Abnormal Vaginal Bleeding

Abnormal vaginal bleeding (AVB) is defined as "any change in menstrual-period frequency or duration, or amount of flow, as well as bleeding between cycles" (1). AVB is also referred to as abnormal uterine bleeding. Women are often quite distressed and worried by the appearance of AVB and it is one of the most common reasons they consult a doctor. There are a number of causes for AVB, some of which are life threatening. Achieving a correct diagnosis, therefore, can be challenging. This article will focus on the causes and treatments of AVB in women who have reached puberty.

Causes

Commonly, AVB in pre/perimenopausal women is pregnancy-related bleeding. It can be an indication of miscarriage or ectopic pregnancy. If these complications occur before a woman is aware she is pregnant she will not identify the AVB as being pregnancy-related. Therefore, it is important that the possibility of pregnancy is discussed in an initial consultation.

AVB is also a common side effect of the oral contraceptive Pill, particularly in the first three months of use. Bleeding can occur if the hormone level is not high enough to keep the lining of the uterus (endometrium) stable or if a woman misses some of the pills, or the absorption is affected by drug interactions or vomiting/diarrhoea. This type of bleeding is referred to as 'break through bleeding'. If the break through bleeding continues (and is not caused by missed pills) a higher dose Pill can be prescribed. AVB can be a side effect of injectable contraceptives (eg. Depo-Provera) and implants (eg. Implanon).

Endocrine abnormalities can also be a cause of AVB. Women with hypothyroidism may experience heavy and/or long periods or, when more severe, a lack of periods (amenorrhea). Hyperthyroid women may find their periods become irregular, scanty, shorter or that they stop altogether. Similarly, Type 1 diabetes and polycystic ovary syndrome (PCOS) are other conditions that can contribute to changes in the normal menstrual cycle.

Medications like anticoagulants, some antidepressants, antipsychotics, corticosteroids and hormonal medications can also cause AVB. Non-prescription medications can play a role with some herbal supplements associated with AVB. For example, ginseng and soy supplements can result in elevated levels of oestrogen, resulting in AVB. Similarly, gingko can also lead to AVB.

AVB can occur as a result of coagulation disorders (eg. von Willebrand disease), genital tract infections, ovarian cysts, polyps, fibroids, cancers of the genital tract, liver disease, hypertension and trauma to the genital area. Other factors which can impact on a woman's menstrual cycle include weight loss, eating disorders, stress, increased exercise and premature ovarian failure.

Diagnosis

As there are numerous causes for AVB it is vital that a thorough history taking and examination is carried out. What diagnostic tests are performed will depend on the woman's symptoms, the length of time the symptoms have been present for, whether she is premenopausal, perimenopausal or postmenopausal and her risk factors for endometrial cancer. Risk factors for endometrial cancer include obesity, diabetes, no children, family history, tamoxifen therapy and, most importantly, age. The incidence of endometrial cancer in those aged 30-34 is 1.6 cases per 100 000 compared to 27.6 and 47.8 cases per 100 000 in those aged 50-54 and 55-59 years respectively (2).

The doctor should start by asking the woman about her normal menstrual cycle and then what the abnormal uterine bleeding is like (When did it start? Is there any pattern to it? What is the colour of the blood? Are there any other accompanying symptoms like pain or cramping? Is it accompanied by any bladder/bowel symptoms? Is it associated with sexual penetration?). The doctor will also enquire about childbearing history, pregnancy termination, contraceptive use, sexual activity, existence of other health conditions and general well being (diet, stress levels, exercise, weight). Whether the woman is taking any medications, including complementary medicines should also be discussed. Other symptoms characteristic to particular conditions might also be noted at this time (eg. hirsutism, obesity - PCOS, palpitations - hyperthyroidism, jaundice - liver disease).

A pelvic examination will be performed to check for obvious causes of the bleeding (eg. lacerations, vaginal atrophy, polyps, signs of infection). The doctor needs to consider the possibility that the origin of the bleeding may in fact not be from the vagina but other sources like the urethra, anus or from haemorrhoids. A pelvic examination will also allow the doctor to visualise the cervix and palpitate the abdomen to check for uterus size and mobility and the presence of ovarian tumours and/or other growths. If the woman is at risk of sexually transmitted infections a cervical swab might be taken. A Pap smear may also be taken at this time.

It is important that all heterosexual women of reproductive age and lesbians trying to conceive undergo a pregnancy test to definitively rule out the possibility of pregnancy. Blood tests can help determine if a woman is ovulating and to check for other conditions like PCOS, insulin resistance, anemia, and thyroid and blood disorders.

Evaluation of the endometrium through ultrasound is the next diagnostic step, although it may not be necessary for some premenopausal women, depending on what is revealed in the history taking, examination and other tests. Transvaginal ultrasonography and saline infusion sonohysterography are the most suitable imaging technologies. A transvaginal ultrasound is similar to abdominal ultrasound except a small probe is inserted into the vagina. In a saline infusion sonohysterography a saline solution is injected into the uterine cavity through the cervix to distend the uterus to improve visualisation. A transvaginal ultrasound is then performed.

Endometrial biopsy is a further diagnostic tool to evaluate the endometrium. The biopsy involves removing a sample of the endometrium for examination. In a simple endometrial biopsy a speculum is used to hold the walls of the vagina open and an instrument is then guided through the cervix into the uterus. The instrument uses suction to remove a small amount of tissue from the lining of the uterus. This procedure can be performed in a doctor's surgery.

If a more extensive investigation is required a dilation and curettage (D & C) with/without hysteroscopy is performed. A hysteroscopy involves the insertion of a thin, viewing instrument into the uterus allowing the doctor to see inside the uterus and obtain a closer look at the endometrium. A dilation and curettage involves the dilation of the cervix and the insertion of a spoon-shaped instrument (curette) to scrape tissue from the endometrium for further testing.

If the abnormal uterine bleeding is not found to be caused by a recognised pelvic or systemic health problem and is not associated with pregnancy complications it is then defined as 'dysfunctional uterine bleeding' (3).

Treatment for dysfunctional uterine bleeding

The woman's age, current contraception requirements and severity of symptoms will influence treatment options. For example, an adolescent within several years of their first period will generally not be given any treatment unless their symptoms are severe (heavy bleeding causing anemia, absenteeism from school) or they are particularly concerned about them. Similarly, a woman who wishes to become pregnant will require different treatment to one requiring contraception.

In the premenopausal woman with anovulatory dysfunctional bleeding, the combined oral contraceptive Pill is usually the first treatment option. If a woman is unable to take oral contraceptives (smoker, at risk of thromboembolism) progestins are usually prescribed for a set number of days a month. For women trying to conceive, ovulation inducing drugs (eg. clomiphene) can be prescribed. Oral contraceptives and progestins are also the treatment of choice for perimenopausal women.

For premenopausal women experiencing ovulatory dysfunctional bleeding there are a number of treatment options. Medical treatment for heavy bleeding includes non-steroidal anti-inflammatory drugs (NSAIDs) such as mefenamic acid, tranexamic acid and the intrauterine system (Mirena) (see box for more information). Oral contraceptives are also used as well as more powerful hormonal drugs like Danazol and GnRh antagonists, although these have unpleasant side effects.

Surgical treatments include endometrial ablation which involves destroying the womb lining. There are different endometrial ablation techniques including rollerball, thermal balloon, microwave and radio wave. Endometrial ablation is not suitable for women who wish to have children. If medical treatments and/or endometrial ablation are unsuccessful at controlling heavy bleeding a hysterectomy (removal of the womb) is a further option.

References

1. Albers J A et al. Abnormal uterine bleeding Am Fam Physician 2004; 69:8:1915-26
   
2. Australian Institute of Health And Welfare and Australasian Association of Cancer Registries (AACR) Cancer in Australia 2001 Canberra: AIHW 2004
   
3. Wang, I Y & Fraser I S. A recommended approach to dysfunctional uterine bleeding Mod Med 1998; 41:7: 34-43
   
4. Hurskainen R & Paavonen J. Levonorgestrel-releasing intrauterine system in the treatment of heavy menstrual bleeding Curr Opin Obstet Gynecol 2004; 16:6:487-90
   
5. Australian Institute of Health and Welfare. Australia's Health 2004 Canberra: AIHW 2004; 21

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This article was written by Kirsten Braun and reviewed by the Editorial Committee for Health Journey, Vol II 2005.

Please note that this article is an archive. While every effort was made to ensure the information was accurate at the time of publication, the article has not been updated since this time. 

Last Modified: June 1, 2005