After studying this chapter you should be able to:
Knowledge criteria
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Describe the causes, significance and management of disorders of menstruation, including: intermenstrual, postcoital and postmenopausal bleeding, menstrual irregularity, heavy menstrual bleeding, dysmenorrhoea and secondary amenorrhoea
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Describe the problems of puberty, including precocious puberty and delayed puberty
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Describe problems of the perimenopause, including abnormal bleeding, vasomotor and other symptoms, osteoporosis and hormone-replacement therapy
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Describe benign conditions of the lower genital tract, including vulval pruritus, vaginal discharge and pelvic pain
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Describe the causes, significance and management of Bartholin’s abscess/cyst, abdominal pain of uncertain origin and acute unscheduled vaginal bleeding
Clinical competencies
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Assess and plan the initial investigation of a patient presenting with abnormal uterine bleeding, pelvic pain, vaginal discharge and amenorrhoea
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Interpret the results of the common investigations in benign gynaecological disorders
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Counsel a patient about indications, contraindications, principles and complications of the common surgical procedures in gynaecology
Introduction
Benign gynaecological conditions affect women’s lives in ways that often remain hidden from society and from health systems. Many aspects of benign conditions such as heavy menstrual bleeding (HMB) and debilitating pelvic pain are often tolerated by women and sometimes dismissed as normal by health care professionals. Many of these conditions do have significant implications for women’s health and well-being, family and social relationships, the working lives of women and on their ability to conceive. The recognition of benign gynaecological conditions requires education of women about what symptoms can be considered part of normal reproductive life and what symptoms may require investigation and treatment. Full appreciation of benign gynaecological conditions also requires that health care professionals develop a deeper understanding of managing reproductive health issues and of identifying potential pathological conditions.
Benign conditions of the upper genital tract
The uterus
The formation of the uterus results from the fusion of the two Müllerian ducts; this fusion gives rise to the upper two-thirds of the vagina, the cervix and the body of the uterus. Congenital anomalies arise from the failure of fusion, or absence or partial development of one or both ducts. Thus, the anomalies may range from a minor indentation of the uterine fundus to a full separation of each uterine horn and cervix ( Fig. 16.1 ). These conditions are also commonly associated with vaginal septa.
Symptoms and signs
The majority of uterine anomalies are asymptomatic and are usually diagnosed in relation to complications of pregnancy. However, the presence of a vaginal septum may result in dyspareunia and postcoital bleeding.
The presence of a double uterus may also be established at routine vaginal examination, when a double cervix may be seen. The separation of the uterine horns is sometimes palpable on bimanual vaginal examination, but in most cases the uterus feels normal and there is a single cervix. When only one horn is present, the uterus may be palpable as lying obliquely in the pelvis. The abnormality of two uterine horns and one cervix is known as uterus bicornis unicollis ( Fig. 16.2 ).
Partial atresia of one horn of the uterus, or a septate vagina resulting in obstruction to menstrual outflow from one horn of the uterus, may result in an unilateral haematocolpos and haematometra with retrograde spill of menstrual fluid. In this case, the patient may present with symptoms of dysmenorrhoea and will have a palpable mass arising from the pelvis.
The complications of pregnancy include:
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recurrent miscarriage: the role of congenital abnormalities in early pregnancy loss is unclear. For example, the incidence of uterine septa is the same in women with normal reproductive histories. However, there is an association with cervical incompetence, which may lead to mid-trimester miscarriage. This problem is usually associated with the subseptate uterus and is not common in the unicornuate uterus or in uterus bicornis bicollis
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premature labour
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malpresentation ( Fig. 16.3 )
Fig. 16.3
Malpresentation and a subseptate uterus.
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retained placenta.
Diagnosis and management
As many cases are asymptomatic, the diagnosis may arise only as a coincidental finding and requires no treatment or intervention. Where the diagnosis is suggested by the history, further investigation should include hysterography and hysteroscopy.
Surgical treatment
The role of surgical reconstruction of a double uterus in women with infertility is difficult to assess as there are no controlled studies demonstrating the benefits in pregnancy outcome. Consideration should be confined to women who have a history of recurrent miscarriage and where the abnormality is one of uterus bicornis unicollis, or there is a uterine septum.
The operation of plastic reconstruction of the uterus with unification of two uterine horns or excision of the uterine septum is known as metroplasty ( Fig. 16.4 ). An incision is made across the fundus of the uterus between the uterotubal junctions, taking care not to involve the intramural portion of the tube. The cavities are then reunited by suturing the surfaces together in the anteroposterior plane. If there is a septum, it is simply divided by diathermy and the cavity is then closed by suturing the transverse incision in the anteroposterior plane. Surgery of this type is associated with postoperative infertility in some cases and with a risk of uterine rupture in subsequent pregnancy.
An alternative surgical management is to divide the septum by diathermy through a hysteroscope inserted through the cervix.
Endometrial polyps
Endometrial polyps (EPs) are localized outgrowths of the surface endometrium. They appear at any age from the early reproductive years through to the postmenopausal period. EPs are usually benign lesions, but have been implicated in subfertility, as removal of these lesions may improve rates of pregnancy and/or reduce pregnancy loss.
Symptoms
EPs are usually asymptomatic lesions, but they may contribute to abnormal uterine bleeding manifesting as either intermenstrual bleeding, heavy menstrual bleeding or postmenopausal bleeding. Occasionally, protrusion of the polyp through the cervix may result in postcoital bleeding. Attempts by the uterus to expel the polyp may cause colicky, dysmenorrhoeic pain.
Signs
EPs are usually detected during the investigation for abnormal uterine bleeding and infertility. If the polyp protrudes through the cervix, it may be difficult to distinguish from an endocervical polyp ( Fig. 16.5 ). EPs can be visualized on ultrasound. They are most easily detected in the secretory phase of the menstrual cycle when the non-progestational type of glands in the polyp stand out in contrast to the normal surrounding secretory endometrium. If their presence is suspected either clinically or on transvaginal ultrasound, further clarification can be undertaken by performing a transvaginal sonohysterography ( Fig. 16.6 ) and/or office or inpatient hysteroscopy with or without directed excisional biopsy.
Pathology
EPs are localized overgrowths of the surface endometrium. Grossly, they are smooth, cylindrical structures, tan to yellow in colour after removal. Microscopically, they consist of a fine fibrous tissue core covered by columnar epithelium glands. The endometrium encasing the polyps varies from normal endometrium to endometrium that is unresponsive to cyclical hormonal influences. Occasionally the endometrial surface develops simple or complex hyperplasia and rarely malignant change occurs.
Treatment
Small asymptomatic polyps may resolve spontaneously and in these cases watchful waiting can be the treatment of choice. However, in women suffering from bleeding symptoms or infertility, surgical intervention is required. Traditionally, EPs were removed by dilatation and curettage (D&C) under general anaesthesia, but because blind curettage may miss EPs in 50–85% of cases, removal is best performed under hysteroscopic guidance or by performing curettage followed by reintroducing the hysteroscope to ensure that all the lesions have been removed.
Benign tumours of the myometrium
Uterine fibroids (myomas) are the most common benign tumour of the female genital tract and are clinically apparent in around 25% of women. They are smooth muscle tumours that vary enormously in size from microscopic growths to large masses that may weigh as much as 30–40 kg. Fibroids may be single or multiple and may occur in the cervix or in the body of the uterus. There are three types of fibroids according to their anatomical location. The most common are within the myometrium (intramural fibroids). Those located on the serosal surface that extend outwards and deform the normal contour of the uterus are subserosal fibroids. These may also be pedunculated and only connected by a small stalk to the serosal surface ( Fig. 16.7 ). Fibroids that develop near the inner surface of the endometrium and extend into the endometrial cavity, either causing a distortion of the cavity or filling the cavity if they are pedunculated are submucous fibroids. Cervical fibroids are similar to other sites in the uterus. They are commonly pedunculated but may be sessile and grow to a size that will fill the vagina and distort the pelvic organs.
The size and site of the tumour has a considerable effect on the symptoms. Subserosal fibroids can put pressure on adjacent organs and cause bowel and bladder symptoms. Submucosal fibroids can lead to HMB and infertility. Cervical fibroids have symptoms similar to other cervical polyps and, in addition, during attempted extrusion pain can occur as well as when there is degeneration of a fibroid or torsion of a pedunculated myoma.
The aetiology of fibroids is not known. They are more common in women who are Afro-Caribbean ethnicity, overweight, nulliparous, have polycystic ovary syndrome (PCOS), diabetes, hypertension and those with a family history of fibroids. Pregnancy causes enlargement and the menopause is associated with involution.
Histopathology
Myomas consist of whorled masses of unstriated muscle cells and the accompanying connective tissue.
Pathological changes
Fibroids can undergo a range of pathological changes including hyaline degeneration, cystic degeneration, calcification, infection and abscess formation and necrobiosis. The latter, known as ‘red degeneration’, can occur in pregnancy or after treatment with embolization. Rarely, with an incidence of between 0.13% and 1%, sarcomatous change can occur.
Symptoms and signs
Some 50% of women with fibroids are asymptomatic and the condition may only be discovered during routine pelvic examination: either at the time of cervical cytology or in the management of a pregnancy. Where symptoms do occur, they are often related to the site of the fibroids. The common presenting symptoms are as follows:
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Abnormal uterine bleeding: submucous and intramural fibroids commonly cause HMB. Submucous fibroids may cause irregular vaginal bleeding, particularly if associated with overlying endometritis or if the surface of the fibroid becomes necrotic or ulcerated. Although a rare occurrence, submucous fibroids may prolapse through the cervix resulting in profuse bleeding.
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Pain: pelvic pain is a fairly common symptom that may occur in association with the HMB. Acute pain is usually associated with torsion of the pedicle of a pedunculated fibroid, prolapse of a submucous fibroid through the cervix, or so-called ‘red degeneration’ associated with pregnancy where haemorrhage occurs within the leiomyoma, causing an acute onset of pain.
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Pressure symptoms: a large mass of fibroids may become apparent because of palpable enlargement of the abdomen or because of pressure on the bladder or rectum. Women may describe reduced bladder capacity with urinary frequency and nocturia. A posterior wall fibroid exerting pressure on the rectosigmoid can cause constipation or tenesmus.
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Complications of pregnancy: recurrent miscarriage is more common in women with submucous fibroids. Fibroids tend to enlarge in pregnancy and are more likely to undergo red degeneration. A large fibroid in the pelvis may obstruct labour or make caesarean section more difficult. There is increased chance of postpartum haemorrhage and the presence of fibroids increases the risk of threatened preterm labour and perinatal morbidity.
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Infertility: obvious fibroids are found in 3% of women with infertility, but ultrasound scanning demonstrates a substantially higher number. The proportion increases greatly with age (up to 50% by age of menopause). Up to 30% of women with uterine fibroids will have difficulty conceiving. Submucous and intramural fibroids are more likely to impair infertility than subserous ones. The mechanism may be mediated by mechanical, hormonal and local molecular regulatory factor effects.
Management
Most fibroids are asymptomatic and do not require treatment. In symptomatic women the choice of approach may be dictated by factors such as the patient’s desire for future fertility, the importance of uterine preservation, symptom severity and tumour characteristics.
Medical treatment
The oral contraceptive pill, progestogens and non-steroidal anti-inflammatory drugs (NSAIDs) have no effect on the size of fibroids but may be of value in controlling menstrual loss. A reduction of up to 45% in size can be achieved using gonadotrophin-releasing hormone (GnRH) analogues. However, the long-term use of these drugs is limited by their effect on bone density and the fibroids return to their original size when treatment is stopped. The progesterone receptor modulator, mifepristone, has been found to be effective in reducing blood loss and fibroid size over a 6 month period, but there is still a lack of long-term data to support its use. Other selective progesterone receptor modulators may also have a role, but their utility awaits the outcome of clinical trials and formal marketing.
Uterine artery embolization (UAE)
UAE involves the catheterization of the uterine arteries via the femoral artery and the injection of polyvinyl particles to reduce the blood supply to the uterus and to the fibroids. The fibroid shrinks because of ischaemia. The advantages of this technique are that it avoids the risks of major surgery and allows the preservation of fertility, although there is evidence that fertility can be impaired and that in those women who do conceive there may be an increased chance of an adverse pregnancy outcome. Impairment of fertility may be associated with a small risk of ovarian damage from the embolization. The side effects of UAE include pain from uterine ischaemia and risk of sepsis in the degenerating fibroid. At present its use is recommended only in selected cases.
Surgical treatment
Where the preservation of reproductive function is not important, the surgical treatment of choice is hysterectomy. Indeed, fibroids account for about a third of all hysterectomies in the UK. In younger women or where the preservation of reproductive function is important, the removal of the fibroids by surgical excision or myomectomy is indicated. This procedure involves incision of the pseudocapsule of the fibroid, enucleation of the bulk of the tumour and closure of the cavity by interrupted absorbable sutures. Myomectomy is associated with similar morbidity to hysterectomy. There may be haematoma formation in the cavity of the excised fibroid, if care is not taken with surgical haemostasis. It is also impossible to be certain that all fibroids are removed without causing excessive uterine damage; there is always a possibility that residual seedling fibroids may regrow.
Recurrence of fibroids occurs within 5 years in up to 60% of cases after myomectomy.
Treatments in development
Clinical trials have shown that MRI guided focused ultrasound (that is only available in a few centers), which utilizes directed energy to heat and destroy the fibroid, is a potentially less invasive treatment option. The method requires treatment of one fibroid at a time and cannot be used for the management of pedunculated fibroids. Pregnancy is not recommended after the procedure and long-term data are lacking.
Adenomyosis
Adenomyosis is a condition characterized by the invasion of endometrial glands and stroma into myometrium with surrounding smooth muscle hyperplasia. It affects around 1% of women and until recently the diagnosis was most commonly made only after histological assessment of tissue removed at hysterectomy.
Symptoms and signs
This condition, unlike endometriosis, typically occurs in parous women and is usually diagnosed in the fourth decade. It is associated with HMB and dysmenorrhoea of increasing severity. On clinical examination, the uterus is symmetrically enlarged and tender. The condition regresses after menopause.
Pathology
The macroscopic appearances of the uterus are those of diffuse enlargement. Adenomyosis and myomas often coexist, although the uterus is rarely enlarged to the size seen in the presence of myomas. The posterior wall of the uterus is usually thicker than the anterior wall. The cut surface of the uterus presents a characteristic, whorl-like trabeculated appearance but occasionally circumscribed nodules with dark haemorrhagic spots can be seen in the myometrium.
Both transvaginal ultrasound and MRI show high levels of accuracy for the non-invasive diagnosis of moderate to severe adenomyosis, but MRI is the most sensitive technique ( Fig. 16.8 ). The microscopic diagnosis is based on the presence of a poorly circumscribed area of endometrial glands and stroma invading the smooth muscle layers of the myometrium.
Treatment
Adenomyosis can be managed conservatively with medical treatment, with UAE or surgically. Medical therapy, as for endometriosis, is effective in some cases and symptomatic relief of dysmenorrhoea and heavy bleeding can best be obtained with insertion of a levonorgestrel-releasing intrauterine system. Prostaglandin synthetase inhibitors may sometimes help. UAE is often an effective alternative. Hysterectomy is the surgical procedure of choice, although less invasive techniques whereby the area of adenomyosis is specifically excised can sometimes be attempted. Other new techniques that may gain credence include high-intensity focused ultrasound to thermally ablate the adenomyotic foci.
Lesions of the ovary
Ovarian enlargement is commonly asymptomatic, and the silent nature of malignant ovarian tumours is the major reason for the advanced stage of presentation. Ovarian tumours may be cystic or solid, functional, benign or malignant. There are common factors in the presentation and complications of ovarian tumours and it is often difficult to establish the nature of a tumour without direct examination. The diagnosis and management of ovarian neoplasms is discussed in more detail in chapter 20 .
Symptoms
Tumours of the ovary that are less than 10 cm in diameter rarely produce symptoms. The common presenting symptoms include:
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Abdominal enlargement: in the presence of malignant change, this may also be associated with ascites.
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Symptoms from pressure on surrounding structures such as the bladder and rectum.
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Symptoms relating to complications of the tumour ( Fig. 16.9 ); these include:
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Torsion: acute torsion of the ovarian pedicle results in necrosis of the tumour; there is acute pain and vomiting followed by remission of the pain when the tumour has become necrotic
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Rupture: the contents of the cyst spill into the peritoneal cavity and result in generalized abdominal pain
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Haemorrhage into the tumour is an unusual complication but may result in abdominal pain and shock if the blood loss is severe
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Hormone-secreting tumours may present with disturbances in the menstrual cycle. In androgen-secreting tumours the patient may present with signs of virilization. Although a greater proportion of the sex-cord stromal type of tumour (see below) are hormonally active, the commonest type of secreting tumour found in clinical practice is the epithelial type.
Fig. 16.9
Common complications of ovarian tumours that precipitate a request for medical advice.
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Signs
On examination, the abdomen may be visibly enlarged. Percussion over the swelling will demonstrate central dullness and resonance in the flanks. These signs may be obscured by gross ascites. Small tumours can be detected on pelvic examination and will be found by palpation in one or both fornices. However, as the tumour enlarges, it assumes a more central position and, in the case of dermoid cysts, is often anterior to the uterus. Most ovarian tumours are not tender to palpation; if they are painful the presence of infection or torsion should be suspected. Benign ovarian tumours are palpable separately from the uterine body and are usually freely mobile.
Endometriosis
Endometriosis is a disease characterized by the presence of extrauterine endometrial-like tissue consisting of glands and stroma, often surrounded by an inflammatory response. It affects between 5% and 15% of reproductive-age women. In women presenting with pelvic pain or infertility, or in adolescents with severe dysmenorrhoea or chronic pelvic pain, the prevalence is significantly higher. Women suffering from endometriosis very often present with a complex of debilitating symptoms including pelvic pain, dyspareunia, dysuria, dyschezia and dysmenorrhoea. Although benign, endometriosis causes a substantial burden to the woman’s health, partly because of an average delay of 8–10 years between the onset of the symptoms and diagnosis. If undiagnosed the condition can progress in severity and result in many years of untreated or ineffectively treated pelvic pain.
Pathophysiology
Aberrant endometrial deposits occur in many different sites ( Fig. 16.10 ). Endometriosis commonly occurs in the ovaries ( Fig. 16.11 ), the uterosacral ligaments and the rectovaginal septum. It may also occur in the pelvic peritoneum covering the uterus, tubes, rectum, sigmoid colon and bladder. Remote ectopic deposits of endometrium may be found in the umbilicus, laparotomy scars ( Fig. 16.12 ), hernial scars, the appendix, vagina, vulva, cervix, lymph nodes and, on rare occasions, the pleural cavity.
Ovarian endometriosis occurs in the form of small superficial deposits on the surface of the ovary or as larger cysts known as endometriomas ( Fig. 16.13 ) which may grow up to 10 cm in size. These cysts have a thick, whitish capsular layer and contain altered blood, which has a chocolate-like appearance. For this reason, they are known as chocolate cysts. Endometriomas are often densely adherent both to the ovarian tissue and to other surrounding structures.
These cysts are likely to rupture and, in 8% of cases, patients with endometriosis present with symptoms of acute peritoneal irritation.
The microscopic features of the lesions may be of endometrium ( Fig. 16.14 ) that cannot be distinguished from the normal tissue lining the uterine cavity, but there is wide variation and, in many long-standing cases, desquamation and repeated menstrual bleeding may result in the loss of all characteristic features of endometrium. Underneath the lining of the cyst, there is often a broad zone containing phagocytic cells with haemosiderin. There is also a broad zone of hyalinized fibrous tissue. One of the characteristics of endometriotic lesions is the intense fibrotic reaction that surrounds them, and this may also contain muscle fibres. The intensity of this reaction often leads to great difficulty in dissection at the time of any operative procedure. The pathogenesis of endometriosis remains obscure. Sampson (1921) originally suggested that the condition was associated with retrograde spill of endometrial cells during menstruation and that some of these cells would implant under appropriate conditions in the peritoneal cavity and on the ovaries. This hypothesis does not account for endometriotic deposits outside the peritoneal cavity. An alternative theory suggests that endometrial lesions may arise from metaplastic changes in epithelium surfaces throughout the body.
Diagnosis
The initial assessment involves taking a detailed history of the duration and nature of pelvic pain with attention to the relationship to the menstrual cycle, the presence of bowel and bladder symptoms, the presence of dyspareunia and the impact of posture and movement on pain. Initial investigations may include urinalysis, screening for sexually transmitted infections and a transvaginal ultrasound scan. The ultrasound, if performed in expert hands, has a high degree of sensitivity and specificity for diagnosing ovarian endometriotic cysts and deep infiltrating bowel endometriosis, but is of little use in identifying the commoner types of peritoneal disease. As there is no consistently reliable non-invasive test, diagnostic laparoscopy by an experienced gynaecological endoscopist remains the best way of confirming or excluding most types of endometriosis.
Management
Endometriosis is a chronic disease that often requires life-long management. Medical treatment involves suppression of ovulation (and ovarian oestrogen secretion) and creating a steady hormone environment. Commonly used medication includes oral progestogens, progestogen subdermal implants and/or the levonorgestrel intrauterine system. Combined oral contraceptive pills are widely used, but it does not make logical sense to use an oestrogen-containing preparation in a woman with an oestrogen-sensitive disease. However, modern pills have a high progestogen-balance and may work well. These medications are all generally well tolerated and are initially preferable to alternatives, such as danazol, gonadotrophin-releasing hormone agonists and aromatase inhibitors. Medical therapy needs to be integrated with use of surgical therapies.
Surgical management of endometriosis usually involves complete excision of visible lesions. This is preferable to attempted diathermy ablation of the lesions, and reduces pain and improves quality of life in 67–80% of operated patients. To prevent recurrences, preventive medical therapy after surgery should always be considered, unless pregnancy is immediately desired. Deep infiltrating pelvic endometriosis that involves sigmoid colon or rectum requires a multidisciplinary approach with a colorectal surgeon. Laparoscopic resection of the rectovaginal endometritic nodule by a ‘shaving technique’ with reconstruction by expert laparoscopic gynaecologists is increasingly practised instead of bowel resection and anastomosis.
There is usually amelioration of endometriosis symptoms during pregnancy and there may sometimes be long-term improvement in pain after pregnancy. However, many women with endometriosis will experience recurrence of symptoms as soon as pregnancy and breast feeding have been completed.
Abnormal uterine bleeding
Abnormal uterine bleeding (AUB) is any bleeding disturbance that occurs between menstrual periods or is excessive or prolonged. This is the overarching term to describe any significant disturbance of menstruation or the menstrual cycle. FIGO (the International Federation of Gynecology and Obstetrics) has recently designed a classification system for underlying causes of AUB. This recommends that causes can be grouped under categories using the acronym PALM COEIN ( Table 16.1 ). The most common menstrual abnormalities are intermenstrual (often associated with postcoital bleeding) and heavy or irregular menstrual bleeding.
| Examples | |
|---|---|
| Structural lesions (‘PALM’) | |
| |
| Non-structural causes (‘COEIN’) | |
| C oagulopathies | Von Willebrand disease |
| Platelet dysfunctions | |
| Rare clotting factor deficiencies | |
| Low platelets (thrombocytopenia) | |
| O vulatory dysfunction | Anovulatory or disturbed ovulatory cycles (disturbance of oestrogen positive feedback or ovarian mechanisms) |
| Polycystic ovary syndrome | |
| Thyroid disease | |
| E ndometrial | Ovulatory endometrial molecular disturbances |
| Endometritis | |
| I atrogenic | Hormonal contraception |
| Anticoagulants | |
| Intrauterine devices | |
| N ot yet classified | Complications of undiagnosed pregnancy |
| Genital tract trauma | |
| Foreign bodies in the reproductive tract | |
| Cigarette smoking | |
The FIGO classification is a very useful and flexible system, which can easily be used both for initial training in understanding underlying causes, as well as being applied to more complex specialized or research classifications.
Intermenstrual bleeding
Intermenstrual bleeding (IMB) generally occurs between clearly defined cyclical, regular menses.
The bleeding may occur at the same time in each cycle or may be random. This symptom is typically associated with surface lesions of the genital tract, and these women may also experience postcoital bleeding. Undiagnosed pregnancy-related bleeding, including ectopic pregnancy and hydatidiform molar disease may result in irregular bleeding mimicking IMB. In 1–2% of women, IMB may be physiological with spotting occurring around the time of ovulation.
IMB is commonly associated with use of hormonal contraception (when it is known as unscheduled or breakthrough bleeding), particularly the combined oral contraceptive pill, intrauterine systems and use of the progestogen-only methods including the pills and implants.
In women with new onset of IMB, sexually transmitted infection of the cervix or vagina should be considered as a possible cause, especially Chlamydia . Less common causes are vaginitis (non-sexually transmitted), cervical ectropion, endometrial or cervical polyps, endometritis, adenomyosis, submucous myomas and sometimes cervical or endometrial cancers.
After a careful examination of the lower genital tract, the investigation of IMB should always exclude pregnancy and infection as a cause. Ensure that Pap smear screening is up to date, and if all these are negative then pelvic ultrasound may reveal an intrauterine cause.
Postcoital bleeding
Postcoital bleeding (PCB) is non-menstrual bleeding that occurs during or after sexual intercourse. The symptom is reported by around 6% of women per year. Causes of PCB include surface lesions of the genital tract, typically infection, cervical or endometrial polyps, cervical, endometrial or (rarely) vaginal cancer and trauma. PCB occurs in 1–39% of women with cervical cancer, and if there is a history of recurrent PCB, with or without IMB, colposcopy examination of the cervix is recommended even if the Pap smear is normal.
Postmenopausal bleeding
Vaginal bleeding that occurs more than 1 year after the last natural menstrual period is known as postmenopausal bleeding . Although it is not the commonest cause of this symptom, the possibility of carcinoma of the body of the uterus should be considered, and an assessment of the endometrium is advised for all women, whether with diagnostic hysteroscopy and endometrial biopsy or with a good quality transvaginal ultrasound measurement of the endometrial thickness and appearance. When the endometrium is measured at less than 3 mm, significant endometrial pathology is very unlikely.
Other causes of postmenopausal bleeding include other benign and malignant tumours of the genital tract, stimulation of the endometrium by exogenous (or endogenous) oestrogen (e.g. hormone replacment therapy (HRT) and oestrogens from ovarian tumours), infection and postmenopausal atrophic vaginitis.
Heavy menstrual bleeding
Heavy menstrual bleeding, defined in research studies as more than 80 mL per month of loss, affects approximately 10% of women. The recommended ‘clinical’ definition of HMB is ‘excessive menstrual loss leading to interference with the physical, emotional, social and material quality of life of a woman, and which occurs alone or in combination with other symptoms’. HMB should be recognized as having a major impact on woman’s quality of life. Although HMB is usually caused by benign conditions, it commonly leads to iron-deficiency anaemia, which can be part of the serious impact on woman’s social, family and working life (through the burden of managing the practical difficulties of excessive blood loss and having to curb normal activities). HMB can commonly arise from an imbalance in the clotting and other regulatory molecular factors at a local endometrial level, without the presence of obvious structural pathology. However, it can be associated with a number of benign gynaecological conditions including leiomyomata, endometrial polyps, adenomyosis, endometrial hyperplasia and sometimes endometrial cancer. The causes of HMB include most of the overall causes of AUB.
Causes
Structural
Leiomyomata (discussed below) are the commonest structural lesions to cause heavy regular bleeding, although most women with fibroids do not experience abnormal loss. Endometrial carcinoma is rare under the age of 40 years and is more likely initially to cause irregular bleeding. Adenomyosis is usually associated with a uniformly enlarged tender uterus, HMB and dysmenorrhoea. Endometrial polyps are a common cause of HMB, but usually also cause IMB. Endometrial hyperplasia is a common structural lesion causing HMB, and may be associated with irregular, anovulatory cycles. It may be a premalignant condition. It may overlap with the disturbed ovulation discussed in the next section.
Non structural
Disturbed ovulation or anovulation can result in very irregular, especially infrequent, cycles with prolonged, heavy and irregular bleeding of such severity that it may occasionally be life-threatening. In this situation, unopposed oestrogen often leads to the endometrium becoming greatly thickened and hyperplastic. This unstable endometrium eventually breaks down in a patchy and erratic fashion. Most ovulatory disorders occur in the menopause transition, in adolescence or can be traced to endocrinopathies, e.g. PCOS, hypothyroidism.
When there is regular heavy bleeding with no underlying structural lesion, HMB is usually the result of a primary endometrial disorder where the mechanisms regulating local endometrial ‘haemostasis’ are disturbed. There may be excessive local production of fibrinolytic factors (especially tissue plasminogen activator), deficiencies in local production of vasoconstrictors and increased local production of substances that promote vasodilation. The commonest iatrogenic cause of heavy bleeding is the presence of a copper-bearing intrauterine contraceptive device (IUD).
History and examination
An accurate history is essential to establish the pattern of bleeding and the duration of symptoms. Clinical estimation of the degree of blood loss is very subjective, although the presence of clots, the need to change sanitary protection at night and ‘flooding’ (the soiling of bedclothes or underwear during menstruation) are more likely to indicate significant bleeding. A recent change in the pattern of menstruation and associated pain are more likely to be associated with the development of structural pelvic pathology. Pain is typically associated with adenomyosis and chronic pelvic inflammatory disease. Endometriosis sometimes causes HMB (as well as pain). Structural surface lesions of the uterus and cervix more typically cause IMB and PCB. Endometrial malignancy is rare under the age of 40 years, but women with a history of diabetes, hypertension, PCOS and obesity are at increased risk of endometrial hyperplasia and carcinoma.
Women with heavy periods should have a general examination for signs of anaemia and thyroid disease and a pelvic examination including cervical smear, if indicated. The finding of a pelvic mass on pelvic examination is most likely to indicate the presence of uterine leiomyomata (fibroids) but may indicate a uterine malignancy, adenomyosis or ovarian tumour.
Investigations
A full blood count with platelets (and sometimes serum ferritin and serum transferrin receptor to assess iron status) is the only investigation needed before starting treatment, provided that clinical examination is normal. Patients should be referred for further investigation if:
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There is a history of repeated or persistent irregular or intermenstrual bleeding, or of risk factors for endometrial carcinoma.
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The cervical smear is abnormal.
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Pelvic examination is abnormal.
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There is significant pelvic pain unresponsive to simple analgesia.
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They do not respond to first-line treatment after 6 months.
Hysteroscopy allows visualization of the uterine cavity using a 3 mm endoscope introduced through the cervix. It can be performed under general anesthetic or as an outpatient investigation using local anesthesia. Hysteroscopy with endometrial biopsy has largely replaced the traditional and unreliable blind D&C. Transvaginal ultrasound is of value in distinguishing the structural lesions of the genital tract. In premenopausal women, ultrasound-measured endometrial thickness will vary at different times of the menstrual cycle, but it is usually possible to visualize structural lesions such as polyps in the endometrial cavity.
Management
Medical treatment
In the absence of malignancy, the treatment chosen will depend on whether contraception is required, whether irregularity of the cycle is a problem and the presence of contraindications to certain treatments. Where a copper IUD is in place, mefenamic or tranexamic acid can be used or the device may be replaced by a levonorgestrel intrauterine system (Mirena®).
Non-hormonal treatments
NSAIDs, such as mefenamic acid or ibuprofen, inhibit prostaglandin synthetase enzymes. They reduce blood loss by around 30% and their analgesic properties may be an advantage if there is associated dysmenorrhoea. The principal side effect is mild gastrointestinal irritation. Tranexamic acid is an antifibrinolytic agent that reduces blood loss by about 50%. It is safe and available over the counter without prescription in many countries. It does not cause venous thrombosis, but it is wise to avoid its use in patients with a previous history of thromboembolic disease. Both groups of drugs have the advantage of only needing to be taken during menstruation.
Hormonal treatments
Use of the combined oral contraceptive pill or the levonorgestrel intrauterine system is associated with around 30% and 90% reduction in average monthly blood loss, respectively ( Fig. 16.15 ). The levonorgestrel-releasing intrauterine system is widely recommended as the first choice for medical therapy of HMB in those women who do not have contraindications to its use. Synthetic oral progestogens, such as norethisterone or medroxyprogesterone acetate, can be given for 21 days out of 28 over prolonged periods to effectively control irregular, heavy bleeding, but do tend to be associated with a higher incidence of nuisance-value side effects. They can also be used in higher doses in an acute situation to control severe heavy menstrual bleeding (oral norethisterone 5 mg, or medroxyprogesterone acetate 10 mg, three times daily for 21 days). Danazol is a synthetic mild impeded androgen derivative that acts on the hypothalamic–pituitary axis and endometrium, and is uncommonly used nowadays. Given at high doses it will normally cause amenorrhoea but is associated with significant side effects in 10% of patients. The efficacy of various medical therapies in reducing HMB is documented in Figure 16.15 .
