Endometriosis and Abnormal Uterine Bleeding (AUB)

Abnormal uterine bleeding (AUB) is defined as menstrual bleeding of abnormal quantity, duration, or schedule. AUB is a major health problem requiring hospital admission in reproductive-aged women and is associated with blood loss, decreased sexual and reproductive health, and increased use of health care. AUB is a common gynecologic complaint, accounting for one-fourth of gynecologic operations and one-third of outpatient visits to gynecologists. Approximately 10% of women experience AUB at least once in their lifetime. AUB is also known as heavy menstruation, heavy flow with clots, and prolonged and heavy periods. Often associated with uterine pain due to cramps, AUB can lead to anemia and decreased quality of life. Adenomyosis, endometriosis, and fibroids along with uterine polyps are the most common causes of AUB. 

Classification

The International Federation of Gynecology and Obstetrics (FIGO) introduced a revised classification system for AUB to avoid poorly defined or confusing terms used previously (eg, menorrhagia, menometrorrhagia, oligomenorrhea). The terms “menorrhagia” and “dysfunctional uterine bleeding” were discontinued and replaced with the terms “heavy menstrual bleeding” and “endometrial dysfunction”, “coagulopathy” or “ovulatory dysfunction”.

The classification system is referred to as PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) (Table 1).

Table 1. FIGO classification of abnormal uterine bleeding

Symptoms of AUB

AUB covers the full range of symptoms of abnormal bleeding. When reporting symptoms, the clinician should consider at least the previous six months. When assessing regularity, the cycle length is defined as the number of days from the start of one period until the start of the next. Table 2 shows the normal reference values for menstrual bleeding. Any abnormalities other than these values are named as AUB.

Table 2. The normal reference values for menstrual bleeding

Diagnosis of AUB

In a patient with a complaint of abnormal bleeding, pregnancy status and reproductive status should be evaluated initially. This guides the further evaluation, differential diagnosis, and disposition of the patient. Detailed gynecologic and obstetric history including menstrual history, sexual history, history of obstetric or gynecologic surgery, and contraceptive history should be obtained. Chronic medical comorbid conditions (thyroid disease, autoimmune disease such as celiac disease, etc) and any medication use such as anticoagulants should be investigated to differentiate the source of the bleeding. The bleeding pattern including volume, frequency, duration, and regularity should be questioned. Following this evaluation, vital signs and general physical health should be assessed. Upon understanding that the bleeding is of uterine origin, further physical and gynecological examinations should be performed.

Most women of reproductive age with AUB should be evaluated initially with a pregnancy test and complete blood count. Thyroid function tests, prolactin levels, hormonal levels (FSH, estradiol, testosterone, etc), and coagulation tests (pt/ptt/fibrinojen/vwf panel) are selective and their use depends on information obtained during the medical history and physical examination.

Transvaginal ultrasound and hysteroscopy are helpful imaging methods to eliminate pathologic structural lesions including polyps, leiomyomas, adenomyosis, and malignant conditions. Pelvic ultrasound is the first-line imaging method for these women. Saline infusion sonography (SIS) or sonohysterography is a technique in which sterile saline is instilled into the endometrial cavity and a transvaginal ultrasound examination is performed simultaneously. This procedure is better to evaluate uterine architecture and detect lesions (eg, polyps or small submucous fibroids) that may be missed or poorly defined by transvaginal sonography alone. Hysteroscopy is an alternative to evaluate the uterine cavity. This technique also allows the biopsy or excision of lesions identified during the procedure.

Endometrial sampling typically as an office biopsy should be performed in women having an increased risk of endometrial hyperplasia or cancer. The evaluation of coexisting pelvic pain with abnormal uterine conditions with heavy bleeding and clots should not impinge on pelvic floor evaluation, uterine prolapse, and myofascial fibrosis.

Treatment of AUB

The goal of initial therapy should be to control the bleeding, treat anemia (if present), and restore quality of life. The choice of treatment depends on etiologic reason, the severity of bleeding, associated symptoms, contraceptive use and needs, plans for future pregnancy, comorbid conditions, and patient preferences. Medical attention is necessary for most women with AUB in an outpatient setting. Emergency medical care may be required if there is an exacerbation of AUB. Empiric treatment without further evaluation is not appropriate in these women due to missing a primary etiology that may be corrected or masking symptoms of neoplastic disease.

Following the differential diagnosis, the first-line therapy of AUB consists of non-hormonal treatments including non-steroidal anti-inflammatory drugs (NSAİD), tranexamic acid, desmopressin, and progestin-based hormonal treatments including combination oral contraceptives (OCs), the 52 mg levonorgestrel-releasing intrauterine device (IUD) with a release rate of 20 mcg/day, and high-dose progestin-only oral medications. Other medical treatments (eg. Danazol, Gonadotropin-releasing hormone agonists) are either less effective or have several adverse effects.

Surgical treatment is necessary for women having structural lesions (eg. leiomyomas, endometrial polyps) and/or who have completed childbearing. Minimally invasive methods including hysteroscopic or laparoscopic approaches can be preferred to minimalize further blood loss. Excisional techniques (eg. polypectomy, myomectomy) are often preferred in women of reproductive age. Hysterectomy is a definitive treatment modality in women who have completed childbearing.

Women with acute AUB, which is defined as a uterine bleeding episode that is of sufficient quantity to require immediate intervention to prevent further blood loss, should be managed immediately. These women require a detailed evaluation in an urgent care facility and should be treated with intravenous conjugated estrogen, tranexamic acid, oral contraceptives, or multidose oral progestins. Medical management may not treat the real cause, however. Hysteroscopic visualization of the cavity, hysteroscopic surgery with curettage, polypectomy, and fibroid resection are conservative approaches that may be necessary. Definitive treatment with hysterectomy may eventually be necessary. Adjunct management of pain with myofascial release, trigger point injections targetting pudendal and sciatic nerves, and acupuncture can lead to limited, temporary, and variable results.

The decision for treatment should be patient-centered considering the patient’s clinical presentation, age, the severity of symptoms, reproductive desires, other comorbidities, side effects and complications related to medical treatment and surgery as well as cost.

Author
Tamer Seckin, MD
Date: January 11, 2021

Dr. Seckin is an endometriosis specialist and women’s reproductive health advocate. He has been in private practice for over 30 years at Lenox Hill Hospital with a team of highly skilled personnel.

Dr. Seckin specializes in advanced laparoscopic procedures and is recognized for his expertise in complex cases of deep infiltrating endometriosis of the pelvis. He is particularly dedicated to performing fertility-preserving surgeries on cases involving the ovaries.

He has developed patented surgical techniques, most notably the “Aqua Blue Excision” technique for a better visualization of endometriosis lesions. His surgical techniques are based on precision and microsurgery, emphasizing organ and fertility preservation, and adhesion and pain prevention.

Dr. Seckin is considered a pioneer and advocate in the field of endometriosis.