Written by Dr Ryan Lee, Consultant obstetrician and Gynaecologist Specialist
Abnormal uterine bleeding (AUB) describes irregularities in the menstrual cycle involving frequency, regularity, duration, and volume of flow outside of pregnancy. The causes of heavy and irregular menstruation can be classified using the PALM-COEIN classification below.
Women who present with abnormal vaginal bleeding should be investigated with routine blood test to exclude iron deficiency anaemia and thyroid disturbances. Next, Pelvic ultrasound should be performed to exclude uterine abnormalities such as polyp, fibroids, adenomyosis, precancer ( hyperplasia) and cancer. Cervical cancer screening by PAP or HPV test should be performed if not previously done.
Those with menstrual abnormalities such as prolonged menses, heavy menses, intermenstrual bleeding , bleeding after sexual intercourse should see their gynaecologist early for appropriate investigations for further evaluation such as a dilation, curettage hysteroscopy.
Dilation and curettage is a procedure that first uses instruments to dilate the cervix, followed by a curette to obtain endometrium to be sent for biopsy.
Hysteroscopy is a minor surgical procedure to look inside the womb using a hysteroscope, an instrument with a small video camera attached to find out the cause of abnormal vaginal bleeding.
Hysteroscopy can be both diagnostic for diagnosis and therapeutic for treatment. This involves the use of further instruments to remove part of the endometrium (lining of the womb), polyps (small growths of the lining of the womb) , removal of fibroids for treatment and fertility.
Dilation curettage hysteroscopy is performed exclude malignancy in abnormal uterine bleeding and treatment of menstrual abnormalities.
Complications of this procedure include
• bleeding
• infection
• abandoned procedure with inability to gain entry into the uterine cavity, inadequate tissue for diagnosis
• damage to the cervix
• scarring of the uterine cavity (Ashermann’s syndrome)
• Uterine perforation through wall of the womb may occur in up to 5 in 1000 women. Most of the these heal by themselves. If this complication is suspected, a diagnostic laparoscopy may be performed in the same setting. Sometimes, a perforation is not obvious at the time of surgery and may present later. On rare occasions, surrounding organs like the bladder bowel and blood vessel may be injured and require further surgical repair such as laparotomy ( open surgery).
Potential complications may be higher in women with risk factors such as postmenopausal, obese, significant abnormality to the uterus such as abnormally shaped uterus, previous surgeries, or those with pre-existing medical conditions such as diabetes, heart disease.
Treatment
Treatment of AUB depends on the underlying cause. This includes lifestyle changes, medications and surgery.
Medication includes both hormonal (birth control pills, GnRH Injections) non-hormonal (tranexamic Acid, NSAIDs) which can reduce heavy and irregular menstruation. Iron therapy is indicated in patients with iron deficiency anaemia.
Mirena Intrauterine Device ( IUD) can be used for heavy and painful menses lasting 5 years
Surgery includes
-Hysteroscopic surgery to remove endometrial polyps or submucosal fibroids.
-Transcervical resection of endometrium to remove the menstruation lining.
-Myomectomy for removal of fibroids and hysterectomy to remove the womb,
