Abnormal Uterine Bleeding Is a Quality-of-Life Issue

Ovulation and the production of progesterone during the luteal phase results in regular menstrual cycles.¹

Any deviation from the normal pattern is categorized as abnormal uterine bleeding (AUB). These criteria include heavy menstruation (menorrhagia) and intermenstrual bleeding (metrorrhagia).¹AUB describes any abnormality in duration, frequency, regularity, or volume.²AUB accounts for about half of all gynecologic visits by adolescents and about one-third of gynecologic visits by adult women and is found to be a common complaint in primary-care settings.^1,2Complaints about AUB results in nearly two-thirds of hysterectomies performed annually.³

A compressive evaluation is needed to determine causation to allow for proper treatment and to eliminate more serious causes, such as carcinoma or atypical hyperplasia.¹Two broad classifications of AUB are defined as non-structural and structural causes. Types of structural causes include adenomyosis, leiomyoma, malignancy and hyperplasia, and polyp. Non-structural causes are coagulability, endometrial, iatrogenic, and ovulation dysfunction.¹

Evaluation

Diagnosis should include a comprehensive history and physical, laboratory testing, and imaging as indicated.¹The history should include family history of any bleeding disorders. A personal history detailing the length of the bleeding and heaviness (daily pad or tampon count) can assist with evaluation of the patient. Reviewing the patient’s medications list is essential, including OTC and herbal preparations, especially those herbals that may affect bleeding, such as ginkgo, ginseng, and motherwort. OTC medications that can affect bleeding include contraceptives, nonsteroidal anti-inflammatory (NSAID) medications, and medications affecting clotting, such as heparin and warfarin.¹The physical examination should include evaluation of the patient’s body mass index and palpitation of the thyroid. Also, a pelvic examination, including a bimanual assessment for uterine size, is essential.¹Recommended laboratory testing should also include blood count, evaluations for bleeding disorders, iron levels, and pregnancy and thyroid testing. A transvaginal ultrasound is also indicated to assist in the diagnosis of AUB, unless otherwise contraindicated.⁴

Additional evaluation of AUB can include uterine sampling, which is used to determine the presence of malignant or pre-malignant lesions. An endometrial biopsy is considered highly accurate when an adequate specimen is obtained.¹Arriving at a clear diagnosis is required for the course of treatment to be established. Excluding anatomic abnormalities, malignancy, and pregnancy, treatment goals can be established. The primary treatment goal is improving the quality of life for women diagnosed with AUB. Regulating periods and minimizing blood loss in the prevention of anemia and improving quality of life are the primary goals for these patients.¹

The most common first-line medication choice for the treatment of AUB is the use of combined oral contraceptives (COC). For most women prescribed COC, a 50% reduction is the amount of bleeding is reported.¹Research also suggests that the use of COCs reduces the number of days of bleeding per year. Adjustments in which COCs are used may be required based on results. These adjustments can be either in dose or type of medication used. In patients with a known contraindication to estrogen therapies, progesterone alternatives can be selected.

Additional medication alternatives NSAIDs. These work by reducing the synthesis of prostaglandin. Research indicates a reduction up to 33% of bleeding when NSAIDs are used as directed to treat AUB. Additional benefits of NSAIDS include a reported reduction in menstrual cramping, when taken during the first 3 days of the menstrual cycle. Current recommendations are 600 mg every 6 hours for the first 3 days of the menstrual cycle.¹

An additional alternative for patients who do not respond to medication therapy may be endometrial ablation. This option is less invasive than a hysterectomy, and it results in long-term relief for some patients. It is important to note that 38% of patients who receive an ablation ultimately require further surgery within the 4 years.¹Success with endometrial ablation is linked to proper patient selection and should include consideration of the patient’s age and risk factors.

Conclusion

AUB for most women is a quality-of-life issue. Determining the cause and severity is instrumental in outlining a treatment plan. An extensive examination and obtaining a patient’s medical history can indicate the best treatment options for those who suffer from the condition. Although AUB is relatively common, if left untreated it can lead to anemia or result in a missed diagnosis of malignancy. All reports of AUB should be evaluated, and a treatment plan focused on improving quality of life should be the primary goal.

Lisa Bridwell Robinson, DNP, CCRN, CNE, NP-C, is a family nurse practitioner and certified nurse educator who practices as a work site health coach. She is also an associate professor of nursing at the University of West Georgia in Carrollton.

References

1. Goldstein SR, Lumsden MA. Abnormal uterine bleeding in perimenopause.Climacteric.2017;20(5):414-420. doi: 10.1080/13697137.2017.1358921.
2. Elmaogullari S, Aycan Z. Abnormal uterine bleeding in adolescents.J Clin Res Pediatr Endocrinol.2018;10(3):191-197. doi: 10.4274/jcrpe.0014.
3. Garg G, Patvekar M. Agarwal K, Bhatia I, Sanghi S. A study of the role of hysteroscopy in abnormal uterine bleeding.Journal of Gynecologic Surgery.2017;3(6);226-230. doi 10.1089/gyn.2017.0028.
4. Saleh HS, Madkour NM, Abdou AM, et al. Role of multidetector computed tomography (CT) virtual hysteroscopy in the evaluation of abnormal uterine bleeding in reproductive age.Biomed Res Int.doi:10.1155/2019/8910374.