Abnormal uterine bleeding is a common female gynaecological issue

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 Abnormal uterine bleeding is a term that encompasses a variety of conditions and not the definate diagnosis of a disease, and indicates or suggests an aberration of change in the normal menstrual flow or rhythm in any patient. It therefore represents a variety of abnormalities of menstruation, which may or not be due to an underlying disease or pathological process. 

Abnormal Uterine bleeding accounts for 10-15% of all new gynaecological cases . It is a problem of all ages with highest occurrence during the active reproductive age group (20-40 years) and the perimenopausal age group, (that is 40years and above) The lowest incidence occurs in patients under, 20 years of age. 

Abdominal uterine bleeding is a common gynecological problem in any female population. Most women present with this complaint at one time or the other in their life. Majority of cases resolve spontaneously or are not severe enough to warrant any detailed investigation or specific therapy. 

Abnormal uterine bleeding may be caused by several factors as follows, :

General Systemic Disease 

Long standing illness tends to affect menstruation by causing a degree or cessation of bleeding. This arises as a result of malnutrition, excessive weight loss and anaemia. However acute febrile illness such as malaria and sudden shock may cause the sudden onset of menstruation prematurely or vaginal bleeding of varying amount. 

Endocrine Disorders 

Endocrine gland disorder may cause various types of abnormal uterine bleeding. Thus hypothyroidism, myxoedema,  may cause menorrhagia or polymenorrhoea. Liver diseases such as cirrhosis and hepatitis may result in disturbance of the normal metabolism and nactivation of oestrogen and thus cause menorrhagia or metorrhagia. 

Blood Disorder 

Disease characterized by coagulation defects or increased capillary fragility may cause abnormal uterine bleeding which may therefore occur in conditions such as thrombocytopenic purpura, aplastic anaemia, leukemia and Christmas Disease. 

Endometriosis 

Endometriosis international, that is adenomyosis, causes menorrhagia while ovarian endometriosis may cause polymenorrhoea or polymenorrhagia. 

Abnormalities of Pregnancy 

Abnormal uterine bleeding may be due to abnormalities  or complications of pregnancy such as abortion, hydatidform mole and ectopic pregnancy. 

Infections

Changes in the pattern of menstrual bleeding may be associated with pelvic infection. For example early or late onset of a heavy and prolonged period usually occurs in association with pelvic infections with the exception of genital tuberculosis which causes oligomenorrhoea or amenorrhea. 

Tumours

Benign or malignant tumours of the genital tract, cervix, uterus or ovaries may cause abnormal uterine bleeding. For example follicular cysts of the ovary may be associated with irregular vagina bleeding. Oestrogen producing tumours can also cause a cyclical anovular bleeding. Uterine fibroids particularly the submucous variety cause progressive menorrhagia because they increase the surface area of the endometrium and become polypoidal. Similarly, endometrial and cervical polyps may cause irregular or continous bleeding especially when they become ulcerative. 

Latrogenic Causes 

Abnormal uterine bleeding may be caused by the use of drugs and contraceptive devices. 

How do I know which of these causes is responsible for my problem? 

Abnormal uterine bleeding is a serious clinical problem because it may be an indication of an underlying clinical entity such as malignancies. Thus meticulous and logical approach is needed to diagnose which is which. This requires doctor’s comprehensive study and observations.  The patient’s comprehensive menstrual and medical history is needed, detailed physical examination including abdominal and pelvic examination as well as selected appropriate investigations. 

Abnormal Uterine bleeding is further classified into 3 based on the aetiology and risk factors ;

Primary 

This are due to factors arising from the genital tract and reproductive system, including pituary and hypothalamic , this may be referred to as dysfunctional uterine bleeding,(D. U. B) 

Secondary 

This is a diagnosis when there is no detectable disease of the genital tract but where there is a known disorder outside the genital tract which is responsible for the abnormal uterine bleeding e. g myxoedema, leukemia, thrombocytopenic purpura 

Latrogenic 

Diagnosed when the abnormal uterine bleeding is associated with some contraceptive or therapeutic agents, for example an IUCD, injectable contraceptives such as Noristerat or Depo-Provera or administration of estrogen to the patient particularly at menopause. 

Special investigation  are;

Hematological investigation 

All cases of abnormal uterine bleeding must have a hemoglobin estimation and full blood count to assess the degree of anemia present. Patients with persistent symptoms should have a blood smear platelet count, bleeding time exclude idiopathic thrombocytopenic purpura or other hematological cause of the bleeding. 

Cervical Smear, Uterine Curettge and Endometrial Biopsy 

A cervical Smear should be performed in women with abnormal uterine bleeding to detect any cytological abnormalities. A diagnostic uterine Curettge should also be carried out in order to exclude any lesions of the uterus, such as incomplete abortion, tuberculosis endometritis or endometrial polyp or carcinoma. 

Endocrine blood test 

Gynaecological endocrine blood test such as hormone assay may be carried out where necessary like in cases of polymenorrhoea and oligomenorrhoea. Test of thyroid or adrenal function are indicated in all cases where there is clinical suspicion of associated endocrine disease. 

Management 

Treatment is dependent on the results of evaluation and the effect of the bleeding on the patient. It is important to say that many cases of menstrual abnormality resolve spontaneously and that treatment option  should only be given where there is indicated findings upon examination and investigation. In such patients, reassurance may be enough as there may be spontaneous resolution. 

Three principles of management are general measures, conservative therapy and radical therapy.