An ideal menstrual cycle lasts for 28 days, with the first day calculated from the onset of menstrual bleeding and ovulation is at day-14 of the cycle. Normal menstrual cycle has a mean interval of 21-35 days, with a duration of 2-7 days and 30-80ml menstrual bleeding.
Anything outside these range may be viewed as abnormal. These can be:
- menorrhagia: excessive (>80ml/day) or prolonged (>7 days) bleeding
- polymenorrhea: menstrual bleeding interval <21 days
- oligomenorrhea: menstrual bleeding interval >35 days
- metrorrhagia: irregular and more frequent menstrual bleeding
- metromenorrhagia: irregular, more frequent and excessive bleeding
- dysmenorrhea: excessive menses pain
- amenorrhea: absent of menstrual bleeding for >6 months
- intermenstrual bleeding: bleeding/spotting in between regular menstrual cycles
- postmenopausal bleeding: bleeding after >6 months menopause
Important causes of abnormal menstrual bleeding that need to be ruled out:
- Pregnancy and its related complication
- Gynecological pathology
- Benign lesion
- uterine fibroid/polyp
- cervical polyp
- adenomyosis
- polycystic ovary syndrome
- Non-benign lesion
- uterine cancer
- ovarian cancer
- cervical cancer
- vaginal cancer
- endometrial cancer
- endometrial hyperplasia
- Pelvic inflammatory disease
- cervicitis
- salpingitis
- endometritis
- Trauma
- cervix
- vagina
- vulva
- Endocrine disorders
- Hyperthyroidism
- Hypothyroidism
- Hyperprolactin
- Blood clotting disorders
- Thrombocytopenia
- Von-Willebrand's disease
- Coagulopathy
- Iatrogenic
- Oral contraceptive pills
- Intrauterine contraceptive devices
- Medication
- anti-coagulants
- Dysfunctional uterine bleeding (diagnosis of exclusion in the absence of organic disease)
- Stress / Excessive exercise etc.
Dysfunctional uterine bleeding is more common in the extremes of reproductive age, which are the first 2 years after the onset of menses (menarche) and a few years before the termination of menses (menopause). About 90% of the abnormal bleeding is anovulatory, in which there is no ovulation within the cycle because of certain disruption in the hypothalamus-pituitary-ovary axis.
Important investigations for abnormal uterine bleeding
- pregnancy test
- pelvis ultrasound scan
- blood test: platelet, coagulation, thyroid function, prolactin
- hysteroscopy
- endometrial sampling/biopsy
Endometrial biopsy
The treatment depends on the underlying cause of abnormal bleeding. If no organic disease can be found (dysfunctional uterine bleeding), treatment available includes:
- Tranexemic acid
- NSAIDs
- Danazol (ethisterone)
- GnRH agonists
- Combined oral contraceptive pills
- Progesterone only pills
- Intrauterine devices with progesterone
- Endometrial ablation (if future pregnancy not wanted)
- Hysterectomy (if future pregnancy not wanted)
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