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Endometriosis and heavy menstruation

by Tamer Seckin, MD | Posted on January 11, 2021

Overview

Abnormal uterine bleeding (AUB) is defined as menstrual bleeding of abnormal quantity, duration, or schedule. AUB is a major health problem requiring hospital admission in reproductive-aged women and associated with blood loss, decreased sexual and reproductive health, and increased use of health care. AUB is a common gynecologic complaint, accounting for one-fourth of gynecologic operations and one-third of outpatient visits to gynecologists. Approximately 10% of women experience AUB at least once in their lifetime (1). Abnormal bleeding is also known as heavy menstruation, heavy flow with clots, prolonged and heavy periods. Often associated with uterine pain due to cramps, and can  lead to anemia, and decreased quality of life. Adenomyosis, endometriosis and fibroids along with uterine polyps are the most causes for excessive and abnormal menstruation. 

The International Federation of Gynecology and Obstetrics (FIGO) introduced a revised terminology system for AUB to avoid poorly defined or confusing terms used previously (eg, menorrhagia, menometrorrhagia, oligomenorrhea) (2). It has been decided to discontinue the terms “menorrhagia” and “dysfunctional uterine bleeding” and to replace them with the terms “heavy menstrual bleeding” and “endometrial dysfunction”, “coagulopathy” or “ovulatory dysfunction”.

The classification system is referred to by the acronym PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) (Table 1).

Table 1. FIGO Classification of Abnormal Uterine Bleeding

PALMECOEIN
  • Polyp
  • Adenomyosis
  • Leiomyoma
    • Submucosal
    • Other
  • Malignancy&Hyperplasia
  • Endometriosis
  • Coagulopathy
  • Ovulatory dysfunction
  • Endometrial
  • Iatrogenic
  • Not yet classified

Symptoms

AUB covers the full range of symptoms of abnormal bleeding. When reporting symptoms, the clinician should consider at least the previous six months. When assessing regularity, cycle length is defined as the number of days from the start (day 1) of one period until the start (day 1) of the next. Table 2 shows the normal reference values for menstrual bleeding. Any abnormalities other than these values are named as AUB.

Table 2. The normal reference values for menstrual bleeding

Menstruation and menstrual cycleTermsNormal values
Frequency of menstruation (days) Frequent <24
  Normal 24-38
  Rare >38
Variability during 12 months (days) Absent Absent bleeding
 

Regular

2-20

  Irregular >20
Duration of bleeding (days) Prolonged >8
  Normal 4.5-8
  Shortened

<4.5

Monthly blood loss (mL)

Heavy >80
  Normal 5-80
  Light <5

Diagnosis

In a patient with a complaint of abnormal bleeding, pregnancy status and reproductive status should be evaluated initially. This guides the further evaluation, differential diagnosis, and disposition of the patient. Detailed gynecologic and obstetric history including menstrual history, sexual history, history of obstetric or gynecologic surgery, contraceptive history should be obtained. Chronic medical comorbid conditions (thyroid disease, autoimmune disease such as Celiac disease, etc) and any medication use such as anticoagulants should be investigated to differentiate the source of the bleeding. Bleeding pattern including volume, frequency, duration, and regularity should be questioned. Following this evaluation, vital signs and general physical health should be assessed. Upon understanding that the bleeding is of uterine origin, further physical and gynecological examinations should be performed (3).

Most reproductive-aged women with AUB should be evaluated initially with the following laboratory tests: pregnancy test and complete blood count. Thyroid function tests, prolactin level, hormonal levels (FSH, estrodiol, testosterone, etc) and coagulation tests (pt/ptt/fibrinojen/vwf panel) are selective and depends upon information obtained on history and physical examination (4).

Transvaginal ultrasound and hysteroscopy are helpful imaging methods to eliminate pathologic structural lesions including polyps, leimyomas, adenomyosis, and malignant conditions. Pelvic ultrasound is the first-line imaging method in these women. Saline infusion sonography (SIS) (also called sonohysterography) is a technique in which sterile saline is instilled into the endometrial cavity and a transvaginal ultrasound examination is performed simultaneously (5). This procedure is preferred to evaluate uterine architecture and to detect lesions (eg, polyps or small submucous fibroids) that may be missed or poorly defined by transvaginal sonography alone. Hysteroscopy is an alternative to evaluate the uterine cavity. This technique also allows biopsy or excision of lesions identified during the procedure (6).

Endometrial sampling typically as an office biopsy should be performed in women having an increased risk of endometrial hyperplasia or cancer (7). The evaluation of coexisting pelvic pain with abnormal uterine conditions with heavy bleeding and clots should not oversight the doctor evaluate pelvic floor evaluation, uterine prolapse, and myofascial fibrosis.

Treatment

The goal of initial therapy should be to control the bleeding, treat anemia (if present), and restore quality of life. The choice of treatment depends on etiologic reason, severity of bleeding, associated symptoms, contraceptive use and needs, plans for future pregnancy, comorbid conditions, and patient preferences. Medical attention is necessiated in most women with AUB in an outpatient setting. Emergent medical care can be required if there is an exacerbation of AUB. Empiric treatment without further evaluation is not appropriate in these women due to missing a primary etiology that may be corrected or masking symptoms of neoplastic disease. Following the differential diagnosis, the first line therapy of AUB consists of non-hormonal treatments including non-steroidal anti-inflammatory drugs (NSAİD), tranexamic acid, desmopressin and progestin-based hormonal treatments including combination oral contraceptives (OCs), the 52 mg levonorgestrel-releasing intrauterine device (IUD) with a release rate of 20 mcg/day, and high-dose progestin-only oral medications. Other medical treatments (eg. Danazol, Gonadotropin-releasing hormone agonists) are either less effective or have several adverse effects.

Surgical treatment is necessary in women having structural lesions (eg. leiomyomas, endometrial polyps) and/or who have completed childbearing. Minimally invasive methods including hysteroscopic or laparoscopic approaches can be preferred to minimalize further blood loss. Excisional techniques (eg. polypectomy, myomectomy) is often preferred in women of reproductive age. Hysterectomy is a definitive treatment modality in women who have completed childbearing.

Women with acute AUB, which is defined as uterine bleeding episode in a woman that is of sufficient quantity to require immediate intervention to prevent further blood loss, should be managed immediately (8). These women with acute bleeding requires a detailed evaluation in an urgent care facility and should be treated with intravenous conjugated estrogen, tranexamic acid, oral contraceptives, or multidose oral progestins. Medical management often  however may not treat the real cause, hysterosocpic visualisation of the cavity, hysteroscopic surgery with curettage, polypectomy, fibroid resection are conservative approches. Definitive treatment with removal of the uterus, otherwise known as hysterectomy  may eventuallybe needed if patient chooses. Adjunt management of pain with myofascial release, trigger point injections targetting pudendal and sciatic nerves , acupuncture has limited temperory variable results.

The decision for treatment should be patient-centered considering patient’s clinical presentation, age, the severity of symptoms, reproductive desires, other comorbidities, side effects and complications related with medical treatment and surgery, and cost. As a conclusion, AUB is a common gynecologic complaint in non-pregnant reproductive-aged women. These women should be managed appropriately to prevent further blood loss and to improve their quality of life.

References

  1. Matthews ML. Abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol Clin North Am. 2015;42(1):103-15.
  2. Munro MG, Critchley HO, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011;113(1):3-13.
  3. Dueholm M, Forman A, Jensen ML, Laursen H, Kracht P. Transvaginal sonography combined with saline contrast sonohysterography in evaluating the uterine cavity in premenopausal patients with abnormal uterine bleeding. Ultrasound Obstet Gynecol. 2001;18(1):54-61.
  4. de Vries LD, Dijkhuizen FP, Mol BW, Brölmann HA, Moret E, Heintz AP. Comparison of transvaginal sonography, saline infusion sonography, and hysteroscopy in premenopausal women with abnormal uterine bleeding. J Clin Ultrasound. 2000;28(5):217-23.
  5. La Sala GB, Blasi I, Gallinelli A, et al. Diagnostic accuracy of sonohysterography and transvaginal sonography as compared with hysteroscopy and endometrial biopsy: a prospective study. Minerva Ginecol. 2011; 63(5):421-7.
  6. Kelekci S, Kaya E, Alan M, et al. Comparison of transvaginal sonography, saline infusion sonography, and office hysteroscopy in reproductive-aged women with or without abnormal uterine bleeding. Fertil Steril. 2005;84(3):682-6.
  7. Van den Bosch T, Verguts J, Daemen A, et al. Pain experienced during transvaginal ultrasound, saline contrast sonohysterography, hysteroscopy and office sampling: a comparative study. Ultrasound Obstet Gynecol. 2008;31(3):346-51.
  8. Munro MG, Critchley HO, Fraser IS. The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years: who needs them? Am J Obstet Gynecol. 2012; 207(4):259-65.

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