ABNORMAL VAGINAL BLEEDING IN REPRODUCTIVE YEARS

FROM MENARCHE TO MENOPAUSE.

Generally we discuss the causes of vaginal bleeding, including the local vaginal, cervical and even urethral bleeding including bleeding from the uterus. I have decided to divide this in two sections. In the first section I will discuss the causes of local bleeding, that is bleeding from the vagina, cervix and rarely from the urethra. These disease processes like anywhere else can be divided, into, infections, trauma, foreign body and pre-cancer and cancer. These have been briefly discussed in the post on vaginal bleeding in adolescence. These never cause profuse vaginal bleeding. It is usually a blood stained often smelly discharge. Candidiasis a very common infection in women almost never causes significant bleeding. Trauma after sexual interference or otherwise can cause moderate bleeding. I always remember a young bride brought to our hospital from the railway station having had sex in the train on her honeymoon journey, which bled so profusely that she required a blood transfusion. Similarly trauma can cause moderate to profuse bleeding. I have witnessed these after severe motor car accidents. Foreign bodies also usually cause blood stained smelly discharge, a left over tampon is a common example, and I have removed 100’s of these in my working life. Vaginal and vulval carcinomas are usually a disease of older post menopausal women. Cervical cancer and precancerous lesions of the cervix are common in this age group often precancerous lesions of the cervix are silent.

In the past fifty years a lot of attention was paid by doing cervical smears. Since we have vaccines for the human papilloma virus, which is the causative virus for cervical cancer, things have improved.  Cervical cancer is still very prevalent in developing countries as most of them have no access to the vaccine and even no facility for cervical cytology. In India some gynaecologists have started to do a simple vinegar test which is giving good results to detect pre-cancer of the cervix. Cervical cancer always causes vaginal bleeding, again often it is a blood stained smelly discharge. It is often very distressing to tell a woman that you have advanced cancer when she only has a blood stained discharge. Besides these, vaginal bleeding can also come from the bladder opening, the urethra or bladder infection or from the rectum, it may just be due to haemorrhoids or even rectal cancer. When you experience vaginal bleeding never forget to ask about bladder infections or rectal bleeding.

Let me now discuss the real causes of abnormal uterine bleeding. (AUB) I have briefly explained the menstrual cycle in my previous posts.  Some woman often have moderate to severe bleeding with their periods along with some pain. Until very recently there was no clear understanding of these problems. One woman can have more than one, two or even three   problems. These lead to chronic ill health and infertility, loss of work and income. Until recently there was no universal nomenclature or classification system for the gynaecological problems.  It made life difficult for the clinicians, patients and research scientist. Luckily in 2010-2011, AUB had been classified by a great Acronym,Palm-coein (prounounced  pahm_koin) which has been approved by the International Federation of Gynaecology and Obstetrics(FIGO).This was published in 2011 by Elsevier Ireland Ltd. I read this in the international journal of Gynaecology and Obstetrics (Volume 113, 2011). I was so elated by finding this classification and all the explanations.

POLYP (P)

In this classification P stands for polyp. They can be of many types, cervical, Endocervical (arising in the cervical canal) endometrial and rarely placental (left over placental tissue after a delivery). They arise from the thickening of the local lining; have some vessels, fibrous and muscular tissue. These polyps often produce no symptoms but generally cause intermittent blood stained discharge. They also have some pain as the uterus contracts trying to get rid of them. The diagnosis is made by good quality ultrasound or by a procedure called saline sonography in which we take an ultrasound after putting some saline in the uterine cavity.

They should be surgically removed and tested by pathology they are almost always benign and harmless but a minority may have a malignant potential.

 ADINOMYOSIS (A)

The word a stands for a condition called Adenomyosis. I wonder why Endometriosis is not included in this group, as this is often a cause of abnormal uterine bleeding which is often painful. Adenomyosis, in a way is endometriosis of the uterus. Endometriosis means that the uterine lining is present outside the uterine cavity affecting the ovaries, tubes, and surrounding area. In Adenomyosis this lining is present within the muscles of the uterus causing abnormal painful bleeding. This diagnosis can be made by ultrasound and an MRI. It is included in AUB classification, but there are several different pathology descriptions from the uterus. Until then the authors of PALM-COEIN agree that Adenomyosis should be included in the classification of AUB, if the diagnosis is confirmed at least by ultrasound, until further classification is done for Adenomyosis.

LEIOMYOMA (L)

The word L in this classification stands for leiomyoma, commonly called Fibroids. This is the most common cause of AUB. Almost 60 to 70 %women in the world get these in their life time. They are not always symptomatic.  They can vary in size from an apple to a very large watermelon. I have removed two fibroids size of watermelon. The symptoms depend where they are located. One of these women did not have any problems except for a large mass.

They are further classified depending where they are located. Intramural means within the uterine muscles, subserous means outside the muscles, and submucous involving the endometrial cavity. These are the most significant as they cause AUB, infertility, post coital bleeding and miscarriages.

A woman can have many fibroids; once upon a time I have removed as many as 25 fibroids from one woman.

She was young and keen to have a baby .She did succeed in having a baby.

ENDOMETRIAL HYPERPLASIAAND MALIGNANCY (AUB-M)

The other cause of AUB is abnormal endometrial proliferation called atypical hyperplasia and endometrial malignancy.  Although uncommon it cannot be ignored. It does happen in reproductive age groups, and is most common in 50 and 60 year olds. It is sub classified, using WHO previous FIGO system. This often happens if the hormone system is imbalanced and oestrogen is predominant as it can happen when menstrual cycles are anovulatory(meaning that they are not making an egg)as happens in polycystic ovarian syndrome, premenopausal years when the ovarian activity goes abnormal, hormones as treatment  with oestrogens only as some times in HRT. This can also happen if women are obese with a body mass index more then 35.  Many reactions in our body happen due to obesity, such as diabetes high blood pressure, enzymes from the fatty tissues, hormone binding and insulin binding chemicals (Called globulins) result in free floating hormones with a predominance of oestrogen activity resulting in endometrial hyperplasia. This in the end is the main cause of endometrial cancer; most recently WHO has classified Endometrial Hyperplasia, in two groups; one with no atypical cells; the other with atypical cells. This has made life very simple. Ones with no atypical cells hardly ever develop endometrial cancer (may be 1-3%) where ones with atypical cells have a risk of almost 50 percent and need urgent and major treatment. I will discuss this in the next post

COAGULOPATHIES (AUB-C)

Coagulopathies includes disorders of blood coagulations. These are inherited or caused by infections or drugs. Most bleeding disorders most often present in adolescence, they also have tell tale signs such as bleeding from the nose, and easy bruising. The most common inherited, bleeding disorder in women is vonWillebrands disease, (they are deficient in 2 clotting factors) about 1% women suffer from this in the general population but all of them do not get heavy AUB. Deficiency of other clotting factors is very rare. The most common acquired bleeding disorders are platelet (these are the most essential part of blood coagulation) disorder, and leukaemia. The most common problems are decreased levels of platelets. Along with others, I am of the opinion that if bleeding disorders are suspected, it is worthwhile to have an input from a haematologist. Severe liver disease can also cause bleeding problems due to clotting factor deficiency.

OVULATORY DYSFUNCTION DISORDERS (AUB-O)

Until recently when abnormal uterine bleeding occurred, In absence of any detectable uterine pathology it was called dysfunctional uterine bleeding(DUB), which the FIGO are now trying to discard in preference to their new classification of AUB. Ovulatory disorders encompass a wide range of disorders ranging from no periods, to scanty periods, irregular bleeding, and unscheduled bleeding, to very heavy profuse bleeding requiring urgent medical or surgical treatment. This happens due to failure of ovulation, there is no progesterone, for a normal menstrual cycle. This often happens in adolescence, and at the time of menopause transition, or abnormal endocrine activity such as PCOS, Hypothyroidism, increased Prolactin levels. Besides these, mental stress, eating disorders, anorexia, excessive exercise (these usually cause no periods), and obesity.
ENDOMERTIAL (AUB-E)

Under normal menstrual cycle menstruation is a very regulated process .under the hormonal control of the menstrual cycle, the bleeding starts when the progesterone

is withdrawn The bleeding process starts, with, this the platelets gather and a plug  is formed , soon after fibrin deposition happens his closes the bleeding blood vessel. Along with this fibrinolysis occurs to keep the blood fluid. Complex reactions take place within the  endometrium with the help of substances called prostaglandins E  and F alpha. Many other hormone and chemicals interact with each other to keep the bleeding under control.  They are vasoconstrictors, and

Coagulants, some are vasodilators and anticoagulants. Tissue factors within the endometrium and coagulation factors keep the endometrial bleeding under control, imbalance between these is probably often the cause of HMB. Recent research has led to a thinking that haemostatic agents such as Tranexamic acid and Desmopressin(Synthetic drug) can help with HMB even in situations of Coagulation disorders. In spite of this knowledge we do not have any tests to measure endometrial dysfunction. This diagnosis is made by exclusion of other local pathologies.

There is no direct relationship between Pelvic inflammatory disease and AUB. It is suspected that 1 in 4 women with Pelvic inflammatory disease may get intermenstrual bleeding or prolonged bleeding. This may also occur if there is deficiency

In endometrial healing .This relationship is often suspected when an endometrial picture showing inflammatory cells particularly a silent infection with Chlamydia (A common sexually transmitted infection). Sometimes abnormal bleeding is also seen in early cases of pelvic tuberculosis. The bleeding (HMB) due to endometrial problems should be classified by exclusion of other causes such as ovulation.

This in the opinion of researchers, needs further evaluation

IATROGENIC (AUB-I)

By iatrogenic causes of AUB we mean drugs, and treatments that cause AUB. These are mainly hormone Drugs we use to regulate the menstrual cycle or for contraception if forgotten or lost due to gastrointestinal causes. This can cause what we call break through bleeding (BTB). Smoking also causes BTB because of enhanced hepatic function .Other causes of reduced oestrogens and progesterone are drugs such as antiepileptic, antibiotics and drugs used for mental disorders. Progesterone only contraceptives such as depo-provera

And implanon( the rod we put in the arm) also causes AUB more so in the smokers. The uterine loop, the intrauterine systems used for contraception (Mirena containing levonorgestrel) also causes AUB, particularly in the first 6 months after insertion. Other very important cause for AUB is women on anticoagulants for medical treatment.  There is very simple explanation that they fail to make adequate clotting.

One recent cause for iatrogenic AUB is called uterine isthmocele secondary to caesarean section. Dehiscence of the uterine scar creates a pouch like reservoir where the blood collects during menstruation, these women present with previous caesarean sections followed by post menstrual AUB and pain.  This is repaired by hysteroscopy or laparoscopy. The other important cause of iatrogenic AUB is the drug, used for breast cancer Tamoxifan. They cause endometrial polyps and proliferation and even cancer thus causing AUB.

ENTITIES NOT YET IDENTIFIED (AUB-N)

These include condition such as endometritis, arteriovenous malformations, hypertrophy of myometrium and the role of endometrium in haemostasis. These need to be further worked, biochemically or biologically before they can be classified.

In my next post I will discuss the management and treatment of Abnormal Uterine Bleeding