Managing the flow

ABNORMAL UTERINE BLEEDING

Managing the flow

Even small aberrations in the menstrual cycle may mean physiological imbalance. Do not neglect any telling signs, advises Dr Leelavathi Devadas

A normal uterine bleeding in a woman lasts for three to four days. During these days, no more than three to four fresh pads should be changed in a day. A regular period should appear once in about 28 days and she should not experience greater pain than perhaps just a feeling of low abdominal cramps.

Besides these, the menstrual cycle should start when the girl is around 12-14 years of age and must stop when the woman is approximately 45-48 years old.

When there are anomalies in this cycle, like menstruation starting at an abnormally young age or continuing well beyond 50 years, it is termed abnormal uterine bleeding (AUB). The process of menstruation is under the complete control of the ovaries, which are governed by the hormones of pituitary and hypothalamus glands.

Thyroid, and to a certain extent, adrenals too have a say in it. Any variation in the quantity and timing of these hormones will inevitably disturb either the regularity of menstrual periods and/or the amount of blood loss. Abnormality in the clotting mechanism may also be a culprit.

When the cause of AUB is purely hormonal, no organic lesions will be present. This situation, formerly called dysfunctional uterine bleeding, needs thorough investigation of the various hormonal levels. The pituitary gland, a tiny ductless organ situated at the base of the brain, is controlled by the hypothalamus, which produces certain endocrines to incite the release of the pituitary hormones. These reach the ovaries via the blood stream.

The ovaries then respond  to them and secrete the key female hormones - oestrogen and progesterone. Oestrogen is in control during the first half of the menstrual cycle, whereas progesterone governs the second half. Any ups and downs in the complex orchestra of events will provoke significant abnormality in the delicate mechanism of menstruation.

Cause for worry

Why should we be worried if uterine bleeding gets abnormal? Because, it has a negative impact on the woman’s general health and wellbeing, as it induces anaemia. The quality of her life is affected, as is her sexuality and fertility. AUB should be viewed with concern, especially if the problem lasts for more than six months.

When the woman consults a gynaecologist about AUB, any pregnancy is first excluded. Similarly, organic etiologies like uterine polyps, fibroids, malignancies and the like are also looked into and treated accordingly, if present. Here, pelvic ultrasound screening (either abdominal or vaginal) and hysteroscopy come in handy. If the woman is over 40 years of age, an endometrial biopsy is a must.

Latrogenic causes like intrauterine contraceptive device, unscientific use of sex steroids  and so on, must be thought of and corrected. A detailed blood test for coagulation dysfunctions must also be done. Ovarian disorders are diagnosed by a careful gynaecological examination and imaging. Thyroid tests must be done. Pelvic Inflammation could also be the mischief-maker.

While treating AUB, anaemia should also be simultaneously corrected. When there is hormonal imbalance, progesterone is usually given in the second half of the menstrual cycle. Oral contraceptive pills in proper dosage may also be advised. Pituitary hormones are at times given. The thickened hyperplastic lining of the uterus (endometrium) is either curetted and sent for histopathological examination, or endometrial ablation is performed in selected cases. These are just outpatient procedures.

Nowadays, thermal and ballooning methods are also in practice.

So, when do we think of removing the uterus (hysterectomy) in such cases? This procedure is proposed when hormone therapy has not been effective or when the woman already has sufficient number of children and has no desire for any more. Hysterectomy alone (routine/laparoscopic) will not have any deleterious effect on the woman’s body as this organ does not produce any hormone on its own. The patient need not have any apprehensions on this score, because it becomes a redundant organ after the child-bearing age.

In case, the ovaries also have to be removed, the woman is invariably given hormone replacement therapy for a particular period. If the problem is overweight or anxiety syndrome, efficient counseling will help. If the ovaries are polycystic, it is treated with insulin-sensitisers.

All will be well if AUB is diagnosed and treated in time. But, unfortunately, many women are hesitant to disclose it. They tend to hide this debilitating aberration until it reaches a stage needing complicated redressal. Always remember that a stitch in time will prevent further complications.

(The author is gynaecological consultant and medical writer)

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