Abnormal Uterine Bleeding

"Abnormal Uterine Bleeding" or "AUB" is a relatively common condition. Normal menstrual flow produces less than 3 ounces of blood, in a maximum of 7 days. AUB patterns are characterized by flows that are heavier, and/or more prolonged or more frequent than a 21-28 day interval. AUB can cause anemia, embarrassment, or marked inconvenience. It has been said by many so afflicted women-" I have to plan my life around my period".
 

The most common conditions associated with AUB are benign fibroid tumors, endometrial polyps, adenomyosis, uterine overgrowths (called hyperplasias), or hormonal imbalance ("dysfunctional uterine bleeding" or "DUB"). There are many but less common causes such as liver or renal disease, drug-associated bleeding disorders, blood clotting disorders, chemotherapy, infection, to name the more common of the unusual AUB associated factors. Generally speaking, the term "AUB" is NOT used in conjunction with uterine bleeding associated with complications of pregnancy. The following discussion will refer to the common conditions of AUB, and the treatment options for the patient.
 

a) Fibroids- Common benign, non-cancerous tumors, (also called "myomas" or "leioyomas") present in about 25-30% of women over the age of 30 years. Most are silent, and cause no symptoms. Unless they are extremely large (about the size of a 3-4 month pregnant uterus) nothing need be done but to observe and follow the patient. Fibroids do not grow in size indefinitely, but most often stabilize at some point, and grow no further. Fibroids may be single, or multiple; they may be located in the wall of the uterus, or protrude outwards from the uterus( and thus may press on adjacent structures such as the bladder or the rectum, causing pressure symptoms in these areas), or they may protrude into the uterine cavity itself, in which case they may be undetectable by clinical examination alone. Paradoxically, it is these small inward-protruding fibroids (called "submucous" fibroids) that are most often associated with heavy and or prolonged menstrual flow. These are detected by ultrasound examination or by direct observation with a tiny telescope ("hysteroscope") passed through the cervix into the uterine cavity (also called the "endometrial cavity", as the lining of the uterus which is shed each month with the menstrual flow is called the "endometrium"). Fibroids may be associated with other symptoms such as pelvic pressure, urinary frequency, rectal pressure, backache, and painful intercourse.
 

b) Adenomyosis - A diagnosis of exclusion, this common problem is associated with a menstrual history that is progressively heavier, often with cramps, a uterus that may be slightly to moderately enlarged, somewhat "soft" or "boggy" on examination, and quite often tender, The latter development may be the cause of evolving painful intercourse. The underlying abnormality is the extension of the superficial uterine lining (the "endometrium") burrowing more deeply into the uterine wall. Thus when the woman has her menses, there is bleeding into the wall of the uterus itself, causing it to be tender, painful, and perhaps slightly enlarged. Diagnosis may be suspected using MRI imaging (expensive!!), observation of a rather characteristic appearance of the endometrium with a hysteroscope, or totally on clinical grounds. Absolute confirmation requires a microscopic observation of uterine tissue.
 

c) Polyps- These are fleshy, almost always benign, growths from the endometrial lining. Single or multiple, the associated AUB is more likely to be characterized by irregular spotting, or pre- or post-menstrual staining. Diagnosis is readily suspected based on the history, ultrasound examination, or hysteroscopy.
 

d) Endometrial hyperplasias- These are conditions where the microscopic appearance of the endometrium is characterized by cellular overgrowth. Approaching the menopause and especially with cycles that are not associated with ovulation, the endometrium is exposed to a hormone environment that is only or primarily estrogen ( the usual progesterone environment seen in the latter half of a normal ovulatory cycle is deficient or absent altogether). Microscopic appearances differ depending on the degree of "overgrowth", as most are of little concern ( "simple cystic hyperplasia") although some have a potentially pre-malignant conotation ( "atypical hyperplasia"). The latter occasionally can be reverted to normal tissue by additional progestrone-like supplements.

Treatment Options

1) Drug/Hormone Therapy- After appropriate diagnostic procedures have been performed, your physician may recommend a trial of hormone therapy. This might include birth control pills, a supplement of a synthetic progesterone-like medication called medoxyprogesterone acetate( or an analog), an ovarian-suppressive drug called a GnRH agonist, or some thing as simple as ibuprofen. If the drug therapy is to be effective, only a trial will tell. Your specific condition might indicate that drug therapy is inappropriate.
 

2) Conservative Surgery- this term is used in contradistinction to more aggressive therapy such as hysterectomy:
 

a) Endometrial resection and/or ablation: This is an outpatient procedure in which a small telescope ("hysteroscope") is passed through the cervix, allowing access and visualization of the uterine cavity. If no submucous fibroids or polyps are present, laser or more commonly, electrical energy can be applied to the endometrium, thus destroying ("ablation") the tissue lining the uterus, and sealing the blood vessels. The largest experience to date uses a device called a "rollerball" to roll over the endometrium as the energy is being applied. This technique has a varying degree of success depending upon the operator's experience and skill level. The percentage of women who will never bleed again ("amenorrhea rate") varies from a reported 30% to about 70%; while 5-10% of procedures will fail (i.e. the bleeding pattern is no better after the procedure than before), and the rest of the patients will experience a significant reduction in the menstrual flow.
 

Actual removal of the uterine lining (endometrium) is called endometrial resection, and if this procedure is accompanied by immediate ablation, the one year amenorrhea rate is reported between 75-89%. Failure of the procedure as defined above (ie. the bleeding pattern is no better after the procedure than before) is almost zero, and the rest of the patients will experience a significant reduction in the menstrual flow.
 

If the patient has a submucous fibroid, the fibroid is shaved off until the cavity of the uterus has been returned to a normal configuration ("submucous resection"). If maintenance of fertility is desired, the procedure is terminated here; if fertility is not desired to be maintained, then the rest of the uterine lining is resected and ablated. This technique is performed in an outpatient setting, carries little risk of serious complications (in experienced hands), there is very little if any post-operative discomfort, resumption of activities is immediate, and costs compared to a hysterectomy is much less.
 

b) Balloon Ablation- This new technique has recently received FDA approval. There are several manufacturers of devices that are inserted into the uterine cavity, after which heat is applied for a short interval of a few minutes, and the endometrium is largely destroyed. All designs report an "adequate" reduction in menstrual flow, of about 90%. The amenorrhea rate is low however, about 25-30%. This technique is not approved for bleeding due to submucous fibroids or polyps. Currently, a large scale training program is underway to instruct physicians in this technology. Advantages are that it may be performed under local anesthesia in the office
 

c) Myomectomy: Fibroids may be present either within the wall ("intramural") of the uterus as mentioned earlier, or protrude outside the wall ("subserous"). AUB may be seen in this situation without submucous fibroids being present .Removal of these tumors either laparoscopically or through an open incision in the abdomen is no assurance that AUB will end. Removal of large fibroids via conventional abdominal myomectomy is usually performed for fertility reasons as opposed to treating AUB problems.
 

d) Myolysis or "Myoma Coagulation"- This is a technique whereby symptomatic intramural or subserous ( large, pressure-producing) fibroids are treated with either electrical energy through needles, or a laser fiber inserted into the fibroids, laparoscopically.
("laparoscopic" means through a telescope/tube inserted through the abdomen as opposed to a hysteroscope where the telescope is inserted through the cervix). This technique is not commonly used for treating AUB.
 

e) Uterine Artery Embolization: This is a newly described indication for an old radiological technique, in which a catheter is passed from the groin, up to the level of the uterine arteries. An "interventional radiologist", not a gynecologist, injects an inert material called "polyvinyl alcohol" which obliterates the blood supply to the fibroid(s), much like tea leaves in a strainer. At this moment only two facilities have announced their involvement in such an investigational study, one in Philadelphia, the other in Los Angeles. Initial observations would suggest that heavy bleeding is "controlled" in about 90% of patients, the Amenorrhea rate is low (25%), and fibroid size reduction varies from about 40-80%. The procedure in essence causes the fibroid equivalent of a massive heart attack!! Most patients require overnight hospitalization for pain control, after which they are discharged on oral pain medication; the post operative pain medication is required for 3-10 days. At this point in time, cost can be expensive.
 

3) Hysterectomy- This is the term used for surgical removal of the uterus. In and of itself, it does not denote removal of the ovaries. The term for the latter removal is "oophorectomy", either one side ("unilateral") or both sides ("bilateral"). Removal of the uterus is associated with complete, permanent cessation of periods! If the ovaries are removed, then the patient will be estrogen deficient and will experience typical menopausal symptoms of hot flushes, night sweats, etc. Because of associated conditions such as painful periods, or uterine tenderness, hysterectomy for a given patient may be the best choice for treating her excessive bleeding. There are several ways to remove the uterus from the pelvis:
 

a) Conventional abdominal hysterectomy- utilizing a 4-6 inch incision, access is made into the pelvis, the attachments of the uterus severed, and the uterus removed. Advantages are that other problems such as adhesions, or endometriosis, may be dealt with and if necessary, the ovaries removed as well. About 75% of hysterectomies currently performed in the USA are performed in this fashion. Disadvantages are a longer hospital stay(4-5 days), greater incisional discomfort, greater disfiguration from a large incision, and full recuperation requires about 6 weeks.
 

b) Vaginal hysterectomy - the uterus is detached and removed through the vagina. Advantages are that there is no large abdominal scar, pain is less, hospitalization is about 3 days, and recovery is about 4 weeks. The disadvantage is that any concomitant problem in the pelvis such as adhesions, ovary problems, or endometriosis usually cannot be dealt with appropriately. Removal of the uterus may solve the bleeding problem, but if the patient has for example adhesions about her ovary(ies) that are causing painful intercourse, this latter difficulty will remain present.
 

c) Laparoscopic hysterectomy- in many ways, this approach provides many distinct advantages over the above mentioned approaches. Using the laparoscope, and small accessory instruments inserted through tiny incisions, the entire status of the organs within the pelvis can be assessed . Most importantly, they can be treated the vast majority of the time ( eg. a diseased appendix can be removed if necessary). Additionally, post operative pain, and recuperation is very much lessened . Actually removing the uterus with or without ovaries) from the pelvis can be done in different ways.
 

i) Total laparoscopic hysterectomy- the uterus is completely (including the cervix) detached from all supporting tissues and removed through the vagina. The top of the vagina is then sutured and closed. Hospitalization time 1-2 days and return to most activities in a couple of weeks with the exception of intercourse (6 weeks, as the incision at the top of the vagina has to fully heal)
 

ii) Laparoscopically-assisted vaginal hysterectomy ('LAVH")- the uterus is partially detached from its supporting tissues, and the operation then completed as a standard vaginal hysterectomy. This operation is more popular than a a totally laparoscopic hysterectomy, because it is technically easier for most gynecologists, and the ability to treat other coincident disease in the pelvis is the same as for total laparoscopic hysterectomy .
 

iii) Laparoscopic-supra-cervical hysterectomy- there has been a resurgence of interest in this approach to hysterectomy, as leaving the cervix appears to really have some merit. Conventional supra-cervical hysterectomy
(also called sub-total hysterectomy) was the norm decades ago, when the non-availability of antibiotics coupled with primitive surgical technique markedly increased the risk of serious pelvic infection post-operatively following conventional hysterectomy in which the vagina was entered in the process of removing the cervix. Not understanding the development of cervical cancer as we do today, women did not have regular screening via PAP smears. Unfortunately some of these patients years after their conventional subtotal hysterectomy developed cervical cancer. The pendulum then swung to removal of the cervix at the time of hysterectomy almost at any cost!

Leaving the cervix today appears to dramatically reduce the incidence of post operative pelvic infections, bladder dysfunction ( urgency, frequency- also called bladder instability) is very much lessened as the bladder is not "moved" in the course of the surgical dissection, long term pelvic support would appear to be better with a significantly lesser incidence of urinary stress incontinence, and sexual performance may be better because there is no tendency to foreshorten the vagina as can happen when the cervix is removed. Post-operative pain is very dramatically reduced, hospitalization time for most patients is less than 24 hours, resumption of almost all activities is a matter of days, and sex may be resumed in about 2 weeks. The actual removal of the uterine tissue is accomplished utilizing an advanced technology instrument that reduces the large tissue mass such that it can be brought through a small tube introduced through the abdominal wall.