Abnormal Menstrual Bleeding

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)