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Abnormal uterine bleeding

Menorrhagia - Metrorrhagia - IMB

Abnormal uterine bleeding

Abnormal uterine bleeding  are together with pelvic pain the most frequent symptoms in gynaecology.

Menorrhagia : abundant menstruation
Metrorrhagia : irregular bleeding
IMB : intermenstrual bleeding
Spotting : slight bleeding

Basic concepts in uterine bleeding in gynecology

The menstrual cycle and the endometrium

Oestrogens make the endometrium grow. Progestagens stop the growth and transform the endometrium either for a pregnancy or a menstruation.

When a women produces only estrogens e.g. an-ovulatory cycles . This means a thicker endometrium and heavier menstruations.

Combined therapy of Oestrogens+progestagens = a thin endometrium since absence of growth and thus less heavy bleeding . This is typical for orals contraceptive pills, for a continuous combined therapy after menopause. But this therapy also has side effects , such as

- spotting in a few to 10% of women. The best explanation is the growth of capillaries in the endometrium by progestagens.
- it therefore is common practice to give this therapy discontinuously.
- it therefore is not useful to increase the dose when spotting occurs.

Menorrhagia = too heavy menstruation

It can be disturbing for the woman, but it becomes a medical problem when associated with anaemia and insufficient reserves of iron, ie when menstruation is more than 80 ml.

Etiology
anovulation
a local problem in the uterus such as a polyp or a myoma.
sometimes without obvious cause / sometimes attributable to adenomyosis
Diagnosis
? ovulation ? ultrasound and hysteroscopy to evaluate the uterine cavity.
Therapy
anovulation : R/ progestagens in the second half of the cycle ; eventually oral contraception
polyp = hysteroscopic polypectomy
myoma = hysteroscopic myomectomy. If larger than 5 cm experience is required and for very large myoma’s a laparoscopic myomectomy should be considered.
menorrhagia without pathology : this is an indication for and ablation of the endometrium as the least invasive therapy. It should be realised that a superficial ablation -> deep ablation -> lap subtotal hysterectomy -> total lap hysterectomy are interventions which are increasingly invasive.

Spotting

Spotting should never be considered as normal and should be investigated by hysteroscopy and or ultrasound
When estrogens and progestagens are used together however spotting occurs in 2 to 10 %

When should we become worried

Menorrhagia with anaemia.
Spotting after menopause
Spotting when taking oral contraception , continuous combined therapy or Orgametril or Mirena is not necessarily abnormal but should anyway be investigated;

Which exams

Biochemistry to detect anaemia

Ultrasound is not invasive and can detect the larger myoma’s outside the cavity.

Hysteroscopy still is the best exam for the cavity. It is  almost non invasive with the small hysteroscope.

Which therapy

Medical

Menorrhagia : start with progestagens, eventually together with coagulation enhancement if the cavity is normal .
Spotting : change therapy

Surgery is a continuum from less to more invasive :

ablation
-> deep ablation
-> lap subtotal hysterectomy
-> lap hysterectomy.

Considerations

An ablation is the least invasive and takes 10 min only. Day surgery. Although a 20% risk of recurrent surgery is often quoted, this figure is much lower for the more experienced hysteroscopists.
Subtotal hysterectomy takes less than 1 hour while the pelvic support structure remains intact : thus less pain and a more rapid recovery.
Total laparoscopic hysterectomy takes 1 hour and an hospitalisation of 3 days. When there is a risk of cervical cancer this should be preferred.

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