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Uterine Bleeding

NORMAL MENSTRUAL BLEEDING
 Defined  as cyclic menstruation every month 28(+_ 7 days) lasting 4 to 7days. 
ABNORMAL UTERINE BLEEDING
Any women who experiences a change in her previously established menstrual pattern or whose lifestyle is adversely   affected  may be considered to have abnormal uterine bleeding.
ADOLESCENT GIRLS (age below 20 years)
•Anovulatory bleeding    -Where the egg is not formed  (not ovulating) leading to not getting menses for longer time  followed by prolonged bleeding and heavy bleeding. Some time need medication to stop the bleeding.
•Coagulation disorders – where the normal clotting process is affected by either genetically or by acquired  defect in the blood clotting mechanism.
•Pregnancy related 
•Vaginal/ pelvic infections – the infection of the birth passage , mouth of womb and inner lining of womb can cause anormal bleeding.
•Medications – certain medicine like hormones which are used to treat bleeding problem if not 
•used correctly as advised can cause abnormal bleeding.
•Benign tumors of genital tract – uterine  leisions like fibroid uterus and ovarian leision like cyst, tertoma ect

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•Pregnancy related – Ectopic pregnancy, threatened miscarriage, missed abortion,incomplete abortion and rarely abnormal placentation.
•Anovulation -Where the egg is not formed  (not ovulating) leading to not getting menses for longer time  followed by prolonged bleeding and heavy bleeding. Some time need medication to stop the bleeding.


•Vaginal/pelvic infection the infection of the birth passage , mouth of womb and inner lining of womb can cause anormal bleeding.


•Pelvic tumor – cervical lesions like polyp, premalignant leision of cervix, endometrial polyp, fibroid uterus,adenomyosis,benign ovarian cyst, dermoid of ovary and endometriosis and malignant ovarian tumor
•Endocrinopathies (PCOS ,Thyroid,etc)
•IUD – copper-T related bleeding.
•Coagulopathy   – where the normal clotting process is affected by either genetically or by acquired  defect in the blood clotting mechanism.


PERI MENOPAUSAL
•Anovulation-Where the egg is not formed  (not ovulating) leading to not getting menses for longer time  followed by prolonged bleeding and heavy bleeding. Some time need medication to stop the bleeding.
•Fibroids – it is a benign tumor affecting the uterus. 20% of womens are affected by this. For its treatment various options available. Every  body does not  need treatment.
•Adenomyosis – extension of the inner lining of uterus to the muscle layer of uterus which causes inside bleeding during menses. Which causes unbearable pain  and excessive bleeding.
•Endometrial polyps  –  abnormal protruding of inner lining of the uterus
•Endometrial hyperplasia  -  Abnormal proliferation of inner lining  of the uterus.
•Genital tract neoplasm  -  cancer uterine of mouth, cancer of inner lining of the uterus and Ovarian cancer. 
POST MENOPAUSAL
•Endometrial atrophy – Due to estrogen deficiency inner lining of the uterus bocomes thinned out and causing breakage in the lining and causing bleeding.
•Fibroids – it is a benign tumor affecting the uterus. In post menopausal women it may change into sarcoma ( Malignant tumor).
•Adenomyosis – extension of the inner lining of uterus to the muscle layer of uterus which causes inside bleeding during menses. Which causes unbearable pain  and excessive bleeding.
•Endometrial polyps  –  abnormal protruding of inner lining of the uterus
•Endometrial hyperplasia  -  Abnormal proliferation of inner lining  of the uterus.
•Genital tract neoplasm   -  cancer uterine of mouth, cancer of inner lining of the uterus and Ovarian cancer. 


•Hormone replacement therapy –  People who is on estrogen replacement therapy.
Associated other symptoms with abnormal bleeding and the probable cause
•Pelvic pain -  Miscarriage, ectopic pregnancy, PID, trauma, sexual abuse or assault
•Nausea, weight gain, urinary frequency, fatigue - Pregnancy
• Weight gain, cold intolerance, constipation – Hypothyroidism
•fatigueWeight loss, sweating, palpitations – Hyperthyroidism
•Easy bruising, tendency to bleed - Coagulopathy
Various Laboratory tests doen to find out the probable cause
•Papanicolaou smear -  Cervical dysplasia
•Urine pregnancy test  -  Pregnancy
•Complete blood count with platelet count -  Coagulopathy 
•Liver function tests, prothrombin time Liver disease
•Thyroid-stimulating hormone Hypothyroidism, hyperthyroidism
•Prolactin Pituitary adenoma
•Blood glucose Diabetes mellitus 
•DHEA-S, free testosterone, 17-hydroxyprogesterone Ovarian or adrenal tumor or if hyper androgenic 
•Cervical testing for infection Cervicitis, PID
Imaging studies done
1.TVUS (Trans vaginal ultra sonography)
2.Saline Infusion Sonography 
3.Hysteroscopy                          ( Gold standard) 
To find out the following problems causing abnormal bleeding
•Fibroids,polyp,intrauterine pregnancy and ectopic pregnancy
•Endometrial polyp and submucus myoma
•Evaluation of endometrial cavity .
•Excision of small submucus myoma and polyp 
Imaging studies
CT SCAN
MRI 

To evaluate and plan the treatment for  the following cause of abnormal bleeding
•In suspected malignancy
•Uterine artery embolization
•prolactinoma 

Non Surgical Management of Abnormal Uterine Bleeding 
Mirena,Emily ( Levo norgesterol releasing intra uterine system) 

Surgical Management of Abnormal Uterine Bleeding 
Surgical procedure (conservative uterine sparing surgery)
•Operative hysteroscopy
•Myomectomy (abdominal, laparoscopic, hysteroscopic)
•Transcervical endometrial resection
•Endometrial ablation (using
various energy systems, principally thermal balloon or rollerball) 
   
Uterine artery embolization 
Surgical procedure (radical surgery)
Hysterectomy –  Total laparoscopic hysterectomy, Laparoscopic  assisted  vaginal hysterectomy and abdominal hysterectomy and Vaginal hysterectomy.
DR.INDHRA NEDUMARAN
M.B.B.S,DNB(OBGYN),FEM(UK),Dip ALS(Germany) 
CONSULTANT GYNECOLOGIST AND LAPAROSCOPIC SURGEON
Department of OBGYN
Billroth Hospitals,Chennai 

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