Abnormal Uterine Bleeding (AUD)

Abnormal Uterine Bleeding Overview:

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Aetiology:

Abnormal uterine bleeding is a symptom rather than a condition, and can have a few different causes. 

+ Regular (Cyclical/Ovulatory) (Menorrhagia)

  • Menorrhagia (heavy/prolonged menstrual bleeding)

Characterised by a normal menstrual cycle, but heavier than normal bleeding. The cause is usually secondary to distortion of the uterine cavity.

This is a common symptom with fibroids, iatrogenic causes (incorrect OCP usage), adenomyosis.

+ Intermenstrual (Metrorrhagia)

  • Often spotting especially post coital

Can be caused by lesions on the cervix (polypi, carcinoma, ectropion), lesions on the uterus (endometriosis, fobroids, polyps, adenomyosis, or carcinoma).

+ Intermittent (Non Cyclical/Anovulatory)

  • Associated with oligomenorhoea +/- menorrhagia
  • Perimenopausal and Postmenopausal (usually spotting)
  • Adolescents

May result from the effects of unopposed estrogen on the endometrium and the development of endometrial polyps.

With anovulation, AUB is the result of chronic exposure of the endometrium to estrogen without the cyclic exposure to postovulatory progesterone. This causes an asynchronous shedding of the endometrium, and lack of vasoconstriction. This cause usually results in heavy and clotted bleeding as a result of the blood not being lysed by endometrial enzymes. Blood clots are passed which can cause cramping in some women.

Chronic anovulation can result from PCOS, hypothyroidism, hyperprolactinemia, Chushing's disease, exogenous steroid hormones, and hemostatic disorders like Von Willebrand disease.

Causes Include:

  • Infection
  • Cervical cancer
  • Endometrial polyps
  • Endometrial cancer
  • Fibroids
  • IUDs
  • Adenomyosis
  • PCOS
  • Oestrogen decline
  • POI

Symptoms:

Heavy periods

Blood clots in menstrual blood

Irregular Menstrual Cycles

Symptom

Symptom

Symptom

Symptom


Diagnostic Considerations:

  • pregnancy test (beta HCG)
  • Computerized tomography (CT) scan or magnetic resonance imaging (MRI) of pituitary area
  • Thyroid stimulating hormone
  • Plasma hormone levels of FSH & LH
  • Oestradiol
  • Prolactin
  • Testosterone
  • Progesterone withdrawal test: give a progestogen for 5 days. If the woman bleeds afterwards, she has oestrogen in her circulation and a uterus.
  • Ultrasound (TVS) assessment of:
    • uterine size;
    • pregnancy;
    • ovarian size and morphology
    • follicular function.
  • Examination under anaesthesia if congenital abnormality:
    • assess the pelvic organs;
    • perform a laparoscopy to inspect the pelvic organs and to take a biopsy of the ovaries
  • Hystero Salpingo Contrast Sonography (HyCoSy)
    • an ultrasound procedure
    • assesses the patency of the fallopian tubes
    • Detects abnormalities of the uterus and endometrium
    • Contrast medium
      • agitated saline and air mixture
      • non-iodinated contrast agent

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Differential Diagnosis:

  • Consider Foreign bodies in the uterus such as intrauterine contraceptives.
  • Hematological conditions may be present that need to be investigated (such as hemophilia, Von Willebrand Disease (VWD), Leukaemia, of Hodgekin's Disease). 
  • Hyperthyroidism
  • Hyopothyroidism
  • Endometrial cancer
 

Cautions:

Always exclude pregnancy for cases of abnormal bleeding in a reproductive aged-woman. This is the most common cause of bleeding in the reproductive age group.

Bleeding from ectopic pregnancy, or miscarriage needs to be ruled out. Both require immediate emergency medical intervention.

Post-Menopausal spotting is a red flag and needs immediate medical attention.

A tendency for abnormal bleeding could idicate VWD, leikemia, of Hodgkin's disease.

Bleeding with IUD could indicate damage or dislodgement of IUD.

Hypo or phyperthyroidism may be a cause for menorrhagia or abnormal bleeding. This needs to be ruled out.

 

Herbs For AUD

  • Capsella bursa-pastoris
  • Claviceps purpurea (specifically ergot)
 

Author:

Justin Cooke

The Sunlight Experiment

Updated: October 2017


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