Abnormal Uterine Bleeding 

Take home points 

 • Normal menstruation is a physiologically coordinated event involving synchronised ovarian hormones secretion and universal endometrial reaction both structurally and functionally. Any deviations from this pattern could lead to abnormal uterine bleeding. 

 • Elaborate history taking would reveal the diagnosis in most cases which only needs to be confirmed by diagnostic means.

 • The best parameter in a clinical setup to indicate abnormal uterine bleeding would be a noticeable change in a patient’s menstrual bleeding pattern. 

 • The following objectives should be set to deal with women with abnormal uterine bleeding: 

   oTo stop the acute bleeding episode and prevent any future similar recurrence.
   o To exclude organic causes especially sinister ones and to find other medically treatable    conditions before resorting to surgery.
   o To identify patients at greater risk of malignancy

.• The empirical use of progestogens for all sorts of abnormal uterine bleeding is not justifiable, non physiological and potentially harmful. This is especially so in cases of ovulatory dysfunctional uterine bleeding and in cases with intracavitary fibroids.

 • Using D&C is no longer a viable option as it samples only 60% of the endometrium and is not sensitive enough for diagnosing polyps, intracavitary fibroids or focal endometrial lesions. 

 • Transvaginal scan examination and saline infusion sonohysterography simplified the management of abnormal uterine bleeding, and should be used in all units by trained gynaecologists. Active bleeding is not a contraindication for these procedures. In fact the presence of some blood in the cavity might cancel the need for saline infusion as it could play the same role and help with the identification of intracavitary lesions. This is especially so when a machine with 3D facilities has been used.

 • The following ultrasound findings could indicate endometrial pathology:
     o >5 mm thick endometrium at the end of menstruation
     o Abnormally thick endometrium >13 mm at other times of the cycle
     o Abnormally thin endometrium at midcycle o Irregular endometrial / myometrial interface    
     o Heterogeneous endometrium with or without fluid in the cavity 

• Endometrial thickness measurements have different significance in pre and postmenopausal women presenting with abnormal uterine bleeding. A thin endometrium almost excludes the possibility of sinister pathology in postmenopausal women, but does not exclude any sort of pathology in the premenopausal group. Accordingly, SIS is indicated in almost all cases with significant uterine bleeding irrespective of the endometrial thickness measurements in the last group.

 • Further investigations are indicated for women with recurrent episodes of postmenopausal bleeding irrespective of the endometrial thickness.

 • The presence of fluid in the uterine cavity could be seen in the following conditions: o During menstruation o During super-ovulation
  
   o Incomplete miscarriage
   o Cervical stenosis o Endometritis with irregular heterogeneous endometrium 
   o Cervical and endometrial carcinoma 

• Most bleeding episodes in women under the age of 20 years are dysfunctional and need to be treated conservatively.

 • Most cases of postmenopausal bleeding episodes follow benign causes. Saline infusion sonohysterography and targeted hysteroscopic biopsies would obviate the need for many hysterectomies.

 • Oligomenorrhoeic women with PCOS should be tested for insulin resistance. 

 • All women with menorrhagia over the age of 30 years should have their thyroid indices tested. The current ‘normal’ range given for TSH excludes many women with mild hypothyroidism who present with abnormal uterine bleeding.

 • Haematological causes of abnormal uterine bleeding are not rare. As many as 20% of young women with such problems could be affected. In such cases haematological tests should be done before any hormonal treatment is given, as it might affect the results of the tested indices. This is especially so for von Willebrand disease. 

 • Minimal access surgery, being hysteroscopic or laparoscopic, should be employed for treating most if not all cases with non-malignant abnormal uterine bleeding. Furthermore, when indicated, supracervical hysterectomy would be less traumatic with faster postoperative recovery period than the total procedure.

 • Iron supplements should be given as patients might have normal haemoglobin levels despite low serum iron and ferritin concentrations.