Abnormal Uterine Bleeding (AUB)

In general, normal menstrual cycles happen once in 21- 40 days and periods can last for 3 - 8 days. If there is any variation from the normal menstrual cycle, then it is known as Abnormal Uterine Bleeding (AUB).

Before we understand the causes, it’s important to understand the hormone that is responsible for causing Abnormal Uterine Bleeding.

 

Generally, the menstrual cycle is divided into two phases, the first phase is the Follicular / Proliferative phase which happens immediately after menstruation is dependent on a hormone called oestradiol and this phase is for about two weeks, following which the ovulation happens (release of the egg from the ovary). After, ovulation happens another hormone called progesterone is activated and this phase is known as the Luteal / Secretory phase and again this is for about two weeks. If conceptions don’t happen then the progesterone levels fall and menstruation occurs.

When a hormonal imbalance occurs or there is growth in the uterus then abnormal uterine bleeding can occur.

When is bleeding considered abnormal?

Bleeding is considered abnormal uterine bleeding in conditions such as 

  • Bleeding or spotting in-between normal monthly periods

  • Bleeding or spotting after sexual intercourse

  • Heavy bleeding during your period (more than 7 days or passing clots

  • If menstrual cycles happen that are longer than 40 days or shorter than 21 days

  • Bleeding after menopause (after monthly periods have stopped for a year)

What are the causes?

Abnormal uterine bleeding can occur at any age after menarche (maturity / first time menstruation starts). However, at certain times in a woman’s life, it is more common for periods to be somewhat irregular. Menstruation may not occur regularly when a girl first starts having them (around age 9 to 14 years). Again, during perimenopause (beginning in the mid-40s), the number of days between monthly periods can change. 

Causes for abnormal vaginal bleeding can vary 

  1. In young girls: Bleeding before maturity (menarche – first periods) can happen and this could be due to trauma to private parts, foreign body in the vagina (such as small stone, toy, etc), bubble bath can cause local irritation and bleed, remember in young girls bleeding can also happen if there has been sexual abuse.

  2. In adolescents: most young women can have AUB for a couple of months or years after maturity. This is mainly due to hormonal issues and generally, they resolve without any treatment.

  3. In reproductive women, AUB can be due to pregnancy, vaginal/cervical infections, fibroid uterus (non-cancerous tumor of the womb), adenomyosis (inner lining of the womb is found in the muscle layer), endometrial polyp (small non-cancerous fleshy growth in the womb) and in PCOS (polycystic ovaries, wherein eggs are not released from the ovary).

  4. Sometimes AUB can be a symptom of bleeding disorders (where blood doesn’t clot normally)

  5. AUB can also be seen in certain types of cancer, such as cancer of the womb and the neck of the womb (cervix).

What are the symptoms?

  • If your menstrual cycles are shorter than 21 days or longer than 40 days

  • Bleeding or spotting in-between your normal periods

  • Heavy bleeding during periods (lasting more than 8 days or passing huge blood clots or need to wake up in the night to change the pad)

  • Bleeding after sexual intercourse

  • Bleeding after menopause.

What test will be required for diagnosis?

After your doctor notes down your symptoms, your doctor will your tummy to note for any lumps and if you are sexually active then the internal examination will be done. Based on the findings you maybe advise for any of the following tests.

1. Ultrasound examination: to check any abnormalities within your womb. Of the two methods of ultrasound transabdominal (TAS) &  transvaginal (TVS), TVS would be preferred in sexually active women as this gives accurate results since the ultrasound probe is close to the pelvic organs. As the name suggests "transvaginal" the ultrasound probe is placed in the vagina while performing an ultrasound. 

2. MRI / CT scan: may be required sometimes, MRI is preferable in young patients.

3. Sometimes you may be advised to have a biopsy of the inner lining of the womb (endometrium), this can be done in OPD / out-patient clinic and doesn’t require admission nor anesthesia.

4. Hysteroscopy: You may also require hysteroscopy; this is a procedure wherein a thin telescope will be passed into your womb to look for any abnormalities. This procedure is usually done under anesthesia. 

What are the treatment options?

Medical management: In the management of AUB, medications are often the first choice.

1.  Oral contraceptive pills (OCP) / birth control pills: these pills will help in making your periods more regular.

2.  Gonadotropin-releasing hormone agonists (GnRH): these medications are sometimes prescribed to reduce the menstrual cycle and this medication may be given to shrink your fibroids.

3.  You may be advised to take tranexamic acid on a monthly basis to decrease your flow of menstruation.

4.  Sometimes you may be given anti-inflammatory drugs which will control heavy bleeding.

5.  If you have any infection then you may be advised to take antibiotics.

Surgical management: if medical management doesn’t help in reducing bleeding surgery may be advised to treat the condition causing AUB.

  • Endometrial ablation:  this is a method wherein a device is inserted into the uterus and the energy device destroys the lining of the uterus. After this procedure, the amount of bleeding is reduced or can stop completely. Pregnancy is unlikely to happen after ablation since the lining of the uterus is destroyed and hence the embryo cannot implant, but rarely it can happen. If pregnancy does happen, the risk of serious complications is greatly increased. If you opt for this procedure, you will need to use birth control until after menopause. 

  • Uterine artery embolization: this is a procedure used to treat fibroids. In this procedure, the main blood vessel to the uterus is identified and is blocked, which in turn stops the blood flow to the fibroid and thus the fibroid shrinks due to lack of blood supply. Similarly, the uterine artery is the main blood vessel to the uterus and there are two (right & left) branches. In case of abnormal uterine bleeding both the branches can be blocked so that bleeding during menstruation decreases. There are conflicting side-effects and pregnancy outcome following this procedure, to know more about this procedure talk to your doctor. 

  • Hysterectomy: this is the last step in surgical management and that is the surgical removal of the uterus, which is used to treat some conditions or when other treatments have failed. Some doctors would advise you to have the fallopian tubes removed at the same time and the ovaries can be retained depending on your age. As the uterus is removed, a woman can no longer get pregnant and will no longer have periods.

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