In adolescents, heavy menstrual bleeding can lead to emotional distress, absenteeism from school, social withdrawal and anaemia. Photograph used for representational purposes only.
| Photo Credit: SAMPATH KUMAR GP
Menstrual disorders are fairly common during a woman’s reproductive years, and can cause significant physical and psychological distress.
Normal menstruation starts at menarche, around age 12, and lasts till menopause around age 50. This bleeding is controlled by the hypothalamo-pituitary-ovarian axis, and consists of cyclical changes in the ovary as well as the endometrium (inner uterine lining). Normal menstruation consists of blood and uterine cellular debris. It usually lasts between 2 and 7 days and occurs every 21 to 35 days.
What is abnormal uterine bleeding?
Abnormal uterine bleeding may include the following conditions: prolongation of bleeding beyond seven days, heavy bleeding, clots are present, or bleeding that stains clothes or causes anaemia, bleeding that is more frequent than once in 21 days, delayed more than 35 days, when bleeding occurs intermenstrual, post-menopausal or where the cyclical pattern is lost. The term ‘dysfunctional uterine bleeding’ implies that there is no structural or pathological cause for this, but only an endocrine abnormality.
The causes of abnormal uterine bleeding in teenage are anovulation (when the ovaries do not release an egg during a menstrual cycle), pelvic infection, use of hormonal pills, disorder of coagulation and hormone-producing tumours. In the reproductive years, the causes are pregnancy, polyps (abnormal growth of tissue), adenomyosis (a condition where the tissue lining the uterus grows into the muscular wall of the uterus), fibroids, anovulation, endometrial hyperplasia (a condition where the lining of the uterus becomes abnormally thick) and endometrial cancers. In the peri-menopausal age group, anovulation, endometrial hyperplasia, endometrial cancer and endometrial atrophy (thinning of the uterus lining) are more likely.
The goals of management are based on the age of the patient, desire for fertility, family history of cancers and functional disability. Investigations would include checking haemoglobin levels, renal and liver function, coagulation disorders, ultrasound scans, cervical cytology and an endometrial biopsy. The doctor would want to know about prior investigations and treatments and establish the cause of the bleeding problem. Patients would be advised on menstrual hygiene and how to keep a menstrual diary. The pattern of bleeding needs to be assessed over a few months. Severe bleeding may need to be controlled and anaemia corrected with iron supplements or blood transfusions. Pain may also be a problem that needs to be alleviated.
In adolescents, heavy menstrual bleeding can lead to emotional distress, absenteeism from school, social withdrawal and anaemia. After a detailed history and physical examination, tests are done to rule out liver, renal and coagulation disorders. An ultrasound scan is done to rule out fibroids and ovarian cysts. Endometrial biopsy is only rarely done.
Treating abnormal uterine bleeding
Girls are taught to cope with heavy menses by keeping track of their menses, using high absorbency pads, menstrual hygiene, staying hydrated, consuming iron-rich foods and controlling body weight. Non-hormonal medications like Tranexamic acid and Mefenamic acid are first-line treatments. If menses are not controlled with these, then hormonal treatment such as progesterone or oral contraceptive pills are prescribed. Surgery is rarely indicated for large fibroids or ovarian tumours.
In the reproductive years, pregnancy has to always be ruled out. Treatment of the underlying cause should be done. Bleeding and pain can be controlled by Tranexamic acid, Mefenamic acid, oral and injectable Progestogens, combined pills, levonorgestrel intrauterine device, mifepristone, ormeloxifene and gonadotrophin analogues. Surgery can be done endoscopically: laparoscopic, robotic or hysteroscopic. In younger women, surgery is most often organ preserving.
In the perimenopausal and post-menopausal group, malignancy and hyperplasia (increase in the number of cells in an organ or tissue) have to be ruled out. The risk of malignancy with post-menopausal bleeding is 10 to 20 %. Endometrial biopsy is a must in this age group before hysterectomy. In these women, removal of the uterus is done more readily. All treatments, both medical and surgical have complications. So, the doctor should weigh the risks and benefits as well as take into consideration the wishes and desires of the patient before embarking on any treatment. It is a principle that the simplest, safest and most cost-effective option should be chosen.
What women should know
Women should understand their body, and the changes in its physiology with time. They should not ignore menstrual problems. They should undergo regular gynaecological check-ups. Timely treatment can spare them from unnecessary psychological and physical distress. A healthy lifestyle, a preventive approach to health and good health seeking behaviours can go a long way in maintaining a good quality of life.
(Dr. Abraham Peedicayil, Dr. Akilasree P. B. and Dr. Jeyasheela Kamaraj are obstetric-gynaecologists at Naruvi Hospitals, Vellore. [email protected],[email protected], [email protected])
Published – April 08, 2025 05:26 pm IST