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Abnormal Uterine Bleeding: When Should I Be Seen?

Bleeding outside your regular #menses is typically not normal, although this doesn't always make it overly concerning. More than ten million women in the United States are experiencing these same symptoms. Over two million women are seen each year for these complaints and it is the most common cause of emergency admissions for gynecologic issues. The real issue: it is commonly mismanaged!

There are a number of reasons this may happen which I'll discuss, but in general, if you see bleeding outside of your menses - pay attention, take note, keep reading, but potentially I'll want ya to give me a call, especially if you are menopausal.

While not always super concerning, abnormal uterine bleeding can cause anxiety and really disrupt a woman's quality of life. Women may have fear or embarrassment, not knowing when their bleeding may occur, spontaneous spotting in their panties, less sexual #intimacy and intercourse due to unanticipated bleeding.

Normal Menstrual Cycles

While cycles can vary greatly among women, and even cycle to cycle, typically women have some level of consistency. Cycle length is often 21 to 35 days, and the length of a woman's cycle is generally seven days or less. The average blood lost is about 35 mL, ranging from 20 to 60 mL.

When Things are Abnormal

Abnormal uterine bleeding might be brief or could be chronic. We use to call this abnormal uterine bleeding, which is no longer a current term, and practitioners use to refer to metrorrhagia (intermenstrual bleeding) and menorrhagia (heavy menstrual bleeding), but now the recommended terms are heavy menstrual bleeding (defined as excessive, >80 mL, or prolonged, > 7 day, or per patient perception), polymenorrhea (intervals less than 21 days) or oligomenorrhea (intervals greater than 35 days). Amenorrhea refers to no bleeding for at least three months and intermenstrual bleeding is variable amounts occurring between regular menstrual periods, but these causes and treatments will be discussed in another blog.

Abnormal uterine bleeding would be outside the regular timing and volume or duration than your typical #menses and is unrelated to pregnancy. If abundant, certainly the concern is hemorrhage, so seek care immediately. If stable however, but abnormal bleeding is present, your clinician will want to get a thorough history. This will guide the labs your clinician will recommend and any radiologic testing.

Up to 13 percent of women with heavy bleeding have some variant of von Willebrand disease and up to 20 percent of have an underlying coagulation disorder. Hemophilia should be ruled out, and platelet function and coagulation factors should be evaluated. Systemic diseases that may cause abnormal uterine bleeding, which would be exceedingly rare but should not be overlooked, are leukemia, liver disease, and medications such as anticoagulants or chemotherapy. More often abnormal uterine bleeding is related to polyps, #fibroids, varicosities, various infections, endometrial causes such as hyperplasia, or ovulatory dysfunction, but malignancy is also a potential factor.

A physical will also be offered, most likely with a pelvic exam including a speculum exam and bimanual. Trauma could be present externally, or to the vagina or cervix, which is part of this assessment. Your clinician will assess for enlargement of the uterus or abnormal findings on the cervix which might result in bleeding and be related to a structural issue, such as a leiomyoma.

Laboratory testing is likely to be recommended starting with a complete blood count, pregnancy test, partial thromboplastin time, prothrombin time, activated partial thromboplastin time, fibrinogen, and if testing for von Willebrand disease, the antigen would need evaluated, as well as Ristocetin cofactor assay and Factor VIII. I can't even count the number of times abnormal bleeding has been ignored by clinicians only to result in repeated miscarriage, infertility, or postpartum hemorrhage which could have been prevented or minimized. There is also potential that clients may be in an unexpected circumstance - car accident or surgery - and they may experience significant bleeding due to an undiagnosed bleeding disorder; these seemingly nuance signs from your body are sometimes very significant.

Other labs that I might consider include the thyroid stimulating hormone, iron, total iron binding, ferritin, liver function tests, and Chlamydia trachomatis. Labs for sepsis or leukemia may also be appropriate. Endometrial tissue sampling should be performed in clients with abnormal uterine bleeding who are older than 45 years as a first-line test. This should also be considered in women younger than 45 years if they have a history of unopposed estrogen exposure such as those with polycystic ovary syndrome (#PCOS). A pelvic ultrasound may also be recommended.

Treatment Options

Certainly this will depend on the underlying concerns and the evidence is fairly limited in how to approach addressing abnormal uterine bleeding. Certainly the priority is stabilizing the bleeding and identifying the impact, such as whether this has resulted in anemia. Otherwise, conventional medicine will recommend hormonal management as a first line treatment. Depending on the severity of the bleeding, conjugated equine estrogen may be recommended intravenously. Oral contraceptives may also be utilized or oral progestins. In one randomized controlled trial of 34 women, IV conjugated equine estrogen 25 mg (every 4-6 hours for 24 hours) was shown to stop bleeding in 72 percent of participants within 8 hours of administration compared with 38 percent of participants treated with placebo but this is only approved by the FDA for a single treatment (DeVore, Owens, & Kase, 1982). These clients should be transitioned to oral contraceptives.

The combined oral contraceptive pills (35 micrograms of ethinyl estradiol) and also the oral progesterone pills may be recommended as frequently as three times daily for the first seven days or medroxyprogesterone acetate 20 mg orally. Bleeding stops in approximately 88 percent of those who utilize the combined hormone pills (birth control pills) and 76 percent of those who utilized the medroxyprogesterone acetate within about three days. Intrauterine devices (#IUD) are yet another option, which are quite popular. Consider contraindications of course.

When the abnormal uterine bleeding is more chronic, conventional providers or even functional medicine providers who need a more immediate response as they work to correct the underlying foundation, may offer antifibrinolytic drugs such as tranexamic acid 1.3 grams orally, three times per day for 5 days. This works by preventing fibrin degradation and are effective. They reduce #bleeding by about 30 to 55 percent.

Bleeding that is more chronic and suspected to be related to an underlying bleeding disorder may respond to those therapies mentioned above, but a referral to a hematologist is still recommended. Desmopressin may help treat acute abnormal uterine bleeding in those with von Willebrand disease, administered intranasally or subcutaneously. There is risk of fluid retention and hyponatremia. Recombinant factor VIII and von Willebrand factor are also available and may be required to control severe hemorrhage. Other factor deficiencies may require factor-specific replacement.

When bleeding disorders are identified, nonsteroidal antiinflammatory drugs should be avoided because of their effect on platelet aggregation and their interaction with drugs that may impact liver function and its production of clotting factors.

Surgical Management

This is largely related to clinical stability and the severity of bleeding. Sometimes clients have contraindications to other treatments, aren't responding to previous efforts, or have an underlying condition that causes surgical management to be of higher priority. This may mean having a dilation and curettage (D&C), endometrial ablation, uterine artery embolization, or a hysterectomy. Polypectomy or myomectomy may also be indicated.

Keep in mind the D&C alone is not appropriate for the evaluation of uterine disorders and may provide only a temporary reduction in bleeding. It is not anticipated that cycles after the D&C are improved; however, if performed with a hysterectomy, certainly this would provide complete cessation of uterine bleeding. Case reports of uterine artery embolization and endometrial #ablation show these procedures are successful at controlling acute causes of abnormal uterine bleeding.

Endometrial ablation, although readily available in many surgical centers, should be considered only if other treatments have been ineffective or are contraindicated, and it should be performed only when a woman does not have plans for future childbearing and when the possibility of endometrial or uterine #cancer has been reliably ruled out as the cause of the acute bleeding. Hysterectomy may be necessary for patients who do not respond to medical therapy.

DeVore, G. R., Owens, O., & Kase, N. (1982). Use of intravenous Premarin in the treatment of dysfunctional uterine bleeding - a double-blind randomized control study. Obstetrics & Gynecology, 59, 285-291

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