Abnormal uterine bleeding: A Quick Guide To Evaluation And Treatment
After vaginitis, abnormal bleeding is the main reason women consult a gynecologist. Fortunately, the armamentarium is as broad as the range of etiologies.
Women who smoke often have difficulties with abnormal bleeding. Nicotine is detrimental to the ovaries and is associated with irregular menses and premature ovarian failure. I pressure smokers to stop, as they seem to fail medical therapy more frequently than any other group. I also encourage overweight patients to lose weight. Stress, depression, eating disorders, and excessive exercise also should be addressed.
Submucosal fibroids and endometrial polyps. These lesions vary in number, location, and size. When they are present, the altered endometrial surface area, increased fragility and vascularity, other endometrial irregularities, and atypical prostaglandin levels contribute to abnormal bleeding. Intracavitary lesions also may coexist with anovulatory and ovulatory cycles.
As I mentioned earlier, office hysteroscopy and SIS are the most accurate methods of detecting these lesions. Treatment generally consists of outpatient hysteroscopic myomectomy or polypectomy, which is quick, safe, eases symptoms, and is associated with high levels of patient satisfaction.17
Intramural fibroids. Intramural fibroids can cause disturbances in menstrual flow. Although the mechanisms of action are unclear, these disturbances probably result from topographic endometrial abnormalities, glandular atrophy overlying the fibroid, venous congestion, increased endometrial surface area, or an alteration in prostaglandin levels.
The type of therapy offered depends on the patient’s desire for pregnancy or preservation of the uterus. Basically, there are 3 options: removing or destroying the fibroids or removing the uterus. When future fertility is desired, the patient typically undergoes abdominal or laparoscopic myomectomy, with the surgical route contingent upon the number, size, and location of fibroids, as well as the surgeon’s level of skill and experience.
Attempts to resect large intramural fibroids hysteroscopically should be avoided in patients who have not completed childbearing, since scarring and/or the obliteration of a significant portion of the endometrium overlying the fibroid can lead to infertility.
When the patient experiences heavy menstrual bleeding and does not wish to preserve her fertility, she may be offered a minimally invasive outpatient procedure called uterine artery embolization (UAE). In this procedure, a catheter is inserted transcutaneously and threaded through the femoral artery into the aortic bifurcation and then to the contralateral uterine artery, which is then occluded. Several products are used for UAE, including Embosphere Microspheres (BioSphere Medical, Rockland, Mass), polyvinyl alcohol (PVA) particles, coils, or gelfoam, cutting off blood flow to the fibroid. The fibroid then necroses and shrinks in size and volume. Of the many symptoms associated with fibroids, menorrhagia is most effectively controlled with UAE. In fact, patients have an 85% to 95% chance of resolving symptoms of menorrhagia after undergoing this procedure.18
Hysterectomy offers definitive therapy for patients who have completed childbearing and have no desire for uterine preservation. Either vaginal, laparoscopic-assisted, or abdominal hysterectomy is an option. Factors influencing selection of the surgical route include the number, size, and location of the fibroids, as well as any concomitant pelvic pathology and the surgeon’s skill. (See “Complex hysterectomy: opting for the vaginal approach”.)
Conclusion
After the initial history, physical examination, and laboratory evaluation, the factors involved in abnormal uterine bleeding usually are well defined. Medical management is the standard unless uterine pathology is present. Most patients respond favorably to hormonal manipulation with OCs or progesterone. Another effective option, particularly for women who cannot tolerate traditional medical therapy, is the levonorgestrel-releasing IUS.
Endometrial ablation offers 90% success for the treatment of menorrhagia and dysfunctional bleeding in women with a normal uterine cavity and negative laboratory workup, provided they do not desire children.
Patients with intrauterine polyps and submucosal fibroids have excellent relief of symptoms following operative hysteroscopy. Also, uterine artery embolization is an excellent nonsurgical intervention for patients with fibroids and menorrhagia who wish to avoid major surgery. Fortunately, in this era of many alternative medical and surgical treatments, hysterectomy is the last resort for abnormal uterine bleeding.
Dr. Bradley reports that she serves as a speaker and consultant/preceptor for Olympus.
