INVESTIGATIONS AND MANAGEMENT OF ABNORMAL UTERINE BLEEDING

According to some literature references 30 to 60% of women in their life time see a doctor for abnormal uterine bleeding (AUB). The bleeding during pregnancy is not included in this, there are special reasons why bleeding happens during pregnancy. Before we start investigating for AUB, we always start with a pregnancy test and make sure the woman in question is not pregnant; the bleeding is not acute and severe. We must ask specific questions about her menarche, periods  duration ,regularity ,how long does her normal period lasts , how many days does she bleed and how much. When did this abnormal bleeding start, has this been happening since the start of her periods. Does she have any bleeding problems such as bleeding from the nose, bruises at the dentist or any other time such as at delivery of her baby? Is there anybody in her family who suffers from bleeding problems? Does she have any medical problems or is she taking any drugs. As we go to the tests and management of these women we will find that these questions play an important role.  As mentioned in my previous posts the menstrual cycle usually starts around 12 – 14 years of age, it happens 28-31 days interval, lasts for 5-6 days and average blood loss is about 80 milliliters. Any bleeding that happens, in between period or at any odd time, lasts for longer than 7 days, heavier than usual, you are passing blood clots or happens after sexual intercourse is AUB.

Next thing we must do is to get these women’s, age, weight and blood pressure. If they have been bleeding too much they look pale, have low blood pressure, and a fast pulse, and often need urgent management. Very obese women are more likely to suffer special disorders such as, diabetes, lower thyroid activity, this can also cause AUB. The other hormone problem in obese women is a condition called polycystic ovarian syndrome (POCS).This can cause both absent periods and AUB. Besides this obese women and women with PCOS are both more prone to uterine cancer.

On further investigations we do a clinical abdominal and vaginal examination. We make sure that the spleen is not enlarged, as in some bleeding conditions, the spleen is enlarged. In the lower abdomen any lumps indicate structural diseases such as uterine fibroids, ovarian cysts. We have already excluded a pregnancy by doing a pregnancy test. Vaginal examination further confirms these abdominal findings. It may show any pathology on the cervix such as a polyp or cervical cancer. Any vaginal pathology can also be observed at the same time. This will help us to know that the bleeding is coming from the uterus. If there is no bleeding we can also do a cervical smear. At this stage a rectal examination can also be useful making sure that the bleeding is not from there.

Sometimes the bleeding can come from the bladder, and we also note that there is no trauma by injury or sexual interference.

Let us now go to the blood tests. First group of blood tests are done to make sure that a woman is healthy.

We do a full blood examination; haemoglobin is a part of it, iron studies for her iron levels. Bleeding and clotting profile is also studied,Theses includes  Prothrombintime, international normalized ratio (INR), Activated thromboplastin time particularly platelet count. If these tests are not normal, then further tests can be ordered for vonWillebrands disease. In von Willebrands disease there is excessive bleeding due to clotting factor disorders.(vonWillebrands disease is genetic )

In this case the woman may tell you that she has been having heavier bleeding since the start of her period as compared to her friends. These tests are vonWillebrands factor antigen, ristocetin cofactor activity, factor VIII, vonWillebrands, factor multimers. All these tests indicate what type of von Willebrands disease you have and how to treat you. Thrombocytopenia (Low platelet count) can also cause severe bleeding problems. Normal platelets in our blood are 150,000 to 450,000 per microlitre of circulating blood. The platelets live only for 10 days; new platelets are made regularly in the bone marrow. The spleen deals with dead platelets. A platelet count of less than 10, 000 can cause severe bleeding. I have encountered one German holiday maker with very profuse bleeding whose platelet count was 6,000. We gave her a platelet transfusion and tranexamic acid. Her bleeding was well controlled. We had to find out why she had severe thrombocytopenia. Thrombocytopenia can be inherited, immune disorders such as in lupus and rheumatoid arthritis, leukaemia, septicaemia (blood infection), severe kidney disease, drugs such as some antibiotics and simple drugs as aspirin. There is transient thrombocytopenia in pregnancy; this is a natural protection against the increased risk of thrombosis during pregnancy.

Other tests are endocrine tests. The most important is plasma progesterone. This will tell us if the menstrual cycle is ovulatory, if the test indicates the presence of plasma progesterone. This test should be done on day 21 to 23 of a regular 28 days menstrual cycle. The other important tests are thyroid function test as thyroid disorders can often cause AUB, and often thyroid problem can be silent. Prolactin is also important as this can also cause AUB. Other hormone tests are androgens to exclude PCOS (Polycystic ovarian syndrome). Diabetes should be excluded as it has a high risk for endometrial cancer, which causes AUB.

There are many drugs that can cause bleeding problems, these include Aspirin, Anticoagulants, Antidepressants, hormones used for HRT or contraception such as MPA and Implanon (little rod inserted in your arm for contraception).Phenothiazines, cortocosteriods,Thyroxin can also cause AUB. Besides these some herbs can also cause abnormal bleeding such as ginseng and ginkgo biloba and soya products. I had the first hand experience of this while doing a caesarean section. For some unknown reason this woman kept bleeding and later on she told me she was on ginseng.

An ESR and CRP can also be done to look for any infection.  Pelvic infections are not usually the cause of AUB but in some situations this can happen, such as early tuberculosis and Chlamydia. We also look for many medical disorders such as leukaemia, Celiac disease, severe liver and kidney disease breast cancer, if the woman is on, Tamoxifan (Drug used for prophylaxis in breast cancer). Tamoxifan can cause endometrial polyps and endometrial cancer (Endometrium is the lining of the uterus) the next series of tests we do are for structural abnormalities. These are also used for treating these problems. Ultrasound is the most important of these. An Abdominal Ultrasound is only done if we can feel a lump from the outside or the uterus is enlarged, otherwise a vaginal ultrasound is performed in women who have been sexually active. This gives a lot more information. This is done by a vaginal probe which is moved around in the vagina, we can see the lining of the uterus, measure its thickness see if there are any polyps, fibroids or uterine adhesions. Next thing we can do is called a saline sonography. 10 mls of saline solution is instilled in the uterine cavity and pictures taken by transvaginal ultrasound.  This shows the details of the uterine cavity.

An endometrial biopsy can be done by a very fine instrument called a Pipelle. This gives us a good idea about any endometrial pathology and also can give us idea about hormone status of the endometrium or if it is thickened. This is done in the clinician’s office without anaesthesia. The woman may have a watery discharge and transient period like pain. 

The final test that is useful is an MRI. This may not be available in all the centres, however if available it is very useful to give us detailed information about how many fibroids there are and where they are located in relation to the uterus. This is useful in planning the treatment. When we are dealing with these cases of AUB it is a good idea to involve a Haematologist if there is bleeding disorders, a Physician if they have medical disorders, and if cancer is found it is a good idea to involve or refer to a gynaecological cancer surgeon.