Abnormal pasage of menstrual flow out of the body

Abnormal uterine bleeding is the name currently used for changes in menstruation resulting from increased volume, duration, or frequency. Abnormal uterine bleeding is a frequent condition that may impact physical, emotional sexual and professional aspects of the lives of women, impairing their quality of life (Pic. 1). 

The causes of abnormal uterine bleeding are varied (Pic. 2), depending largely on the age and life stage of the women. The common causes in women of reproductive age include pregnancy and pregnancy-related disorders, medications, iatrogenic causes (induced inadvertently by a physician or surgeon), systemic conditions, genital tract pathology, and dysfunctional uterine bleeding (anovulatory (ovaries do not release an egg) or ovulatory). The rare ones are genital cancers.

In cases of abnormal uterine bleeding without systemic repercussion, identifying the cause of the bleeding is mandatory before the start of treatment. Considering the main diagnosis of this clinical manifestation, pregnancy and the presence of vaginal and cervical lesions should be excluded by physical examination. Afterwards, an evaluation of the uterine cavity by imaging exams should be performed to identify the presence of organic lesions in the endometrial cavity.

Blood test, vaginal examination, endometrial curettage, ultrasound, and hysterogram are helpful in the diagnosis and differential diagnosis. For cases not responding to conservative treatment, pelvic angiogram (X-ray test that uses a special dye and camera to take pictures of the blood flow in an artery or a vein) and magnetic resonance imaging (MRI) scan, even hysteroscopy may be performed to detect the lesions in the uterus.

If there is acute bleeding with impairment of the patient's general condition, her hemodynamic stabilization should be prioritized, followed by the immediate start of treatment, whether clinical or surgical, even if the bleeding cause is not completely established, ruling out only vaginal and cervical lesions and pregnancy.

In the presence of endometrial lesions such as endometrial polyps and submucosal leiomyomas, surgical treatment may be indicated. The only definitive treatment for adenomyosis is hysterectomy, but the control of symptoms by medical drug treatment is not rare.

Symptoms

• vaginal bleeding that occurs more often than every 21 days or farther apart than 35 days (a normal teen menstrual cycle can last up to 45 days)
• vaginal bleeding that lasts longer than 7 days (normally lasts 4 to 6 days)
• vaginal bleeding between periods
• heavier bleeding (more than 80 mL)

Associated diseases

• adenomyosis (the presence of endometrial tissue within the myometrium – muscle layer of uterine wall)
• uterine fibroids (tumors in the uterus)
• anemia (decrease in the total amount of red blood cells)

Complications

In cases of acute and severe bleeding, women may need urgent treatment with volumetric replacement and prescription of medication. In some specific cases with more intense and prolonged bleeding, surgical treatment may be necessary.

Risk factors

• anovulation 
• obesity
• teens age

Prevention

Some women have abnormal uterine bleeding even though they have no risk factors, so avoiding risk factors may not be a 100% prevention.

Abnormal uterine bleeding in reproductive-aged women is a manifestation of a number of disorders or pathologic entities. In the clinical, women of reproductive age with heavy bleeding should be given immediate intervention to prevent further blood loss. 

In most cases, it is associated with anovulatory or oligoovulatory cycles (irregular ovulation), leading to a shoot in the estrogen levels, which are unopposed due to absence of progesterone. When a woman is anovulatory, she can't get pregnant because there is no egg to be fertilized. Women who are anovulatory have irregular, few or no periods.

In women with low risk for endometrial cancer and normal ultrasonography, excluding structural causes such as polyps, fibroids, endometrial thickening or other malignancies, the treatment can be pharmacological, through the use of drugs, or surgical. 

The goal of the treatment is the reduction of the menstrual flow, thereby reducing morbidity and improving quality of life. Treatment by drug or pharmacological therapy is considered the first line whenever possible. 

The follow-up is largely dependent on whether they require investigation and ongoing care for some underlying diseases. Thus it is important to find the cause of bleeding. The chance of fertility preservation depends on the underlying cause and severity of abnormal uterine bleeding.