Abnormal uterine bleeding (AUB) refers to any bleeding from the uterus that differs from the normal menstrual cycle in volume, frequency, regularity, or duration. It can affect women of all ages and is a common reason for gynecological visits. Understanding AUB is essential to identify its cause and ensure effective treatment.
What is Abnormal Uterine Bleeding?
AUB includes a wide range of irregularities, including:
- Bleeding between periods.
- Heavy menstrual bleeding (HMB), also known as menorrhagia.
- Bleeding after menopause. (Post menopausal bleeding -PMB)
- Prolonged periods (lasting more than 7-10 days).
- Irregular menstrual cycles.
- Bleeding after sexual intercourse (postcoital bleeding).
Common Causes of Abnormal Uterine Bleeding
The causes of AUB are often categorized using the PALM-COEIN classification system, which divides causes into structural and non-structural categories:
Structural Causes (PALM) – (A structural cause refers to a physical abnormality within the uterus. These issues alter the shape or function of the uterine lining, leading to irregular or heavy bleeding):
- P – Polyp: Growths in the lining of the uterus (endometrium) that may cause irregular or heavy bleeding.
- A – Adenomyosis: A condition where endometrial tissue grows into the uterine muscle, leading to painful and heavy periods.
- L – Leiomyoma (Fibroids): Benign growths in the uterus that can cause heavy or prolonged bleeding.
- M – Malignancy or Hyperplasia: Abnormal growth of the uterine lining, which can lead to bleeding and may indicate cancer or precancerous changes.
Non-Structural Causes (COEIN) – (Non-structural causes of abnormal uterine bleeding involve functional or systemic issues rather than physical abnormalities in the uterus. These include hormonal imbalances, ovulatory dysfunction, bleeding disorders, medication effects, or issues with the endometrium’s ability to regulate normal bleeding):
- C – Coagulopathy: Bleeding disorders like von Willebrand disease that impair blood clotting.
- O – Ovulatory Dysfunction: Irregular ovulation or lack of ovulation (anovulation) causing unpredictable bleeding.
- E – Endometrial Causes: Problems with the uterine lining that cause abnormal bleeding without other identifiable causes.
- I – Iatrogenic Causes: Bleeding caused by medications (e.g., hormonal contraceptives, anticoagulants) or medical devices (e.g., IUDs).
- N – Not Otherwise Classified: Rare conditions that don’t fit into other categories. Examples are: Chronic endometritis, uterine arteriovenous malformations (AVMs), or other unusual systemic or uterine conditions that affect bleeding but are not well defined or commonly encountered.
Other causes may include:
- Pregnancy-related complications: Miscarriage, ectopic pregnancy, or placenta previa.
- Infections: Pelvic inflammatory disease (PID) or sexually transmitted infections (STIs).
- Hormonal imbalances: Thyroid dysfunction, PCOS (polycystic ovary syndrome).
Symptoms of Abnormal Uterine Bleeding
Women with AUB may experience:
- Heavy bleeding that requires frequent pad or tampon changes, sometimes both pads and tampons are used together.
- Passing large blood clots during menstruation.
- Spotting or bleeding between periods.
- Bleeding lasting longer than 7 days.
- Irregular or unpredictable menstrual cycles.
- Fatigue or symptoms of anemia, such as dizziness or shortness of breath.
- Painful periods or pelvic pain.
Work-Up for Abnormal Uterine Bleeding
Proper evaluation of AUB involves a detailed history, physical examination, and diagnostic testing to determine the underlying cause.
1. Medical History
- Menstrual history: Regularity, duration, volume of bleeding.
- Sexual history: Risk of pregnancy or sexually transmitted infections.
- Family history: Bleeding disorders or uterine conditions.
- Medications: Hormonal treatments, anticoagulants, or supplements.
2. Physical Examination
- Pelvic Exam: To assess for structural abnormalities, infections, or signs of trauma.
- General Exam: Check for signs of anemia, thyroid dysfunction, or coagulopathy.
3. Diagnostic Tests
- Pregnancy Test: To rule out pregnancy-related causes.
- Blood Tests:
- Complete blood count (CBC) to check for anemia.
- Coagulation studies for bleeding disorders.
- Hormone levels (TSH, prolactin, LH, FSH) to assess for hormonal imbalances.
- Imaging:
- Ultrasound (transvaginal or abdominal) to evaluate the uterus, ovaries, and endometrium.
- Saline infusion sonohysterography (SIS) for detailed assessment of the uterine cavity.
- Endometrial Biopsy: To rule out endometrial hyperplasia or cancer, especially in postmenopausal women or women over 45 with risk factors.
- Hysteroscopy: Direct visualization of the uterine cavity if abnormalities are suspected.
When to See a Doctor
Seek medical attention for AUB if you experience:
- Heavy bleeding that soaks through multiple pads or tampons in an hour.
- Bleeding accompanied by severe pain.
- Symptoms of anemia (fatigue, dizziness).
- Bleeding after menopause.
- If you are concerned by your bleeding,
Management of Abnormal Uterine Bleeding
Treatment depends on the underlying cause, severity of symptoms, and the patient’s reproductive goals:
Medications
- Hormonal Therapy: Birth control pills, IUDs (e.g., Mirena), or progestins to regulate the menstrual cycle.
- Non-Hormonal Options:
- NSAIDs (e.g., ibuprofen) to reduce menstrual flow and pain.
- Tranexamic acid to decrease bleeding.
- Treatment of Underlying Conditions:
- Antibiotics for infections.
- Thyroid medications for hypothyroidism or hyperthyroidism.
Surgical Options
- Hysteroscopy: Removal of polyps or fibroids.
- Endometrial Ablation: Destruction of the uterine lining for women who no longer wish to conceive.
- Hysterectomy: Removal of the uterus in severe cases or when malignancy is present.
Conclusion
Abnormal uterine bleeding is a complex condition with various potential causes. Early recognition and proper evaluation are essential to identify the underlying issue and provide effective treatment. If you’re experiencing symptoms of AUB, consult a healthcare provider to discuss your options and ensure the best care for your reproductive health.