Makindo Medical Notes

Related Subjects: |Causes of abnormal Vaginal bleeding |Vaginal Carcinoma |Cervical cancer |Antepartum haemorrhage |Post Menopausal Bleeding |Postpartum haemorrhage

Introduction

Abnormal vaginal bleeding, also known as abnormal uterine bleeding (AUB), is a common gynecological complaint among women of reproductive age and beyond. It encompasses any bleeding that differs in frequency, regularity, duration, or volume from normal menstrual bleeding. The prevalence of AUB among reproductive-aged women internationally is estimated to be between 3% to 30%, with higher incidence occurring around menarche and perimenopause. Identifying the underlying cause is crucial for appropriate management and improving patient outcomes.

The prevalence of abnormal uterine bleeding among reproductive-aged women internationally is estimated to be between 3% to 30%, with a higher incidence occurring around menarche and perimenopause.

Classification

The International Federation of Gynecology and Obstetrics (FIGO) has developed the PALM-COEIN classification system to categorize causes of AUB in non-pregnant women of reproductive age:

• PALM (Structural Causes):
  • Polyp
  • Adenomyosis
  • Leiomyoma (fibroids)
  • Malignancy and hyperplasia
• COEIN (Non-Structural Causes):
  • Coagulopathy
  • Ovulatory dysfunction
  • Endometrial
  • Iatrogenic
  • Not yet classified

Etiology

Abnormal vaginal bleeding can result from a variety of physiological and pathological conditions. It is essential to differentiate between these to determine the appropriate course of treatment.

• Physiological Causes:
  • Menarche and perimenopause transitions
  • Ovulatory bleeding (mid-cycle spotting)
  • Implantation bleeding in early pregnancy
• Pathological Causes:
  • Pregnancy-Related: Ectopic pregnancy, miscarriage
  • Infections: Pelvic inflammatory disease (PID), sexually transmitted infections (STIs)
  • Endocrine Disorders: Polycystic ovary syndrome (PCOS), thyroid dysfunction, hyperprolactinemia
  • Structural Abnormalities: Uterine fibroids, endometrial polyps, adenomyosis
  • Malignancies: Endometrial, cervical, vaginal, or vulvar cancer
  • Coagulopathies: Von Willebrand disease, thrombocytopenia
  • Iatrogenic Causes: Hormonal contraception, intrauterine devices (IUDs), anticoagulant therapy
  • Medications: Antipsychotics, corticosteroids, herbal supplements

Clinical Features

Patients presenting with abnormal vaginal bleeding may report a variety of symptoms. A thorough history and physical examination are essential.

• Patterns of Bleeding:
  • Menorrhagia: Excessive menstrual blood loss (>80 mL per cycle) or prolonged bleeding (>7 days).
  • Metrorrhagia: Irregular bleeding between periods.
  • Menometrorrhagia: Heavy and irregular bleeding.
  • Oligomenorrhea: Infrequent menstrual periods (>35 days apart).
  • Polymenorrhea: Frequent menstrual periods (<21 days apart).
  • Postcoital Bleeding: Bleeding after sexual intercourse.
  • Postmenopausal Bleeding: Any bleeding occurring 12 months after cessation of menstruation.
• Associated Symptoms:
  • Pelvic pain or pressure
  • Fatigue or dizziness (indicative of anemia)
  • Discharge or signs of infection
  • Symptoms of pregnancy (nausea, breast tenderness)
  • Signs of endocrine disorders (hirsutism, acne, weight changes)

History and Examination

• Menstrual History: Age at menarche, cycle regularity, duration, and flow.
• Obstetric History: Pregnancies, miscarriages, deliveries.
• Sexual History: Contraceptive use, risk of STIs.
• Medical History: Coagulopathies, endocrine disorders, previous surgeries.
• Medication Use: Hormonal therapies, anticoagulants, herbal supplements.
• Family History: Bleeding disorders, cancers.
• Physical Examination:
  • Vital signs (hemodynamic stability)
  • Signs of anemia (pallor, tachycardia)
  • Abdominal examination (masses, tenderness)
  • Pelvic examination (visual inspection, bimanual exam)

Causes and Differential Diagnosis

The following table summarizes common causes of abnormal vaginal bleeding, their clinical presentation, investigations, and management options.

Investigations

A systematic approach to investigations helps identify the underlying cause of abnormal vaginal bleeding.

• Pregnancy Test: Urine or serum β-hCG to rule out pregnancy-related causes.
• Laboratory Tests:
  • Full Blood Count (FBC): Assess for anemia (hemoglobin, hematocrit levels).
  • Coagulation Studies: PT, aPTT, platelet count, von Willebrand factor assays.
  • Thyroid Function Tests: TSH, free T4, free T3.
  • Hormonal Profile: LH, FSH, estradiol, prolactin, androgen levels.
  • Infection Screening: Cervical swabs for chlamydia, gonorrhea, other STIs.
• Imaging Studies:
  • Transvaginal Ultrasound (TVUS): First-line imaging to assess uterine and ovarian structures, endometrial thickness.
  • Saline Infusion Sonohysterography: Enhances visualization of intrauterine pathology.
  • MRI: Provides detailed imaging for adenomyosis, fibroids, or if malignancy is suspected.
• Procedures:
  • Endometrial Biopsy: Essential for women over 45 or with risk factors to exclude endometrial hyperplasia or cancer.
  • Hysteroscopy: Direct visualization of the uterine cavity, allows for diagnostic and therapeutic interventions.
  • Pap Smear and HPV Testing: Screening for cervical dysplasia or cancer.

Management

Management depends on the underlying cause, the severity of symptoms, patient age, reproductive desires, and comorbidities.

• Initial Stabilization:
  • Assess hemodynamic status; manage severe bleeding with intravenous fluids, blood transfusions if necessary.
  • Monitor vital signs and hemoglobin levels.
• Medical Management:
  • Hormonal Therapy:
    • Combined oral contraceptives to regulate menstrual cycles and reduce bleeding.
    • Progestin-only therapies (oral, injectable, or intrauterine devices).
    • GnRH agonists for short-term management of fibroids or endometriosis.
  • Non-Hormonal Therapy:
    • Tranexamic Acid: Antifibrinolytic agent to reduce menstrual blood loss.
    • NSAIDs: Reduce prostaglandin levels, decreasing bleeding and dysmenorrhea.
    • Iron Supplements: Treat iron-deficiency anemia.
  • Treat Underlying Conditions: Manage thyroid disorders, coagulopathies, infections accordingly.
• Surgical Management:
  • Minimally Invasive Procedures:
    • Endometrial Ablation: Destroys the lining of the uterus to reduce bleeding.
    • Hysteroscopic Polypectomy or Myomectomy: Removal of polyps or fibroids.
  • Definitive Surgery:
    • Hysterectomy: Removal of the uterus; considered when other treatments fail or in cases of malignancy.
    • Uterine Artery Embolization: Blocks blood flow to fibroids causing them to shrink.
• Follow-Up Care:
  • Regular monitoring of symptoms and hemoglobin levels.
  • Adjust treatment plans based on response and side effects.
  • Screening for reproductive cancers as appropriate.
• Patient Education:
  • Discuss treatment options, side effects, and expectations.
  • Encourage adherence to medication and follow-up appointments.
  • Lifestyle modifications: Weight management, smoking cessation.

Conclusion

Abnormal vaginal bleeding is a symptom with a broad differential diagnosis requiring careful evaluation. A systematic approach involving history-taking, physical examination, appropriate investigations, and individualized management plans is essential. Collaboration between primary care providers, gynecologists, and other specialists enhances patient outcomes and addresses underlying conditions effectively.

References

• Munro MG, et al. FIGO Classification System (PALM-COEIN) for Causes of Abnormal Uterine Bleeding in Non-Gravid Women of Reproductive Age. Int J Gynaecol Obstet. 2011;113(1):3-13.
• American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 128: Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women. Obstet Gynecol. 2012;120(1):197-206.
• National Institute for Health and Care Excellence (NICE). Heavy Menstrual Bleeding: Assessment and Management. NICE Guideline [NG88]; 2018.
• Fraser IS, et al. Recommendations for Terminology, Definitions, and Research in Menstrual and Abnormal Uterine Bleeding. Fertil Steril. 2007;87(3):466-476.
• Lunsford KE, et al. Uterine Fibroids: Clinical Features and Impact on Women's Health. Clin Obstet Gynecol. 2016;59(1):9-24.
• Shapley M, et al. Identifying Risk of Endometrial Cancer in Primary Care: Derivation and Validation of a Risk Prediction Algorithm. Br J Gen Pract. 2013;63(614):e852-e860.
• Royal College of Obstetricians and Gynaecologists (RCOG). Management of Endometrial Hyperplasia. Green-top Guideline No. 67; 2016.