Abnormal Vaginal Bleeding

Abnormal Vaginal Bleeding
Is a descriptive term applied to any alteration in the normal menstrual flow. The following table outlines the classical terminology applied to abnormal uterine bleeding:

Menorrhagia Prolonged & increased menstrual flow
Metrorrhagia Regular intermenstrual bleeding
Polymenorrhea Menses occurring at < 21 day interval
Menometrorrhagia Prolonged menses & intermenstrual bleeding
Oligomenorrhea Menses at intervals of > 35 days

The average menses lasts for 3-7 days with a mean blood loss of 35 ml. Menorrhagia is defined as blood loss of greater than 80 ml as women who lose this amount or more will have a lower haemoglobin & haematocrit value.

Aetiology:
Abnormal uterine bleeding can be classified into :
1. Idiopathic: where no organic pathology can be found, also called dysfunctional uterine bleeding. The principal factors implicated in the pathogenesis of menorrhagia are disordered production of prostaglandinsn ( PGE2 & PGF2? ), enhanced fibrinolytic activity & abnormalities of endometrial vascular development. It is further divided into :
a. Anovulatory: this tend to occur in women at the extremes of the reproductive life & is typified by irregular cycle. It is more common in obese women.
b. Ovulatory: more common in women aged 35 to 45 years & is typified by regular heavy & often painful menstrual periods. It may be due to an inadequate production of progesterone by the corpus luteum.

2. Secondary: to organic pathology, the major organic causes of abnormal uterine bleeding include:
• Local causes :
1. Uterine fibroid : especially submucous fibroid.
2. Adenomyosis: presence of endometrial tissue embedded within the myometrium, characterized by painful heavy periods.
3. Endocervical polyp, endometrial polyp or endometrial hyperplasia: classically cause intermenstrual bleeding due to irregular shedding of the endometrium.
4. Intrauterine contraceptive device (IUCD): periods may become heavier & longer in duration. Insertion of IUCD is thought to elevate the circulating level of plasminogen activator leading to an increase in fibrinolytic activity.
5. Pelvic inflammatory disease (PID): cause erratic menstrual bleeding due to local endometrial inflammatory response, Chlamydial infection is more likely to cause intermenstrual bleeding.
6. malignancy of the cervix, uterus & ovaries : presence of postcoital bleeding should lead to the possibility of cervical lesion in particular, including cervical ectropion. Hormone producing ovarian tumors can cause endometrial hyperplasia & menstrual irregularities.
7. Trauma: can be a cause for acute presentation of abnormal vaginal bleeding.

• Systemic causes:
1. Endocrine disorders:
? Hyper or hypothyroidism.
? Diabetes mellitus.
? Adrenal disease.
? Prolactin disorders.
2. Disorders of haemostasis: mostly found in teen-agers who present with heavy bleeding. Examples are von Willebrand s disease & idiopathic thrombocytopenic purpura (ITP).
3. Liver disorders: may interfere with metabolism of estrogen.
4. renal disease : may alter the excretion of estrogen & progesterone.
5. Medication: steroid hormones, neoroleptics & anticoagula-nt.
• Pregnancy: this possibility should always be considered in women of reproductive age group. Miscarriage, ectopic pregnancy & gestational trophoblastic disease may present with abnormal bleeding.

Management :
Diagnosis:
History: the following points should be stressed on :
• A description of the pattern of abnormal bleeding & an estimation of its severity which is usually a subjective one , however an impression can be gained by ascertaining the number of pads or t ampons the patient use & at which frequency these are changed, the use of menstrual pictograsm can help the assessment.
• Other cyclical symptoms such as dysmenorrhea, abdominal bloating or psychological disturbance.
• Ask specifically about intermenstrual or postcoital bleeding.
• Detailed account of the patient s gynecological history including current & past contraceptive use, cervical smear history & any history of STD.
• Detailed reproductive history.

Examination: this include vital signs, general examination for stigmata of systemic illness such as hirsutism, striae, thyroid enlargement, pitechiae & ecchymosis & assessment of secondary sexual characteristics. Palpation of the abdomen for liver enlargement & any pelvic masses.
The vulva should be examined for any signs of bleeding or local infection. Speculum examination of the vagina & cervix ,endocervical swab & cervical smear should be taken if indicated. Bimanual examination to assess for uterine or adnexial enlargement or tenderness.

Laboratory Investigation : these are guided by the patient s history & physical examination.
• Full blood count.
• Serum ?hCG: if any possibility of pregnancy.
• Thyroid function test.
• Coagulation screen / bleeding time.
• Renal / liver function test.
The purpose of investigations is to exclude organic pathology. If the woman is young (< 40 years) & has regular menstrual cycles, further invasive assessment is not necessary before proceding to treatment. If the woman is older, give a history of irregular bleeding ( including intermenstrual or postcoital bleeding), or if the initial conservative treatment fails, detailed investigation is warranted to exclude pathology within the uterine cavity. These include:
o Imaging Technique:
• Transvaginal ultrasound ,indicated when the uterine size by examination is more than 10 weeks, this will detect fibroids, their number & position.
• Saline sonohysterography: ultrasound-based technique of saline infusion is useful to delineate the uterine cavity when hysteroscopy is not available.
o Hysteroscopy :is regarded as the gold standard for endometrial evaluation when used in combination with biopsy.Hysteroscopy is ideally performed during the proliferative phase of the cycle when the endometrium is at its thinnest.
o Endometrial sampling:
• Aspiration technique: these carried out as out patient procedures providing rapid screening test. It is important to note their limitation as the sample obtained may not be representative of the whole endometrial cavity.
• Hysteroscopically directed endometrial biopsy: Traditionally dilatation & curettage was performed. However, when this is combined with hysteroscopy the accuracy of the diagnostic process is improved.

Treatment:
In the acute situation the main priorities of treatment involve:
• Resuscitation.
• Correction of anaemia.
• Arresting ongoing bleeding.
If an underlying cause is found ( secondary ), treatment should be directed towards the cause. If the bleeding is dysfunctional, the treatment depends on the patient s age, reproductive wishes & severity of symptoms. Treatment is divided into medical & surgical.
Medical treatment: is further divided into:
• Non-hormonal therapy:
1. Non-steroidal anti-inflammatory drugs NSAID: antiprostaglandins act by inhibiting cyclo-oxygenase enzyme thereby reducing local prostaglandin levels. They reduce the menstrual loss by 30% , also are beneficial in reducing dysmenorrhea. Example is mefinamic acid.
2. Antifibrinolytics: e.g, tranexamic acid. Reduce menstrual blood by 50%, used during menstruation only & is contraindicated in patients with history of thromboembolism.
• Hormonal therapy:
1. Synthetic progestogens: e.g, norethisteron, used from day 5 of the cycle for 21 days.They are more useful for anovulatory DUB.
2. Combined oral contraceptive pills: for women require contraception & for whom hormonal agents are acceptable. It reduce menstrual blood loss, control irregularities, & relieve menstrual pain.
3. Levonorgestrel-Intrauterine system: In addition to its contraceptive benefit, it cause a mean reduction in menstrual blood loss of about 95% by 1 year after insertion. It was suggested as an alternative to surgical treatment. However its side effect of causing irregular menses for the first 3-6 months after insertion should be discussed with the patient.

Second line drugs with few advantages over the foregoing & whose side effects limit long term use:
1. Danazol: a derivative of testosterone, act as a competitive inhibitor of sex steroids, reduce the menstrual blood loss by 60%. Its androgenic side effects like weight gain, hirsutism , acne & voice changes make it unacceptable to most patients.
2. Gonadotrphin releasing hormone (GnRH) analogues: used in selected cases, induce medical menopause by suppressing gonadotrophin release from the pituitary, so should not be used (without add back therapy) for longer than 6 months because of the risk of osteoporosis.
3. Gestrinone: is a synthetic derivative of 19-nortestosterone with antiestrogenic, antigestagenic & androgenic activity, cause a marked reduction in menstrual blood loss.

Surgical Treatment: reserved for those in whom medical treatment has failed & has completed their family size. It include:
• endometrial ablation: all endometrial destructive procedures employ the same principle that ablation of the endometrial lining of the uterus to sufficient depth including the basal layer prevents regeneration of the endometrium by inducing changes similar to those seen in Asherman syndrome. There is a variety of methods by which endometrial ablation can be achieved, these include :
Methods performed under direct visualization at hysteroscopy:
1. Laser
2. Diathermy
3. Transcervical endometrial resection
Methods performed non-hysteroscopically(i.e. without direct visualization of the endometrial cavity at the time of the procedure):
1. Thermal balloon uterine therapy
2. Microwave ablation
3. Heated saline
These procedures are performed through the uterine cervix, the patient can return home the same day. The mean reduction in endometrial blood loss is 90%. Complications include uterine perforation, haemorrhage & fluid overload.
• Hysterectomy: provides the definitive cure of menorrhagia. It can be total when the uterine cervix is also removed or subtotal. Hysterectomy is often accompanied by removal of the ovaries (bilateral oophorectomy), the main advantage of which is reduced risk of ovarian cancer,also it is of benefit in women with pelvic pain or severe premenstrual syndrome. Modes of hysterectomy:
• Abdominal hysterectomy
• Vaginal hysterectomy
• Laparoscopically assisted hysterectomy