Abnormal Uterus Bleeding- Obstetrics and Gynecology

Abnormal uterine bleeding (AUB) is unusual bleeding from the uterus. This can occur between monthly cycles or constitute an exceptionally heavy period or prolonged bleeding.

Pregnancy, fibroids, polyps, thyroid problems, hormonal abnormalities, an infection of the cervix, vagina, or uterus, and in rare instances, malignancy are potential causes of abnormal uterine bleeding.

Your healthcare provider may order several tests to diagnose abnormal uterine bleeding. Procedures such as endometrial ablation, uterine artery embolization, myomectomy, hysteroscopy, and hysterectomy can treat abnormal uterine bleeding.

Diagnosing Abnormal Uterine Bleeding

When attempting to identify the cause of abnormal uterine bleeding, your healthcare practitioner will ask several questions. These questions may include the following:

• Are you expecting?
• Have you observed what triggers the bleeding?
• Are there any other symptoms that you have noticed?

This is followed by a physical examination, including a pelvic and cervical exam. This may also include a pap smear.

Tests for diagnosis

When determining the cause of abnormal uterine bleeding, your doctor may recommend several tests or treatments. These tests could consist of the following:

1. A pregnancy test

Miscarriages result in significant bleeding, and you can test positive for pregnancy 35 days after a miscarriage. Additionally, slight bleeding is typical in the early stages of pregnancy.

2. Blood tests

Your doctor may prescribe a complete blood count and examine blood clotting ability.

3. Thyroid examination

Problems with your thyroid function may also indicate ovarian dysfunction, which may be the source of your bleeding.

4. Checking hormone levels

Hormonal imbalances could bring on abnormal bleeding, or it could be a symptom of another ailment.

5. Hysteroscopy

A hysteroscopy evaluates the lining of your uterus (endometrium). This examination looks for polyps, fibroids, or features of malignancy. It can be a part of both the diagnostic and treatment processes.

Diagnostic hysteroscopy identifies any structural issues of the uterus that could be causing abnormal bleeding. Additionally, hysteroscopy may be utilized to confirm the results of additional exams, such as an ultrasound or hysterosalpingography (HSG).

6. Pelvic ultrasonography

With imaging, your doctor can look for any growths in your reproductive organs that might be the source of your bleeding. A sonohysterogram, also known as saline-infusion sonography, is a very sensitive imaging treatment that can help in locating abnormal uterine structures like polyps or fibroids.

7. Endometrial biopsy

During this test, tissues from your endometrium are sampled. In addition, your healthcare provider may take tissue samples from the lining of your uterus and examine them for signs of cancerous or pre-cancerous cells.

Treatment of Abnormal Uterine Bleeding

Treatment of AUB depends on the underlying cause. Several options are available to manage bleeding or treat the cause.

Non-surgical options

Medications that are commonly used to treat AUB include:

• Progestin (can be injected or implanted inside your uterus).
• Birth control pills.
• Nonsteroidal anti-inflammatory drugs (NSAIDs).
• Gonadotropin-releasing hormone (GnRH) antagonists can control heavy menstrual bleeding caused by fibroids.
• Gonadotropin-releasing hormone (GnRH) agonists might momentarily stop or lessen bleeding by delaying ovulation.

Surgical options

Several procedures can treat AUB, such as:

Uterine artery embolization

Uterine artery embolization (UAE) is a minimally invasive procedure. The term is frequently used interchangeably with uterine fibroid embolization (UFE) and uterine artery embolization (UAE). They are distinct, though. UFE is a specific type of UAE used to treat uterine fibroids.

Uterine fibroids and several other diseases that might result in vaginal bleeding are treated using Uterine Artery Embolization. During this procedure,  tiny particles similar in size to sand grains are injected into the arteries that supply blood to your uterus.

Then, fluoroscopy, a type of X-ray that records moving images, is used to guide these particles into your uterine arteries using a small, flexible tube (referred to as a catheter). When these particles obstruct uterine blood vessels, excessive bleeding can be stopped. In addition, due to the interruption in blood supply, tumors or fibroids diminish in size.

What to expect?

A hospital stay is not usually necessary for uterine artery embolization (UAE). Generally, the entire process lasts 90 minutes.

An interventional radiologist carries out the operation using medical imaging to guide minimally invasive procedures. As you lay down on an examination table, your vital indicators, such as your heart rate and blood pressure, will be monitored. The skin around your groin is treated with an anesthetic (pain reliever) to numb the area.

An intravenous (IV) line is used to administer sedative drugs and fluids to you. Your femoral artery is punctured at a small spot on your skin close to your groin, and a thin needle is then inserted. The catheter used to access your uterine arteries is guided there using contrast dyes and an X-ray (fluoroscopy). In an X-ray, the dye illuminates to show your doctor where your arteries are located and how blood travels to your uterus.

Once in position, the catheter releases small, plastic or gelatin-based particles known as embolic agents that will obstruct blood flow from your arteries to your uterus.

The catheter is eliminated after use. After stopping any bleeding at the puncture site, a bandage is put on.

Myomectomy

Uterine fibroids often referred to as leiomyomas, are removed from the uterus through a myomectomy technique. There are three ways in which a myomectomy can be performed:

• Open myomectomy (or abdominal myomectomy)
• Robotic or laparoscopic myomectomy, which is minimally invasive
• Hysteroscopic myomectomy

The number, size, and location of fibroids, as well as other variables, will all affect the type of myomectomy you will have. A surgeon performs an open myomectomy (abdominal myomectomy) through an incision in your belly. The cut may be horizontal (across) or vertical (up and down). Because the surgeon can examine all of your pelvic organs during this type of treatment, it may be the best choice for exceptionally large fibroids.

Like any other major operation, an open myomectomy requires a similar recovery time. First, you will be hospitalized for a few days. Then, it could take up to six weeks before you get back to your daily routine.

A myomectomy can also be performed using a variety of minimally invasive techniques. Generally, these procedures are easier on your body and have a shorter recuperation time.

During a laparoscopic or robotic myomectomy, your surgeon inserts a small, illuminated telescope through your navel. The surgeon will then make additional minor incisions on your abdomen, inserting surgical instruments to help remove the fibroids.

The fibroids are then removed either through your vagina or the tiny abdominal holes. During this kind of surgery, some surgeons employ a robot to direct the movement of their instruments (robotic myomectomy).

In a single port myomectomy, all the surgical tools are inserted through a single aperture close to the belly button.

Hysteroscopic myomectomy does not require any incisions. Instead, your surgeon can remove fibroids when they are precisely located within your uterus by inserting a camera with specialized equipment through your vagina and into your uterus. Compared to other types of surgery, this one is swift.

What To Expect?

Recovery will depend on the type of surgery you undergo. Any procedure-related issues that may develop can also affect recovery. For the first few days, you can anticipate some pain.

You will be prescribed pain medication by your doctor. They will also advise you to walk around or move your legs following surgery to avoid blood clots.

After an open myomectomy, it may take up to six weeks to fully recover and resume your regular activities. You might leave the hospital on the same day after a laparoscopic myomectomy. Recovery takes two to four weeks.

Complete recovery may only take a few days if the treatment is performed hysteroscopically (via your vagina without incisions).

During the post-op period, you can anticipate the following:

• Bleeding and discharge from the vagina for a few weeks.
• During the first week following surgery, refrain from lifting anything heavier than 5 to 10 pounds. If you underwent open abdominal surgery, you might have to wait longer.
• Step up your activity level gradually. Refrain from returning to your regular activities too quickly. Instead, start carefully and keep an eye on how you feel.
• Sex is not recommended during the first six weeks following surgery.

Operative Hysteroscopy

During operative hysteroscopy, a surgeon will use a narrow, illuminated tube called a hysteroscope to see inside your uterus and your cervix through your vagina. It treats any abnormality that is detected during a diagnostic hysteroscopy.

To minimize the necessity for a second surgery, your doctor could simultaneously conduct a diagnostic and an operative hysteroscopy. Your surgeon uses a device during an operative hysteroscopy to remove anomalies that could be causing abnormal uterine bleeding.

Your surgeon will examine your medical history and assess your present state of health to decide whether a hysteroscopy is necessary. Hysteroscopy has a lot of advantages, but only some individuals are good candidates. You should not undergo a hysteroscopy, for instance, if you are expecting or have a pelvic infection.

What to expect?

Hysteroscopy is regarded as minor surgery, so an overnight hospital stay is typically not necessary. However, your doctor might advise you to spend the night in order to observe the effects of anesthesia.

Prior to the procedure, you will be asked to change into a hospital gown and empty your bladder. Then, you might be given sedatives or anesthetic medications to make you more relaxed. The type of anesthesia administered depends on whether the hysteroscopy will be performed in a hospital or at your surgeon's office, as well as whether additional procedures will be carried out concurrently.

The duration of a hysteroscopy might range from five minutes to more than an hour. Whether the operation is diagnostic or surgical, as well as whether another procedure, such as laparoscopy, is performed concurrently, determines how long it takes.

Typically, diagnostic hysteroscopy takes less time than an operative hysteroscopy. However, if you underwent anesthesia for your hysteroscopy, you might be kept under observation in the recovery area for several hours.

You can experience short-term cramps or minor bleeding. Additionally, it is normal to experience some dizziness or nausea immediately after your treatment.

Endometrial ablation

Endometrial ablation is a technique that removes the uterine lining by using heat, cold or other types of energy. Your doctor may suggest an endometrial ablation to address heavy periods if they are a concern.

You might experience no bleeding, reduced bleeding, or no change in your menstrual bleeding after endometrial ablation. The procedure may be used when drugs are ineffective at controlling severe bleeding.

You may be a good candidate for endometrial ablation if you have had a tubal ligation (tubes tied) and are absolutely certain you do not want to get pregnant, your partner has had a vasectomy, or you are willing to utilize birth control.

Endometrial ablation may also be suitable if your doctor cannot identify a medical condition such as thyroid illness or cancer as the reason for your heavy periods.

The procedure is only appropriate for some, though. Your doctor will assess your bleeding to see if endometrial ablation is suited for you. Generally speaking, endometrial ablation is not advised in the following scenarios:

• Your uterus has an abnormal shape or uterine muscle wall weakness
• You have uterine, cervical, or endometrial cancer
• You have an infection affecting the cervix or vagina or pelvic inflammatory disease
• You use an intrauterine device
• You were pregnant recently or underwent C-section involving a classic or vertical incision
• Some women with fibroids or who have undergone specific uterine procedures are ineligible for endometrial ablation
• You or your partner have not undergone tubal ligation or vasectomy, and you are unwilling to utilize birth control following the operation
• You have attained menopause

What to expect?

Endometrial ablation may be done in the operating room or the office. You will be given a gown and an IV and asked to position yourself on a table same as during a pelvic exam. Before the endometrial ablation, you can be given medication to deal with post-procedure discomfort. Your healthcare practitioner may numb your pelvic area and administer sedatives, depending on the type of endometrial ablation. This will ensure you do not experience any pain or discomfort throughout the process.

Your doctor inserts thin, wand-like equipment into your vagina to perform endometrial ablation. This tool enters your uterus through your cervix and can access the lining. The gadget sends energy, heat, or cold to partially obliterate the lining, depending on the type of endometrial ablation being performed. Because of the technology, the process is short, and you should feel little to no pain.

Following endometrial ablation, you will undoubtedly notice some changes. However, there is no need for concern because they are typical. Give yourself time to heal.

You might experience nausea and need to urinate more on the first day after the surgery. After endometrial ablation, cramping, like those from a period, could last from one to three days. You can experience minor bleeding or pink discharge for a few weeks afterward.

The second and third days following the treatment are typically the most intense. Bleeding expels the destroyed lining of the uterus, preventing heavy menstruation later. Refrain from douching or using a tampon for the first three days following the surgery.

Hysterectomy

During a hysterectomy, the uterus and, in many cases, the cervix is surgically removed. Depending on the goal of the procedure, a hysterectomy may require the removal of surrounding organs and tissues as well, such as the ovaries and fallopian tubes. Based on your circumstances, your healthcare professional will discuss the kind of hysterectomy required.

The following are the different types of hysterectomy:

1. Total hysterectomy: This involves the removal of the uterus and cervix, but not the ovaries.
2. Supracervical hysterectomy: During this procedure, only the upper portion of the uterus is removed, leaving the cervix intact.
3. Total hysterectomy with bilateral salpingo-oophorectomy: This involves the removal of the uterus, cervix, fallopian tubes (salpingectomy), and ovaries (oophorectomy). Removing your ovaries will cause menopausal symptoms if you have never gone through it.

4. Radical hysterectomy with bilateral salpingo-oophorectomy: This constitutes the removal of your uterus, cervix, fallopian tubes, ovaries, the upper region of your vagina, some surrounding tissue, and lymph nodes. When malignancy is present, this kind of hysterectomy is done.

What to expect?

After changing into a hospital gown, sensors that track your heart rate will be attached to you. Next, an intravenous (IV) line is inserted into a vein in your arm to deliver medications and fluids.

Subsequently, you will either be administered general anesthesia, in which you will not be conscious during the procedure, or regional anesthesia (also known as epidural or spinal anesthesia), in which drugs are injected close to the lower back nerves to "block" pain while you are conscious.

The procedure may last for 1-3 hours. The length of time can vary depending on the size of your uterus, the presence of other tissues, the necessity to remove scar tissue from prior operations, and whether or not other organs are being removed along with your uterus (like your fallopian tubes or ovaries).

Your healthcare professional may choose one of the numerous surgical techniques to carry out a hysterectomy.

An abdominal hysterectomy removes your uterus through a six- to eight-inch-long abdominal incision. The incision is made either across the top of your pubic hairline or from your belly button to your pubic bone. The wound will be closed by the surgeon using stitches or staples.

This procedure is preferred when the abnormal bleeding is due to cancer, the disease has spread to other areas of the pelvis, or if the uterus is enlarged. However, it typically requires a longer recovery time and an extended hospital stay (two or three days).

In comparison, during a laparoscopic hysterectomy, a laparoscope is placed into your lower abdomen through a tiny belly button incision. Then, several further small incisions are used to implant surgical instruments.

Your uterus can be taken out in little parts through the incisions in your belly or through your vagina. Some patients leave the hospital the same day or the following morning. Compared to an abdominal hysterectomy, full recovery is quicker and less painful in a laparoscopic hysterectomy.

References:

• https://www.ncbi.nlm.nih.gov/books/NBK532913/
• https://www.ncbi.nlm.nih.gov/books/NBK459245/
• https://www.ncbi.nlm.nih.gov/books/NBK519016/
• https://pubmed.ncbi.nlm.nih.gov/28447445/  
• https://www.ncbi.nlm.nih.gov/books/NBK564345/  
• https://www.ncbi.nlm.nih.gov/books/NBK564366/

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