Learn about abnormal uterine bleeding in a few minutes

The uterus is a very important organ for women. The health of the uterus is related to a woman's fertility. If there is a problem with the uterus, it will bring great hidden dangers to the woman herself or the future development of the fetus. Abnormal uterine bleeding is a common gynecological phenomenon. Once this phenomenon occurs, menstruation is likely to be disordered, such as prolonged or reduced menstruation, irregular bleeding, anemia, etc. This has a serious impact on women. So, what is abnormal uterine bleeding? What factors can cause abnormal uterine bleeding in women? What should I do if abnormal uterine bleeding occurs? I hope that through today's explanation, I can help more people!

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1. What is normal menstruation? What is abnormal uterine bleeding (AUB)?

The normal menstrual cycle is 21-35 days, with an average of 28±7 days; <21 days, frequent menstruation. >35 days, infrequent menstruation. Normal menstruation <7 days, >7 days, prolonged menstruation. Cycle regularity: normal <7 days, irregular menstruation ≥7 days. Excessive menstruation: measured by the patient's subjective feeling, that is, the amount of menstruation is measured by the self-feeling of too much or too little, and the quality of life such as physical, social, emotional and daily life is affected, regardless of the presence of anemia, excessive menstruation can be diagnosed. Oligomenorrhea: If the menstruation feels significantly reduced and drip-like, it is oligomenorrhea.

Abnormal uterine bleeding: It is a common symptom and disease in gynecological clinics. It refers to abnormal bleeding from the uterine cavity that is inconsistent with any of the frequency, regularity, length of menstruation, and amount of menstrual bleeding of the normal menstrual cycle. It is limited to non-pregnant women of childbearing age, and bleeding related to pregnancy and puerperium must be excluded. It does not include bleeding before puberty and after menopause.

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1. Causes and treatment of abnormal uterine bleeding:

In the past, my country divided the causes of AUB into three categories: organic disease, functional disorder, and iatrogenic causes. FIGO divides the causes of AUB into two categories and nine types. The English acronyms are PALM-COEIN. "PALM" refers to the structural changes of the uterus itself, which can be diagnosed by imaging technology and (or) histopathological methods; while "COEIN" usually has no obvious structural changes of the uterus (except for AUB caused by other causes).

These diseases do not exist alone. Some patients may have several diseases coexisting at the same time, which together cause AUB. Let us learn more about them below.

1. Endometrial polyps (AUB-P)

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The prevalence of endometrial polyps is 7.68%-34.9%, which is the most common type of structural cause of abnormal uterine bleeding. It can be single or multiple, and of varying sizes. The cause is still unclear, and may be related to a variety of factors, such as genetic, biochemical and hormonal changes; it is more likely to occur in women who are perimenopausal, obese, hypertensive, or taking tamoxifen.

【Symptoms】Clinically, 67% of polyp patients mainly present with irregular vaginal bleeding (increased menstrual volume, prolonged menstrual period, intermenstrual bleeding, postmenopausal vaginal bleeding) and infertility. A small number of patients present with increased leucorrhea and bloody leucorrhea. About 33% of patients still have no obvious clinical symptoms.

[Treatment] For functional endometrial polyps with a diameter of less than 1 cm, if asymptomatic, the natural disappearance rate within 1 year is about 27%, and the malignant transformation rate is low, so they can be observed and followed up. For endometrial polyps with a diameter of more than 1 cm and symptoms, hysteroscopic endometrial polypectomy is recommended. The recurrence rate of endometrial polyps is high, and long-term management after polyp surgery is recommended. The use of combined oral contraceptives (COC) or levonorgestrel intrauterine sustained-release system LNG-IUC (Mirena ring) or progesterone (dydrogesterone tablets) can reduce the risk of recurrence; hysterectomy can be performed for those who do not have fertility requirements and have atypical hyperplasia or malignant transformation of polyps.

2. Adenomyosis (AUB-A)

Adenomyosis is the ectopic location of endometrial glands or stroma in the myometrium, accompanied by proliferation and hypertrophy of surrounding myometrial cells. Typical clinical manifestations are dysmenorrhea (15%~77.8%) or chronic pelvic pain.
[Symptoms] Menorrhagia is generally manifested as heavy bleeding for several consecutive menstrual cycles, generally exceeding 80ml. Nearly 30% of patients with adenomyosis have no obvious symptoms.

【Treatment】It depends on the patient's age, symptoms and whether they want to have children. It can be divided into drug treatment and surgical treatment. Drug treatment includes: oral progestin therapy, COC, levonorgestrel intrauterine sustained-release system LNG-IUC (Mirena ring), gonadotropin-releasing hormone and aromatase inhibitors. For patients who do not want to have children, endometrial ablation, high-intensity focused ultrasound ablation and radiofrequency ablation, uterine artery embolization or hysterectomy can also be performed.

3. Uterine leiomyoma (AUB-L)

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In the 2018 revision of the FIGO uterine fibroid subclassification system, uterine fibroids are divided into 9 types.

Uterine leiomyoma is the most common benign gynecological tumor. The prevalence is about 25%. In the 2018 revision of the FIGO uterine fibroid subclassification system, uterine fibroids are divided into 9 types. Adult women will develop different types of uterine fibroids in their lifetime. According to the location of growth, uterine leiomyoma can be divided into submucosal fibroids that affect the morphology of the uterine cavity and other fibroids. Among them, submucosal uterine fibroids are the most likely to cause abnormal uterine bleeding.

[Symptoms] Symptoms generally include increased menstrual flow and prolonged menstrual period. In severe cases, anemia, fatigue, palpitations and other symptoms may occur.

[Treatment] The treatment plan depends on age, symptoms, size, number, location of fibroids, and whether or not there is a desire to have children. There are mainly drug treatment and surgical treatment. For women with heavy menstruation and no desire to have children, COC, hemostatics, non-steroidal anti-inflammatory drugs, LNG-IUC and other drug treatments can be selected to relieve symptoms. Those who want to have children can be treated with CNRH-a and mifepristone for 3-6 months, and then natural pregnancy or assisted reproductive technology can be used after the fibroids shrink and bleeding symptoms improve. Surgical treatment is suitable for those with secondary anemia caused by heavy menstruation, those who are ineffective with drug treatment, or those who suspect that the fibroids have become malignant. Hysteroscopic transurethral resection of uterine myoma (TCRM) is considered to be the preferred mode of treatment for submucosal uterine fibroids.

4. Atypical endometrial hyperplasia and malignancy (AUB-M)

Atypical endometrial hyperplasia is a precancerous lesion, with a cancer rate of 8-29% in a follow-up of 13.4 years. It is common in patients with polycystic ovary syndrome (PCOS), obesity, and tamoxifen use, and occasionally in patients with ovulation but luteal insufficiency.

【Symptoms】Irregular uterine bleeding, which may occur alternately with infrequent menstruation. A few cases present with intermenstrual bleeding, and patients often have infertility.

[Diagnosis] For patients aged ＞45 years, with long-term irregular uterine bleeding, high-risk factors for endometrial cancer (such as hypertension, obesity, diabetes, family history of Lynch syndrome, etc.), B-ultrasound shows excessive endometrial thickening and uneven echo, and drug treatment is ineffective, diagnostic curettage and tissue are sent for pathological examination. If conditions permit, a fixed-point biopsy under direct hysteroscopy is performed. If Lynch syndrome is suspected, genetic testing and appropriate tumor screening can be performed.

[Treatment] The treatment of atypical endometrial hyperplasia requires different treatment plans according to the severity of endometrial lesions, the patient's age, and whether or not there is a desire to have children. Hysterectomy is recommended for patients aged >40 years who do not have a desire to have children. For young patients who want to have children, full-cycle continuous high-efficiency synthetic progesterone can be used to treat endometrial atrophy after comprehensive evaluation and full consultation. The diagnosis and treatment of endometrial malignancies should refer to relevant clinical guidelines.

5. Systemic coagulation-related diseases (AUB-C)

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Including aplastic anemia, various types of leukemia, abnormalities of various coagulation factors, thrombocytopenia caused by various reasons and other systemic coagulation mechanism abnormalities.

【Symptoms】Excessive menstruation, intermenstrual bleeding or prolonged menstruation. In severe cases, anemia and fever may occur.

【Treatment】In principle, hematology treatment measures should be the main focus, and gynecology should assist in controlling menstrual bleeding. Gynecology is the first choice for drug treatment, and the main measure is large-dose high-efficiency synthetic progesterone to treat endometrial atrophy. If drug treatment fails, surgical treatment can be considered after the hematology department controls the disease and improves the overall condition.

6. Ovulatory dysfunction (AUB-O)

Ovulatory disorders include rare ovulation, anovulation, and corpus luteum insufficiency, which are mainly caused by abnormal hypothalamic-pituitary-ovarian axis function. They are common in adolescence and menopausal transition, and can also be caused by polycystic ovary syndrome, obesity, hyperprolactinemia, thyroid disease, etc. during the reproductive period.
[Symptoms] Irregular menstruation is common, with abnormal menstrual volume, period length, cycle frequency, and regularity, sometimes causing heavy bleeding and severe anemia.

[Treatment] The principle is to stop bleeding and correct anemia during the bleeding period. After the bleeding stops, the cycle should be adjusted to prevent endometrial hyperplasia and recurrence of AUB. Ovulation induction treatment should be performed for those who want to have children.

7. Localized abnormalities of the endometrium (AUB-E)

When AUB occurs in a regular cycle with ovulation, especially when no other explanation is found after investigation, it may be caused by local abnormalities in the endometrium. Common causes include endometrial inflammation, abnormal inflammatory response to infection, and abnormal endometrial vascular growth. Hysteroscopy, pathological examination, and immunohistochemical CD138 testing can be performed to improve the diagnostic accuracy of endometritis.

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【Symptoms】Excessive menstrual bleeding, intermenstrual bleeding or prolonged menstrual period.

【Treatment】Broad-spectrum antibiotics are commonly used in clinical practice, such as doxycycline 0.2g/d. For Gram-negative bacteria, ofloxacin 0.5g/d or ciprofloxacin are commonly used for anti-inflammatory treatment; amoxicillin clavulanate 2g/d is commonly used for Gram-positive bacteria. If combined with anaerobic bacteria, metronidazole or tinidazole 0.5g/d can be combined. The treatment duration is 7-10 days. If necessary, probiotics can be used in combination. For such non-organic diseases causing menorrhagia, drug treatment is recommended first. The recommended drug treatments include tranexamic acid antifibrinolytic therapy or nonsteroidal anti-inflammatory drugs (NSAIDs); short-acting oral contraceptives; progesterone. For those who do not want to have children, conservative surgery, such as endometrial resection, can be considered.
8. Iatrogenic AUB (AUB-I)

Medical interventions such as hormone therapy or intrauterine devices can also cause it. If the amount is small, you can continue to take it for observation, and if necessary, you can add a small dose of estrogen. If the amount is large, stop taking it and treat it as this menstruation. The prolonged menstruation caused by the placement of an intrauterine device may be related to excessive local prostaglandin production or hyperfibrinolysis, and antifibrinolytic drugs are the first choice for treatment.

9. Unclassified AUB (AUB-N)

Individual patients with AUB may be associated with other rare factors, such as arteriovenous malformations, uterine scar defects after cesarean section, uterine myometrial hypertrophy, etc. It may also be impossible to determine which of the above 8 types the cause belongs to. These factors are classified as "unclassified (AUB-N)

(1) The causes of AUB due to arteriovenous malformations can be congenital or acquired (uterine trauma, such as after cesarean section).

[Symptoms] Sudden heavy uterine bleeding. It can be confirmed by transvaginal Doppler ultrasound examination, uterine angiography examination, and other auxiliary diagnostic methods include pelvic CT or MRI examination.

【Treatment】For those who want to have children and have a small amount of bleeding, COC or expectant management can be used; for those with severe bleeding, selective uterine artery embolization can be used. For those who do not want to have children, hysterectomy can be used.

(2) Post-cesarean scar defect, also known as post-cesarean scar diverticulum (CSD), is a defect in the healing of the uterine incision secondary to cesarean section due to various reasons. The high-risk factors for AUB caused by post-cesarean scar defect include improper cesarean incision position, cesarean section before lower uterine segment formation, and other reasons.

[Symptoms] Heavy bleeding after normal menstruation.

[Treatment] COCs are used for those who do not desire to have children; if drug treatment is ineffective, hysteroscopic surgery can be considered. Surgical treatment includes hysteroscopy, hysteroscopy and laparoscopy, laparotomy or vaginal excision and repair of the uterine incision diverticulum and surrounding scars, or folding and reinforcing suture of the uterine scar.

3. What should you do when abnormal uterine bleeding occurs?

When we have abnormal uterine bleeding, we need to go to the hospital specialist clinic for treatment. What kind of examinations can be done? At present, we can do gynecological examination; blood routine and coagulation function; leucorrhea routine; cervical cancer screening; B-ultrasound; six sex hormones, thyroid function, liver function, kidney function; hysteroscopy, biopsy.

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Conclusion:

In summary, abnormal uterine bleeding is a symptom that can be caused by a variety of diseases. Therefore, when you find yourself experiencing this symptom, you must go to the hospital for examination in time to avoid other diseases or worsening of the condition. Only in this way can women's physical and mental health be guaranteed.

Reference: Gynecological Endocrinology Group, Obstetrics and Gynecology Branch, Chinese Medical Association, Diagnosis and Treatment of Abnormal Uterine Bleeding (2022 Update) (J). Chinese Journal of Obstetrics and Gynecology. 2022, 57, (07): 481-490