Abnormal uterine bleeding is one of the most common reasons for patients to visit the gynaecologist. At different ages, different factors may be responsible for uterine bleeding. In younger patients, it is mainly hormonal disorders or polyps, while in older women, tumours of the reproductive tract must necessarily be taken into account. It should be remembered that bleeding may also be caused by systemic problems outside the gynaecology, such as blood clotting disorders.
Uterine myomas - benign tumours of the uterus
Uterine myomas are 95% benign uterine tumours originating from the uterine muscularis. We classify them as: submucosal (growing towards the uterine cavity), intramural (developing within the wall) and subserosal (growing on the outer surface of the uterus, towards the abdominal and pelvic cavities). These are very common lesions, the presence of which the patient is often unaware because they remain asymptomatic for a long period of time.
It is uterine myomas that are the main cause of abnormal uterine bleeding at around 35-45 years of age, because it is also at this age that this type of lesion most often forms, which in up to 90% of cases are multiple. Uterine myomas can reach a size of up to several centimetres. Patients may then complain, in addition to excessively heavy, prolonged periods, of constipation, sacral pain, frequent urination and pain during intercourse.
The treatment of myomas is based on their removal during hysteroscopy or laparoscopy, depending on their location in the uterus. In very advanced cases, if the woman has already completed her childbearing, removal of the entire uterus is considered.
Malignant tumours of the uterus
Uterine adenocarcinoma is a diagnosis that always needs to be considered when a postmenopausal patient presents to the gynaecologist with a problem of abnormal uterine bleeding. The aforementioned causes of bleeding such as endometrial proliferations or the presence of polyps are rather hormonally driven. After the menopause, sex hormone levels should stabilise at a consistently low level, which means there is little chance that bleeding is caused by, for example, polyps in older patients.
Risk factors for endometrial cancer include, in particular, obesity, long-term hormone therapy with oestrogens without balancing with gestagens, diabetes, hypertension, non-pregnancy, early first menstruation and late menopause.
The prognosis in endometrial cancer is quite good, as the cancer quickly produces symptoms in the form of bleeding. Of course, the prerequisite for successful treatment is that the patient sees a gynaecologist as soon as possible and does not underestimate the problem. The treatment of choice is removal of the uterus.
photo: panthermedia
Diagnosis of abnormal uterine bleeding
The diagnosis of abnormal uterine bleeding begins with a thorough history and a basic gynaecological examination. The doctor must find out for how long the patient has been experiencing the problem of bleeding, whether it relates to menstrual bleeding or whether it occurs between periods (here it is necessary to differentiate whether the patient is referring to physiological perovulatory bleeding, associated with a fall in oestrogen levels in the middle of the cycle). It is also necessary to determine exactly (the number of pads or tampons consumed per day) what the patient means by the abundance of bleeding. This is because it sometimes happens that the amount reported by her as excessive is the normal, physiological volume of menstrual blood. Once the history has been taken, the doctor proceeds with the gynaecological examination. While inserting the speculum, he assesses whether there are any lesions or abrasions in the vagina and cervix that could be the cause of the bleeding. He then looks for any cervical polyps or erosions.
However, the primary diagnostic method for abnormal uterine bleeding is ultrasound examination. This assesses the thickness of the endometrium of the uterus and looks for lesions such as polyps or uterine myomas. The next diagnostic steps depend on the age of the patient. If the Medical US examination fails to visualise a specific lesion that could be the cause of the bleeding, laboratory tests for hormone levels are performed in younger patients, as hormonal disorders are often responsible for abnormal uterine bleeding. In postmenopausal women who present to the doctor with bleeding, because of the high risk that the cause may be cancer, a 'curettage' of the cervical canal and the uterine cavity is performed in order to submit the collected material to histopathological examination in search of cancer cells.
