Abnormal Uterine Bleeding

Abnormal Uterine Bleeding

Women usually go to the gynecologist due to irregular bleeding. Irregular bleeding is extremely common, and the best way to think about its etiology is by category. 

·         If the woman is of reproductive age, meaning from the beginning of menstruation to menopause (age 13-50), pregnancy-related causes, such as miscarriage, should be considered until proven otherwise.

·         Systemic disease, such as chronic and thyroid diseases, can manifest as vaginal bleeding.

·         Organic causes, such as endometritis, polyps, and submucous leiomyomata (fibroids), also cause bleeding. These causes are due to things that are physically and intrinsically wrong with the uterus.

·         If everything else is ruled out, abnormal uterine bleeding can be diagnosed as dysfunctional uterine bleeding (DUB). This is considered metrorrhagia (“met”), in which bleeding is irregular or too frequent. In order to clarify specific terms, menorrhagia (“men”) is defined as prolonged heavy bleeding at normal intervals.

·         Bleeding can also be hyperplasia (precancerous lesions) or carcinoma.


 

Abnormal Bleeding by Age Group

Causes of irregular bleeding can also be categorized by age groups. 

At both ends of the reproductive spectrum, the most common cause of bleeding is usually DUB due to anovulation.

·         In adolescence, anovulation is due to an immature hypothalamic-pituitary-ovarian axis.

·         In perimenopause, anovulation is due to ovarian failure. Perimenopausal women can also present with abnormal bleeding due to organic or hyperplastic/carcinoma causes. 

For women of reproductive age, pregnancy, such as ectopic pregnancy, must first be ruled out. Abnormal bleeding can also be due to organic causes or DUB. 

Post-menopausal women have not had periods for 1 whole year. There must not be any staining or spotting. Therefore, spotting in Grandma needs to be investigated and checked because it might be due to endometrial cancer. Hyperplasia and organic causes may also be reasons for abnormal bleeding.

Organic Causes of Uterine Bleeding

·         Endometritis

o        This is inflammation of the endometrium.

o        Acute endometritis is not commonly seen anymore. They used to be common during the times of illegal abortions due to non-sterile conditions. Histologically, you see neutrophils and pus.

o        Chronic endometritis causes can be specific or non-specific. Histologically, the hallmark of chronic endometritis is plasma cells in the endometrium. Plasma cells are never normally found in the endometrium. Polymorphonuclear leukocytes and lymphocytes are normal in the endometrium, especially around the menstrual flow period.

§         Specific causes are due to actinomyces or TB.

§         Non-specific causes are the most common cause of chronic endometritis.

·         Endometrial polyps are very common.

·         Submucous leiomyomata, fibroids under the endometrium, can cause organic etiologies of uterine bleeding.

Dysfunctional Uterine Bleeding

Dysfunctional Uterine Bleeding is caused by a hormonal flux that is usually, but not always, associated with anovulation. 

The etiology of Dysfunctional Uterine Bleeding varies with age.

·         In adolescents Dysfunctional Uterine Bleeding is due to immature HPO axes.

·         In women of reproductive age, Dysfunctional Uterine Bleeding is caused by polycystic ovarian disease, obesity, or stress (irregular periods).

·         In perimenopausal women, Dysfunctional Uterine Bleeding can be due to ovarian failure. 

Dysfunctional Uterine Bleeding can progress to hyperplasia and even carcinoma. If excess estrogen is secreted, the endometrium can grow even more than it normally does during the proliferative stage (estrogen-only stage!) to become hyperplastic. This can eventually lead to cancer. The majority of endometrial cancers is found to be hormone-related.

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