and Paula Briggs2
(1)
Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
(2)
Sexual and Reproductive Health, Southport and Ormskirk Hospital, Southport, UK
A number of different types of bleeding problem fall under the umbrella of AUB.
Definition
Heavy menstrual bleeding (HMB) is excessive menstrual bleeding.
Intermenstrual bleeding (IMB) is bleeding between periods.
Post coital bleeding (PCB) is bleeding after sex.
Post menopausal bleeding is bleeding at least 1 year after the last menstrual period.
Incidence
AUB is one of the commonest reasons for referral to see a gynaecologist.
Aetilogy and Pathogenesis
Using the “pathological shopping list” all possible potential aetiological factors will be covered. To make this more logical, from a clinical perspective, possible factors will be considered in order of frequency.
Degenerative – The peri-menopause could be considered, “a degenerative condition of ovulation”, with subsequent deficiency in progesterone resulting in disruption of the menstrual cycle with possible HMB.
Neoplastic Benign – Leiomyomata or fibroids are a common cause of HMB. These benign growths are composed of fibromuscular tissue. The propensity for fibroids to cause HMB is dependent upon the position of the tumour in the uterus (see Fig. 13). Fibroids are classically described as sub-serous (on the outer aspect of the uterus), intramural (embedded in the muscle) or submucous (distorting the uterine cavity). As a result of the proximity to and the associated distortion of the endometrial cavity, submucous fibroids are the most likely fibroids to be associated with HMB.
Congenital – Any congenital abnormality that increases the surface area of the uterine cavity can result in an increase in the amount of endometrium shed, e.g. bicornuate uterus.
Traumatic – The introduction of a foreign body, for example an intrauterine device (IUD) can be associated with HMB, particularly in the first few months following insertion.
Inflammatory/Infective – Pelvic Inflammatory Disease (PID) can result in increased blood flow to the uterus, with possible HMB.
Vascular/Haematological – Any abnormality of coagulation has the potential to result in excessive bleeding at the time of menstruation. Although rare, a vascular malformation in the uterus, can result in HMB.
Neoplastic Malignant – Endometrial cancer may present as HMB, and needs to be excluded, particularly if there are risk factors present. Potential risk factors include, nulliparity, polycystic ovarian syndrome, obesity and diabetes. Endometrial cancer is becoming commoner in association with the global rise in obesity.
Ovarian cancer can also be associated with HMB, although the presenting symptom is more commonly pain and abdominal distension.
Endocrine – Hypothyroidism can be associated with HMB.
Psychogenic – The mind can have a wide and varied effect on body systems, and it is possible that stress may be associated with HMB.
Iatrogenic – This means a cause due to medical intervention. HMB after the insertion of an IUD would be considered iatrogenic. Administration of exogenous hormones may also a cause HMB.
Clinical Assessment
History
It can be difficult to assess the extent of the bleeding suffered by an individual woman. Some women who have significant blood loss don’t complain of HMB, whereas other women who perceive that they have HMB, do not actually lose all that much blood when assessed quantitatively. For this reason, NICE Clinical Guideline 44 stresses that if the woman feels that her blood loss is excessive, then it is. Measuring the amount of blood lost is regarded as old fashioned and is no longer considered relevant as it has no place in clinical management. Questions which might be helpful when trying to determine the impact of bleeding on the individual woman include enquiring as to whether clots are passed, and whether the patient has to use more than one method of sanitary protection e.g. towels and tampons.
A lifelong history of HMB (since menarche) in association with excessive bleeding during other operations e.g. on tooth extractions, or easy bruising may suggest an inherited coagulopathy such as von Willebrands Disease. This is a rare condition, but von Willebrand factor should be checked for if the history is suggestive.
Examination
Pallor of skin and conjunctivae can assess the possibility and degree of anaemia, although this can only be reliably determined by measuring a full blood count (FBC). Otherwise examination is directed towards determining any of the aetiological factors described above. The size of the uterus, and any localised enlargements due to fibroids may be detected on bimanual examination.
Investigations
Haematology – Full Blood Count.
Coagulation profile is only indicated if there is a chronic history of bleeding, or a family history of a coagulation defect. Liaison with a haematologist may be helpful.
Ultrasound examination of the uterus (preferably transvaginal TV U/S) is the most helpful investigation. It can be used to exclude intrauterine pathology, and accurately detect any uterine abnormality including structural defects such as the presence of fibroids.
The introduction of a negative contrast medium e.g. saline, can be used to facilitate the detection of endometrial polyps.
Endometrial biopsy – this can be done using a variety of samplers with the patient awake. All of the available sampling techniques are based on suction. In association with TV U/S, endometrial sampling is as sensitive as hysteroscopy, historically viewed as the gold standard investigation for HMB.
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