Abnormal Bleeding Fibroids

Abnormal Uterine bleeding (AUB)

Abnormal bleeding from the uterus is one of the commonest problems that come to gynecology OPD.It may happen in any age group starting from adolescence to perimenopause to even post menopausal bleeding.

Clinical Parameter	Descriptive term	Normal limits (5–95th percentiles)
Frequency of menses (days)	Frequent Normal Infrequent	<24 24–38 >38
Regularity of menses, cycle to cycle (Variation in days over 12 months)	Absent Regular Irregular	No bleeding Variation ± 2–20 days Variation >20 days
Duration of flow (days)	Prolonged Normal Shortened	>8.0 4.5–8.0 <4.5
Volume of monthly blood loss (mL)	Heavy Normal Light	>80 5–80 <5

The International Federation of Gynecology and Obstetrics ( FIGO 2011) has classified abnormal bleeding by PALM-COEIN method to facilitate accurate diagnosis.

There could be many reasons for abnormal bleeding eg.

• Hormonal imbalance like thyroid
• Pregnancy related complications
• PCOD
• Fibroids
• Endometriosis, adenomyosis
• Polyps
• Ovarian cysts
• Endometrial hyperplasia or thickening
• Endometrial or uterine or ovarian malignancy

The management of AUB depends on mainly the age of the woman and the severity of the problem.

The most common reasons for abnormal cycles could be stress and anxiety which could make the cycles irregular.

Sometimes taking an emergency contraceptive pill could cause abnormal bleeding.

After evaluating the history, usually some investigations are suggested.

• The commonest and most important investigation for AUB is an Ultrasonography. It is mandatory to evaluate uterus, adnexa and ET.More specialised tests like
  • Doppler ultrasonography can help detect AV malformation, malignancy, and differentiate between fibroid and adenomyosis.
  • A 3D-USG can help in evaluating intra myometrial lesion , for fibroid mapping.
  • SIS: Saline infusion sonography is done by inserting fluid through a tube to distend the uterus and seeing it on ultrasound if an intracavitary lesion is suspected and hysteroscopy is not available
• Hysteroscopy: This is a procedure where a thin telescope with a camera is used to enter the uterus from below and to see the uterine cavity from inside. It is the gold standard test for any AUB after the age of 35 for diagnosis and characterization of intrauterine abnormalities.
• MRI: To differentiate between fibroids and adenomyosis, mapping exact location of fibroids while planning conservative surgery and prior to therapeutic embolization for fibroids

A biopsy of the endometrium is recommended in most cases if

• In women > 40 years
• In women < 40 years with
  • risk factors for Ca endometrium
  • irregular bleeding
  • obesity associated with hypertension, PCOS, diabetes,
  • Endometrial thickness > 12 mm
  • family history of Ca-ovary/breast/endometrium/colon
  • Use of tamoxifen for HRT or breast cancer
  • Late menopause, HNPCC, AIB unresponsive to medical treatment

Endometrial aspiration and not Dilatation and curettage should be the preferred procedure Ideally we should obtain an endometrial sample only in the context of diagnostic hysteroscopy instead of a 'blind' endometrial biopsy in women with Heavy menstrual bleeding.

There is now an increased availability of medical options for management of AUB and we try the more conservative approach available. The choice of treatment depends on factors like

• Individual choice
• pressure symptoms
• desire for fertility and contraceptive needs
• achieve improved quality of life

Etiology	Treatment
Polyp	Hysteroscopic surgical removal Multiple polyps or polypoidal endometrium and fertility is not desired– LNG-IUS can be combined with surgical removal
Adenomyosis	LNG-IUS, if LNG IUS is not accepted– GnRH agonists with add back therapy; if it fails OCP, NSAIDs, progestogens
Malignancy	Atypical endometrial hyperplasia– surgical treatment fertility not desired– hysterectomy Hyperplasia without atypia LNG-IUS followed by oral progestins or PRMs
COEIN	LNG-IUS or tranexamic acid, NSAIDs, followed by COCs or cyclic oral progestins Medical or surgical treatment failed or contraindicated: GnRH agonists with add-back hormone therapy When steroidal and other options unsuitable: Centchroman
Intramural or subserosal myomas (grade 2-6)	Tranexamic acid or COCs or NSAIDs, LNG-IUS, if treatment fails myomectomy depending on location In women >40 years of age, fertility is not desired, for small fibroids (< 4- 5 cm)– medical management followed by hysterectomy Short-term management (up to 6 months)– GnRH agonists with add back therapy followed by myomectomy Long-term management– LNG-IUS Newer medical options: ulipristal acetate or low dose mifepristone Sub mucosal myoma (grade 0-1) hysteroscopic (< 4 cm) or abdominal(open or laparoscopic for > 4 cm)