विवरण
Abnormal uterine bleeding (AUB) is a significant concern that can affect women in both premenopausal and postmenopausal stages. In premenopausal women, AUB may manifest as irregular or heavy menstrual bleeding, often due to hormonal imbalances, uterine fibroids, or polyps. The evaluation typically involves a thorough history, physical examination, and sometimes imaging or endometrial biopsy to identify the underlying cause. In postmenopausal women, any vaginal bleeding after 12 months of amenorrhea is considered abnormal and requires immediate evaluation to rule out endometrial cancer or other serious conditions. Transvaginal ultrasound and endometrial sampling are essential diagnostic tools in this population. Management strategies vary depending on the cause, and may include medical treatments, hormonal therapies, hysteroscopic procedures, or, in severe cases, hysterectomy.
सारांश
- Abnormal Uterine Bleeding (AUB) affects women of all ages, impacting their physical, emotional, sexual, and professional lives. Normal menstrual cycles involve approximately 80 ml of blood loss over 2-7 days, with a cycle length of 28-35 days. AUB is defined by changes in frequency, duration, or amount of menstrual flow. Causes can be organic (related to reproductive organs or hormones) or non-organic (systemic diseases, medications).
- Organic causes of AUB include malignancy, infections, fibroids, and polyps. Non-organic causes include blood disorders (Von Willebrand's disease, leukemia), thyroid dysfunction, cirrhosis, and medications like contraceptives, steroids, and certain psychiatric drugs. AUB can be ovulatory or anovulatory, the latter being more common in adolescent and perimenopausal women due to continuous estrogen production without progesterone.
- The FIGO classification system for AUB, known as PALM-COEIN, categorizes causes as structural (polyp, adenomyosis, leiomyoma, malignancy/hyperplasia) or non-structural (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified). Heavy menstrual bleeding (HMB), formerly menorrhagia, involves regular cycles with excessive flow or prolonged duration, often with blood clots. Intermenstrual bleeding occurs between periods.
- Diagnosis involves evaluating bleeding patterns (frequency, interval, duration, amount), physical examination, and diagnostic tests. Physical examinations include abdominal and pelvic exams. Diagnostic evaluations include Pap smears, cervical cultures, pregnancy tests, hemoglobin levels, serum ferritin, thyroid tests, coagulation tests, and endometrial biopsies (especially in perimenopausal women).
- Medical management of AUB includes NSAIDs to reduce prostaglandin levels, antifibrinolytic agents like tranexamic acid, and hormonal treatments. Progesterone-releasing intrauterine devices (IUDs) like Mirena are commonly used in perimenopausal women. Gonadotropin-releasing hormone (GnRH) agonists induce a reversible hypogonadal state to reduce uterine and myoma volume.
- Surgical management options include dilation and curettage (D&C) for both diagnosis and treatment, endometrial ablation (cryoablation, laser ablation, radiofrequency ablation) to destroy the endometrium, and hysterectomy as a permanent solution for women who have completed childbearing. The choice of treatment depends on the patient's age, symptoms, desire for future fertility, and overall health.
- Postmenopausal bleeding (PMB) requires prompt evaluation to rule out endometrial cancer. Common causes include atrophic endometritis or vaginitis, endometrial polyps, and endometrial hyperplasia. Risk factors for endometrial cancer include early menarche, nulliparity, history of chronic anovulation, obesity, hypertension, diabetes, and tamoxifen use. Treatment depends on the underlying cause and may include topical estrogen, polyp removal, or hysterectomy.
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