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Abnormal Uterine Bleeding (AUB)

Dr Lodé Fourie Specialities Gynaecologist and Obstetrician.

HPC Reg No MP0431117 Practice No 0160000333441. Qualification. 1994 MBChB, University of Free State 2000 MMed (O et G), University of Free State.

Introduction:

AUB is the direct cause of a significant health care burden for women, their families, and society as a whole. Up to 30% of women will seek medical assistance for this problem during their reproductive years. 

Definition:

Abnormal uterine bleeding includes both dysfunctional uterine bleeding and bleeding from physical causes. Dysfunctional bleeding may occur when women don’t ovulate, which is characterized by irregular unpredictable bleeding, or in women who do ovulate, which is characterized by heavy but regular periods (ie, menorrhagia). Physical causes include fibroids, polyps, endometrial cancer, and pregnancy complications. Abnormal bleeding can also result from contraceptive methods.

Management:

A thorough history and physical examination will be done by your doctor. Special investigations will include a pregnancy test, thyroid function test, full blood count, and blood tests that determine if there is not an underlying bleeding tendency.

A trans vaginal ultrasound will determine any physical causes ie endometrial polyps, fibroids or complicated pregnancies.

Treatment options:

There are several treatment options for abnormal bleeding. Your treatment will depend on the cause of your bleeding, your age, and whether you want to get pregnant in the future. Your doctor will help you decide which treatment is right for you. Or you and your doctor may decide to wait and see if the bleeding improves on its own. Some treatment options include the following:

Birth control pills. 

Birth control pills contain hormones that can stop the lining (endometrium) of your uterus from getting too thick. They also can help keep your menstrual cycle regular and reduce cramping.

Intrauterine Systems (IUS). 

An IUS is a small, plastic device that is inserted into your uterus through your vagina to prevent pregnancy. It releases a hormone called progestogen, at a rate of 10 micrograms per day over a period of 5 years. This can significantly reduce abnormal bleeding. 40% of women stop completely, 40 % has a significant reduction of bleeding, and 20 %, like with birth control pills, can contribute to abnormal bleeding.

A D&C, or dilation and curettage. 

A D&C is a procedure in which the opening of your cervix is stretched just enough so a surgical tool can be put into your uterus. Your doctor uses this tool to scrape away the lining of your uterus. The removed lining is checked in a lab for abnormal tissue.

If you’re having heavy bleeding, your doctor may perform a D&C both to find out the problem and to treat the bleeding. The D&C itself often makes heavy bleeding stop, although it very seldom a long term solution

Hysterectomy.

This is a procedure that removes the uterus. You won’t have any more periods and you won’t be able to get pregnant. A hysterectomy is major surgery that has potential complications, and it may require a long recovery period.

Endometrial ablation.

It is a surgical procedure that destroys the lining (Endometrium) of the uterus.

Several techniques have been developed over the years with variable results. The procedure is done in a hospital under general or local anaesthesia combined with sedation.

The uterine cavity is first evaluated by a hysteroscopy (camera investigation), to exclude and treat physical pathology such as fibroids or polyps, and also to determine the uterine size.

Different devices are available, but the aim is to destroy (ablate) the endometrium (uterine lining), to prevent it from preparing for a pregnancy, and in the process, decrease or stop the menstruation completely.

Risks:

The most common complications may include perforation of the uterus, infection (endometritis), or the formation of a haematometra (Fluid collection in the uterine cavity)

Expected outcome:

  • +-70% will stop completely (less under the age of 40 years)
  • 85-90% will be satisfied with the decrease in bleeding volume
  • 16% might undergo a hysterectomy in the future due to other pathology for example adenomyosis (endometriosis of the uterus), or haematometra

Conclusion:

Every patient should be individualized regarding treatment options offered for AUB.

If the family is completed, and a more permanent solution is required, an endometrial ablation can be considered before a hysterectomy. It is less invasive and offers a much shorter down time. It must however be emphasised that, although it is not a contraceptive method, a pregnancy is not possible after an ablation. Additional contraception should be used to prevent complicated pregnancies like tubal or cornual pregnancies, therefore, a sterilization is often performed at the time of an ablation.

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