Periods are part of the normal physiological processes occurring monthly in a woman. Normal periods are regular, with cycles varying from 30 +/- 4 days and lasting 2-7 days.

Menorrhragia by definition occurs if the menstrual blood loss exceeds 80 ml per cycle. However, clinically, excessive menstrual bleeding is suspected if the period is heavy associated with clots and flooding with excessive usage of sanitary pads.

Abnormal uterine bleeding occurs if the amount of bleeding is excessive, if the cycle is irregular or if there is intermenstrual or postcoital bleeding. Any woman with abnormal bleeding should consult a gynaecologist, although in the majority of cases, these are due to physiological or benign causes.

The causes for abnormal bleeding are numerous. In the adolescents and teenagers, it is usually due to dysfunctional uterine bleeding due to immaturity of the hypothalamus. In the adult woman, these are usually due to benign diseases of the genital tract such as fibroids, adenomyosis, pelvic imflammatory disease, polycystic ovary disease and dysfunctional uterine bleeding. In the older perimenopausal age group, bleeding can be due to dysfunctional uterine bleeding or organic causes such as fibroids.

However, in the older woman, it is important to exclude carcinoma of the cervix, endometrium or ovary. Non-gynaecological causes such as bleeding disorders, thyroid diseases or drugs can also give rise to abnormal bleeding and it is important to elicit these information from the history

Examination is important to look for signs of anaemia or goitre. Abdominal examination may reveal a large pelvi-abdominal mass and vaginal examination can show local causes such as polyps from the endometrium, cervix or vagina and these can easily be avulsed at the time of examination. A pap smear is usually taken during the examination to exclude cervical pathology.

Other investigations that are indicated are ultrasound pelvis which provides useful information on the uterus, the endometrial thickness and the ovaries. In a postmenopausal woman, the endometrial thickness should not exceed 5 mm.

Blood tests include the hormonal profile, FSH/ LH/ E2 in the perimenopausal age group, and thyroid function tests or coagulation studies if clinically indicated. In women above 40 with irregular bleeding, it is essential to have an endometrial assessment to exclude malignancy. This may take the form of a pipelle endometrial sampling or office hysteroscopy which can be done in the outpatient setting or a formal hysteroscopy, dilataion and curettage under a short general anaesthesia depending on the index of suspicion.

Treatment depends on the cause. Medical treatment can be given to reduce the menstrual flow such as NSAIDS or tranexamic acid taken during the periods for fibroids or adenomyosis.

Progestogens or the oral contraceptive pill can be given to regulate the cycle length in cases of dysfunctional uterine bleeding or polycyctic ovary disease.

Endometrial laser ablation or microwave endometrial ablation are effective in reducing the flow when medical treatment fails and are useful alternatives to hysterectomy.

Submucosal fibroids can also be treated by transcervical resection of the myoma. Surgical options include myomectomy or hysterectomy for fibroids depending on the severity of the condition and the patient’s desire for fertility.

Endometrial cancer is best treated by total hysterectomy bilateral salpingo-oophorectomy and bilateral pelvic lymph node dissection which can be done via laparotomy of laparoscopically.

Laparosocpic surgery has advantages of reduced postoperative pain and better patient recovery and are ideal for cases with well- differentiated tumour grade and small uterus. Adjuvant treatment may be required depending on the stage and histology of disease and may include radiotherapy or chemotherapy.

 

Lisa Wong
Assoc Consultant
Obstetrics & Gynaecology
Singapore General Hospital