than a week)
• Bleeding or spotting between periods
• Bleeding after sexual intercourse
• Bleeding after menopause
• Irregular menstrual cycles (shorter than 21 days or longer than 35 days)
• Passing blood clots larger than 1 inch in diameter

Additional symptoms may include:

• Fatigue or weakness due to anaemia
• Shortness of breath
• Pale skin
• Abdominal or pelvic pain

What Causes Abnormal Uterine Bleeding?

Abnormal uterine bleeding can have various causes, ranging from hormonal imbalances to structural abnormalities. Here are some common abnormal vaginal bleeding causes:

1. Hormonal imbalances: These are particularly common during adolescence or perimenopause, where the regulation of hormones (oestrogen and progesterone) is less stable. Conditions like Polycystic Ovary Syndrome (PCOS) can also contribute to hormonal irregularities and abnormal bleeding. 
2. Uterine fibroids (Leiomyomas): These benign tumors can distort the uterine cavity and result in heavy, prolonged periods. Treatment depends on the size, position, and symptoms associated with fibroids. 
3. Adenomyosis: This condition involves the growth of endometrial tissue within the uterine muscle and is associated with heavy menstrual bleeding and pelvic pain. 
4. Endometrial polyps: Small, benign growths on the uterine lining that can cause irregular bleeding. 
5. Endometrial cancer: Particularly a concern in postmenopausal women, abnormal bleeding of any sort can be a key sign. 

Abnormal Uterine Bleeding Diagnosis

Diagnosing abnormal uterine bleeding involves a comprehensive approach. Here are some of the tests that your doctor might suggest: 

• Complete Blood Count (CBC): To check for anaemia and rule out blood disorders.
• Pregnancy Test: To exclude pregnancy-related bleeding.
• Thyroid Function Tests: To assess thyroid hormone blood levels.
• Hormone Tests: To evaluate levels of oestrogen, progesterone, and other relevant hormones.
• Ultrasound: To assess for uterine fibroids, polyps, or other structural issues. Your doctor might also suggest other imaging studies to visualise the uterus and surrounding structures.
• Endometrial biopsy: To rule out endometrial hyperplasia or cancer, particularly if there’s heavy bleeding or a woman is postmenopausal. 
• Hysteroscopy: A procedure that allows direct visualisation and many times removal of the uterine cavity to detect polyps, fibroids, or other abnormalities. 
• Pap smear: To screen for cervical cancer. 

How is Abnormal Uterine Bleeding Treated?

Abnormal uterine bleeding treatment depends on the underlying menometrorrhagia causes, the severity of symptoms, and the patient’s age and reproductive goals. Options may include:

Hormonal treatments: 

• Oral contraceptives: Used to regulate the menstrual cycle and reduce bleeding.
• Progestins: Can help control heavy bleeding in women with hormonal imbalances or endometrial hyperplasia. 
• Levonorgestrel-releasing intrauterine device (IUD): Reduces bleeding, especially in cases of fibroids or adenomyosis and hormonal imbalances. 

Non-hormonal treatments: 

• Tranexamic acid: Helps reduce excessive bleeding. 
• Nonsteroidal anti-inflammatory drugs (NSAIDs): Can help manage pain and reduce menstrual blood flow. 
• Medications for coagulation problems. 

Surgical options: 

• Hysteroscopic procedures: To remove polyps or fibroids. 
• Endometrial ablation: A procedure to destroy the lining of the uterus to reduce or eliminate bleeding in women who are not planning to have more children.
• Hysterectomy: Surgical removal of the uterus, typically considered when other treatments fail or in cases of severe structural abnormalities like cancer. 

Management of underlying conditions: 

For example, managing thyroid dysfunction, treating polycystic ovary syndrome (PCOS), or addressing blood clotting disorders. 

Lifestyle Changes:

• Stress reduction techniques
• Maintaining a healthy weight
• Regular exercise

How can I Reduce my Risk?

While some causes of abnormal uterine bleeding are not preventable, you can take precautionary steps to reduce your risk:

• Maintain a healthy weight through diet & exercise
• Manage stress through relaxation techniques or counselling
• Practice safe sex to prevent STDs or sexually transmitted infections
• Attend regular gynaecological check-ups
• Be aware of your family history and discuss any concerns with your doctor
• If using hormonal contraceptives, take them as prescribed
• Avoid smoking and limit alcohol consumption

When to Seek Medical Attention 

If you are experiencing any of the following, it’s important to seek medical attention: 

• Heavy bleeding (e.g., soaking through more than one pad or tampon every hour for several hours), bleeding leading to anaemia. 
• Prolonged bleeding (e.g., bleeding lasting more than 7 days). 
• Irregular or missed periods (if previously regular). 
• Bleeding between periods including bleeding after intercourse or after menopause.
• Pain or pressure in the pelvic area. 

Conclusion

Abnormal uterine bleeding can be a common condition that can significantly impact a woman’s life. By understanding its causes, symptoms, and available treatment modalities, females can take proactive steps to manage their health & seek appropriate care when needed. If you experience any unusual vaginal bleeding, it’s essential to consult with a gynaecologist for proper diagnosis and treatment. With the right approach, most cases of abnormal uterine bleeding can be effectively managed, allowing women to maintain their overall health and well-being.

FAQ’s

What is the leading cause associated with abnormal uterine bleeding?

There is no single leading cause of abnormal uterine bleeding, as it can result from various factors. However, some of the principal causes include hormonal imbalances (polycystic ovary syndrome or thyroid disorders), structural abnormalities in the uterus (like fibroids or polyps), and certain medications. In some cases, it may be due to more serious conditions such as uterine cancer. The exact cause can vary depending on a woman’s age, medical history, and other factors.

How to cure abnormal uterine bleeding?

Abnormal uterine bleeding treatment depends on its underlying cause. Some common approaches include:

• Hormonal treatments (birth control pills, progesterone, or hormonal IUDs)
• Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce bleeding and pain
• Iron supplements for anaemia
• Surgical procedures like endometrial ablation or hysterectomy in severe cases
• Treatment of underlying conditions (e.g., thyroid disorders or infections)

What hormone tests are done for abnormal uterine bleeding?

Several hormone tests may be conducted to diagnose the cause of abnormal uterine bleeding:

• Thyroid-stimulating hormone (TSH) and thyroid hormone levels
• Follicle-stimulating hormone (FSH) and luteinising hormone (LH)
• Oestrogen and progesterone levels
• Testosterone and other androgen levels
• Prolactin levels
• Human chorionic gonadotropin (hCG) to rule out pregnancy

The specific tests prescribed depend on the patient’s age, symptoms, and other clinical factors.

How long does hormonal imbalance bleeding last?

The duration of bleeding caused by hormonal imbalances depends on the underlying cause and individual factors. It may sometimes last for a few days to a couple of weeks. However, without proper treatment, hormonal imbalance bleeding can persist for months or even become chronic. If you experience prolonged or frequent abnormal bleeding, consult your gynaecologist for accurate diagnosis & treatment. 

What is the Difference Between Menorrhagia and Menometrorrhagia

While these terms are often used interchangeably, there is a subtle difference. Menorrhagia refers to excessively heavy or prolonged menstrual bleeding that occurs at regular intervals. 

Menometrorrhagia, on the other hand, refers to heavy or prolonged menstrual bleeding that occurs at irregular intervals, including bleeding between periods.