Abnormal uterine bleeding

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Abnormal uterine bleeding
Other namesAtypical vaginal bleeding, dysfunctional uterine bleeding (DUB), abnormal vaginal bleeding
Specialty Gynecology
Symptoms Irregular, abnormally frequent, prolonged, or excessive amounts of uterine bleeding [1]
Complications Iron deficiency anemia [2]
Causes Ovulation problems, fibroids, lining of the uterus growing into the uterine wall, uterine polyps, underlying bleeding problems, side effects from birth control, cancer [3]
Diagnostic method Based on symptoms, blood work, medical imaging, hysteroscopy [2]
Differential diagnosis Ectopic pregnancy [4]
Treatment Hormonal birth control, GnRH agonists, tranexamic acid, NSAIDs, surgery [1] [5]
FrequencyRelatively common [2]

Abnormal uterine bleeding (AUB), also known as atypical vaginal bleeding (AVB), is vaginal bleeding from the uterus that is abnormally frequent, lasts excessively long, is heavier than normal, or is irregular. [1] [3] The term dysfunctional uterine bleeding was used when no underlying cause was present. [3] Vaginal bleeding during pregnancy is excluded. [3] Iron deficiency anemia may occur and quality of life may be negatively affected. [2]

Contents

The underlying causes may include ovulation problems, fibroids, the lining of the uterus growing into the uterine wall, uterine polyps, underlying bleeding problems, side effects from birth control, or cancer. [3] More than one category of causes may apply in an individual case. [3] The first step in work-up is to rule out a tumor or pregnancy. [5] [3] Medical imaging or hysteroscopy may help with the diagnosis. [2]

Treatment depends on the underlying cause. [3] [2] Options may include hormonal birth control, gonadotropin-releasing hormone (GnRH) agonists, tranexamic acid, NSAIDs, and surgery such as endometrial ablation or hysterectomy. [1] [5] Over the course of a year, roughly 20% of reproductive-aged women self-report at least one symptom of AUB. [2]

As adenomyosis is a common disorder with a prevalence of 20-35% it is often causative related. Recent research suggests that abnormal angiogenesis is associated to conditions of adenomyosis leading to abnormal uterine bleeding. [6] [7] This suggests options for therapeutic intervention with angiogenesis inhibitors.

Signs and symptoms

Symptoms include vaginal bleeding that occurs irregularly, at abnormal frequency, lasts excessively long, or is more than normal. [1] Normal frequency of periods is 22 to 38 days. [1] [3] Variation in the length of time between cycles is typically less than 21 days. [3] Bleeding typically last less than nine days and blood loss is less than 80 mL. [1] [3] Excessive blood loss may also be defined as that which negatively affects a person's quality of life. [2] Bleeding more than six months after menopause is also a concern. [4]

Causes

The causes of AUB are divided into nine groups: uterine polyps, fibroids, adenomyosis, cancer, blood clotting disorders, problems with ovulation, endometrial problems, healthcare induced, and not yet classified. [3] More than one category of causes may apply in an individual case. [3] Healthcare induced causes may include side effects of birth control. [3]

Mechanism

The underlying mechanism is often a hormonal disturbance: reduced levels of progesterone cause high levels of prostaglandin F2-alpha and cause abnormally heavy flow as progesterone stabilizes the endometrium and inhibits synthesis of prostaglandin F2-alpha; increased levels of tissue plasminogen activator (t-PA), a fibrinolytic enzyme, lead to more fibrinolysis.[ citation needed ]

Ovulatory

Ten percent of cases occur in women who are ovulating, but progesterone secretion is prolonged because estrogen levels are low. This causes irregular shedding of the uterine lining and break-through bleeding. Some evidence has associated ovulatory DUB with more fragile blood vessels in the uterus. It may represent a possible endocrine dysfunction, resulting in menorrhagia or metrorrhagia. Mid-cycle bleeding may indicate a transient estrogen decline, while late-cycle bleeding may indicate progesterone deficiency.[ citation needed ]

Anovulatory

About 90% of DUB events occur when ovulation is not occurring (anovulatory DUB). Anovulatory menstrual cycles are common at the extremes of reproductive age, such as early puberty and perimenopause (period around menopause). In such cases, women do not properly develop and release a mature egg. When this happens, the corpus luteum, which is a mound of tissue that produces progesterone, does not form. As a result, estrogen is produced continuously, causing an overgrowth of the uterus lining. The period is delayed in such cases, and when it occurs menstruation can be very heavy and prolonged. Sometimes anovulatory DUB is due to a delay in the full maturation of the reproductive system in teenagers. Usually, however, the mechanisms are unknown.[ citation needed ]

The cause can be psychological stress, weight (obesity, anorexia, or a rapid change), exercise, endocrinopathy, neoplasm, drugs, or it may be otherwise unknown.[ citation needed ]

Diagnosis

Diagnosis of AUB starts with a medical history and physical examination. [2] Normal menstrual bleeding patterns vary from woman to woman, so the medical history covers specific details about the woman's individual menstrual bleeding pattern, such as its predictability, length, volume, and whether she experiences cramps or other pain. The healthcare provider will also check to see whether she or any family members have any potentially related health conditions, and whether she is taking medication that might increase or decrease menstrual bleeding, such as herbal supplements, hormonal contraceptives, over-the-counter drugs such as aspirin, or blood thinners. [8]

Medical tests include a blood test, to see whether the abnormal bleeding has caused anemia, and a pelvic ultrasound, to see whether the abnormal bleeding is caused by a structural problem, such as a uterine fibroid. [2] Ultrasound is specifically recommended in those over the age of 35 or those in whom bleeding continues despite initial treatment. [4] Laboratory assessment of thyroid stimulating hormone (TSH), pregnancy, and chlamydia is also recommended. [8]

More extensive testing might include an MRI and endometrial sampling. [2] Endometrial sampling is recommended in those over the age of 45 who do not improve with treatment and in those with intermenstrual bleeding that persists. [2] The PALM-COEIN system may be used to classify the uterine bleeding. [8]

Management

Treatment depends on the underlying cause. [3] [2] Options may include hormonal birth control, gonadotropin-releasing hormone (GnRH) agonists, tranexamic acid, NSAIDs, and surgery such as endometrial ablation or hysterectomy. [1] [5] Polyps, adenomyosis, and cancer are generally treated by surgery. [2] Iron supplementation may be needed. [2]

Terminology

The terminology "dysfunctional uterine bleeding" is no longer recommended. [3] Historically dysfunctional uterine bleeding meant there was no structural or systemic problems present. [3] In AUB underlying causes may be present. [3]

Epidemiology

About one-third of all medical appointments with gynecologists involve AUB, with the proportion rising to 70% in the years around menopause. [8]

Related Research Articles

<span class="mw-page-title-main">Endometrium</span> Inner mucous membrane of the mammalian uterus

The endometrium is the inner epithelial layer, along with its mucous membrane, of the mammalian uterus. It has a basal layer and a functional layer: the basal layer contains stem cells which regenerate the functional layer. The functional layer thickens and then is shed during menstruation in humans and some other mammals, including apes, Old World monkeys, some species of bat, the elephant shrew and the Cairo spiny mouse. In most other mammals, the endometrium is reabsorbed in the estrous cycle. During pregnancy, the glands and blood vessels in the endometrium further increase in size and number. Vascular spaces fuse and become interconnected, forming the placenta, which supplies oxygen and nutrition to the embryo and fetus. The speculated presence of an endometrial microbiota has been argued against.

<span class="mw-page-title-main">Menstruation</span> Shedding of the uterine lining

Menstruation is the regular discharge of blood and mucosal tissue from the inner lining of the uterus through the vagina. The menstrual cycle is characterized by the rise and fall of hormones. Menstruation is triggered by falling progesterone levels and is a sign that pregnancy has not occurred.

<span class="mw-page-title-main">Menstrual cycle</span> Natural changes in the human female reproductive system

The menstrual cycle is a series of natural changes in hormone production and the structures of the uterus and ovaries of the female reproductive system that makes pregnancy possible. The ovarian cycle controls the production and release of eggs and the cyclic release of estrogen and progesterone. The uterine cycle governs the preparation and maintenance of the lining of the uterus (womb) to receive an embryo. These cycles are concurrent and coordinated, normally last between 21 and 35 days, with a median length of 28 days, and continue for about 30–45 years.

Gynecologic hemorrhage represents excessive bleeding of the female reproductive system. Such bleeding could be visible or external, namely bleeding from the vagina, or it could be internal into the pelvic cavity or form a hematoma. Normal menstruation is not considered a gynecologic hemorrhage, as it is not excessive. Hemorrhage associated with a pregnant state or during delivery is an obstetrical hemorrhage.

<span class="mw-page-title-main">Uterine cancer</span> Medical condition

Uterine cancer, also known as womb cancer, includes two types of cancer that develop from the tissues of the uterus. Endometrial cancer forms from the lining of the uterus, and uterine sarcoma forms from the muscles or support tissue of the uterus. Endometrial cancer accounts for approximately 90% of all uterine cancers in the United States. Symptoms of endometrial cancer include changes in vaginal bleeding or pain in the pelvis. Symptoms of uterine sarcoma include unusual vaginal bleeding or a mass in the vagina.

Heavy menstrual bleeding (HMB), previously known as menorrhagia or hematomunia, is a menstrual period with excessively heavy flow. It is a type of abnormal uterine bleeding (AUB).

An anovulatory cycle is a menstrual cycle characterised by the absence of ovulation and a luteal phase. It may also vary in duration from a regular menstrual cycle.

<span class="mw-page-title-main">Adenomyosis</span> Extension of endometrial tissue into the myometrium

Adenomyosis is a medical condition characterized by the growth of cells that proliferate on the inside of the uterus (endometrium) atypically located among the cells of the uterine wall (myometrium), as a result, thickening of the uterus occurs. As well as being misplaced in patients with this condition, endometrial tissue is completely functional. The tissue thickens, sheds and bleeds during every menstrual cycle.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

<span class="mw-page-title-main">Endometrial polyp</span> Medical condition

An endometrial polyp or uterine polyp is a mass in the inner lining of the uterus. They may have a large flat base (sessile) or be attached to the uterus by an elongated pedicle (pedunculated). Pedunculated polyps are more common than sessile ones. They range in size from a few millimeters to several centimeters. If pedunculated, they can protrude through the cervix into the vagina. Small blood vessels may be present, particularly in large polyps.

<span class="mw-page-title-main">Uterine fibroid</span> Medical condition with benign tumors of uterus

Uterine fibroids, also known as uterine leiomyomas or fibroids, are benign smooth muscle tumors of the uterus. Most women with fibroids have no symptoms while others may have painful or heavy periods. If large enough, they may push on the bladder, causing a frequent need to urinate. They may also cause pain during penetrative sex or lower back pain. A woman can have one uterine fibroid or many. Occasionally, fibroids may make it difficult to become pregnant, although this is uncommon.

Progestogen-only pills (POPs), colloquially known as "mini pills", are a type of oral contraceptive that contain synthetic progestogens (progestins) and do not contain estrogens. They are primarily used for the prevention of undesired pregnancy, although additional medical uses also exist.

Intermenstrual bleeding (IMB) is vaginal bleeding at irregular intervals between expected menstrual periods. It may be associated with bleeding with sexual intercourse.

<span class="mw-page-title-main">Menstrual disorder</span> Medical condition affecting menstrual cycle

A menstrual disorder is characterized as any abnormal condition with regards to a woman's menstrual cycle. There are many different types of menstrual disorders that vary with signs and symptoms, including pain during menstruation, heavy bleeding, or absence of menstruation. Normal variations can occur in menstrual patterns but generally menstrual disorders can also include periods that come sooner than 21 days apart, more than 3 months apart, or last more than 10 days in duration. Variations of the menstrual cycle are mainly caused by the immaturity of the hypothalamic-pituitary-ovarian (HPO) axis, and early detection and management is required in order to minimize the possibility of complications regarding future reproductive ability.

Polymenorrhea, also known as frequent periods, frequent menstruation, or frequent menstrual bleeding, is a menstrual disorder in which menstrual cycles are shorter than 21 days in length and hence where menstruation occurs more frequently than usual. Cycles are regular and menstrual flow is normal in the condition. Normally, menstrual cycles are 25 to 30 days in length, with a median duration of 28 days.

Hypomenorrhea or hypomenorrhoea, also known as short or scanty periods, is extremely light menstrual blood flow. It is the opposite of heavy periods or hypermenorrhea which is more properly called menorrhagia.

Genital leiomyomas are leiomyomas that originate in the dartos muscles, or smooth muscles, of the genitalia, areola, and nipple. They are a subtype of cutaneous leiomyomas that affect smooth muscle found in the scrotum, labia, or nipple. They are benign tumors, but may cause pain and discomfort to patients. Genital leiomyoma can be symptomatic or asymptomatic and is dependent on the type of leiomyoma. In most cases, pain in the affected area or region is most common. For vaginal leiomyoma, vaginal bleeding and pain may occur. Uterine leiomyoma may exhibit pain in the area as well as painful bowel movement and/or sexual intercourse. Nipple pain, enlargement, and tenderness can be a symptom of nipple-areolar leiomyomas. Genital leiomyomas can be caused by multiple factors, one can be genetic mutations that affect hormones such as estrogen and progesterone. Moreover, risk factors to the development of genital leiomyomas include age, race, and gender. Ultrasound and imaging procedures are used to diagnose genital leiomyomas, while surgically removing the tumor is the most common treatment of these diseases. Case studies for nipple areolar, scrotal, and uterine leiomyoma were used, since there were not enough secondary resources to provide more evidence.

<span class="mw-page-title-main">Fertility testing</span>

Fertility testing is the process by which fertility is assessed, both generally and also to find the "fertile window" in the menstrual cycle. General health affects fertility, and STI testing is an important related field.

<span class="mw-page-title-main">FIGO classification of uterine bleeding</span>

The International Federation of Gynecology and Obstetrics is an international organization that links about 125 international professional societies of Obstetricians and Gynecologists. In 2011 FIGO recognized two systems designed to aid research, education, and clinical care of women with abnormal uterine bleeding (AUB) in the reproductive years. This page is a summary of the systems and their use in contemporary gynecology.

<span class="mw-page-title-main">Uterine niche</span> A medical disorder of the uterus

A uterine niche, also known as a Cesarean scar defect or an isthmocele, is an indentation of the myometrium at the site of a cesarean section with a depth of at least 2 mm.

References

  1. 1 2 3 4 5 6 7 8 "Abnormal Uterine Bleeding". ACOG. March 2017. Retrieved 11 September 2018.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Whitaker L, Critchley HO (July 2016). "Abnormal uterine bleeding". Best Pract Res Clin Obstet Gynaecol. 34: 54–65. doi:10.1016/j.bpobgyn.2015.11.012. PMC   4970656 . PMID   26803558.
  3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Bacon JL (June 2017). "Abnormal Uterine Bleeding: Current Classification and Clinical Management". Obstetrics and Gynecology Clinics of North America. 44 (2): 179–193. doi:10.1016/j.ogc.2017.02.012. PMID   28499529.
  4. 1 2 3 "Vaginal Bleeding". Merck Manuals Professional Edition. Retrieved 11 September 2018.
  5. 1 2 3 4 Cheong Y, Cameron IT, Critchley H (1 September 2017). "Abnormal uterine bleeding". British Medical Bulletin. 123 (1): 103–114. doi: 10.1093/bmb/ldx027 . PMID   28910998.
  6. ↑ Harmsen MJ, Wong CF, Mijatovic V, Griffioen AW, Groenman F, Hehenkamp WJ, Huirne JA (September 2019). "Role of angiogenesis in adenomyosis-associated abnormal uterine bleeding and subfertility: a systematic review". Human Reproduction Update. 25 (5): 647–671. doi:10.1093/humupd/dmz024. PMC   6737562 . PMID   31504506.
  7. ↑ Middelkoop MA, Don EE, Hehenkamp WJ, Polman NJ, Griffioen AW, Huirne JA (February 2023). "Angiogenesis in abnormal uterine bleeding: a narrative review". Human Reproduction Update. 29 (4): 457–485. doi:10.1093/humupd/dmad004. PMC   10320491 . PMID   36857162.
  8. 1 2 3 4 Khafaga A, Goldstein SR (2019). "Abnormal Uterine Bleeding". Obstet Gynecol Clin North Am. 46 (4): 595–605. doi:10.1016/j.ogc.2019.07.001. PMID   31677744. S2CID   207891429.
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