One of the more common diagnoses of patients with abnormal uterine bleeding that we see in the clinical setting and in the operating room is uterine fibroids. Patients with submucosal fibroids may have metrorrhagia (intermenstrual bleeding). Menorrhagia (heavy menses) also may be experienced by patients with uterine fibroids.
In the emergency room setting ectopic pregnancy should be ruled out as causing abnormal bleeding. Patients with ectopic pregnancy may present with delayed menses, spotting, or heavy bleeding along with pelvic pain, acute abdomen, shoulder pain (referred from irritation of diaphragm), unstable vital signs and acute anemia.
The most common reason for patients' abnormal uterine bleeding is anovulation. The term dysfunctional uterine bleeding applies to abnormal bleeding from the uterine endometrium that is unrelated to blood dyscrasias such as thrombocytopenic purpura and Von Willebrand disease or anatomic lesions of the uterus such as uterine fibroids, endometrial polyps, cancer and abnormal pregnancies. Causes of abnormal bleeding related to pregnancy include threatened and spontaneous abortions, molar pregnancies, abruption, previa, postpartum uterine atony and retained products of conception.
In anovulatory patients with irregular heavy bleeding the endometrial biopsy usually is proliferative. The anovulation may be due to an immature hypothalamic-pituitary axis as anovulatory cycles are common for 1-2 years post menarche. Anovulation is also part of the classic triad associated with polycystic ovary syndrome. The triad also includes hirsutism and obesity. With psychologic stress and vigorous exercise, the hypothalamus may be affected with a reduction in gonadotropin releasing hormone (GnRH) secretion and resultant anovulation. Patients with incipient ovarian failure may also experience anovulatory cycles before complete amenorrhea occurs.
In less than 15% of patients with dysfunctional uterine bleeding (DUB) the patient is ovulatory and has secretary endometrium when biopsied. The abnormal bleeding in these patients may be due to the mid cycle estrogen withdrawal, polymenorrhea (short menstrual cycles), or short luteal phase (less than 12 days). In adolescents with abnormal bleeding, up to 20% will have a coagulopathy.
The history obtained should include a menstrual history with details of menorrhagia, metrorrhagia, and oligomenorrhea (cycles greater than 35 days) and postcoital bleeding. Postcoital or contact bleeding may occur as a result of cervicitis or even cervical cancer. In the social history, exposure to STD/HIV may be elicited as well as alcohol abuse, emotional stress or vigorous exercise.
Medications such as anticoagulants, antibiotics, oral contraceptives, morphine, reserpine, phenothiazine, monoamine oxidase inhibitors, anticholinergic drugs and aspirin may also cause abnormal bleeding. Any systemic illness may contribute to abnormal bleeding eg both hypothyroidism and hyperthyroidism may cause anovulatory bleeding as well as hyper- or hypo-andrenalism.
A family history of polycystic ovary disease or of a coagulation disorder might be obtained.
On physical exam obesity and reduced body fat, both, may cause anovulation. Hirsutism and acanthosis nigricans (hyperpigmented thickened areas in folds of skin) may be associated with polycystic ovary disease. Galactorrhea may occur with hypothyroidism and hyperprolactinemia. Abdominal or pelvic masses and tenderness as well as signs of virilization including clitoromegaly, temporal balding, deepening of the voice may be present.
Laboratory evaluation should include CBC if there is heavy or prolonged bleeding, serum bHCG for reproductive-aged women, and TSH and prolactin for anovulatory women. If the patient is hirsute, testosterone and DHEA-S levels may be helpful. Coagulation studies may be necessary.
Vaginal and or abdominal ultrasound may note uterine fibroids, endometrial or endocervical polyps, adenomyosis, endometrial hyperplasia or cancer, ovarian cyst or tumor, and retained IUD. Adenomyosis is the presence in the myometrium of endometrial glands and stroma, and is more common in patients in their 40's. It may present with menorrhagia, dysmenorrhea and an enlarged tender uterus.
An abdominal USG shows a calcified uterine fibroid (Scan 1).
An endometrial biopsy is done to rule out hyperplasia or adenocarcinoma in a patient with long term anovulation (Scan 2).
In a patient who is also infertile, a hysterosalpingogram (HSG) may be normal with no intrauterine filling defects and with tubal patency and dispersion of dye into peritoneal cavity (Scan 3).
A large irregular intrauterine filling defect in this HSG results from a uterine fibroid (Scan 4).
An irregular border to the endometrial cavity in this HSG is due to Asherman's syndrome (Scan 5).
Dye is noted in myometrial pockets with adenomyosis in this HSG (Scan 9).
Hysteroscopy may be performed in the clinic setting to diagnose Asherman's syndrome (intrauterine adhesions), adenomyosis, and polyp.
Through the hysteroscope one may view a septum, endometritis, an IUD, synechiae or a fibroid (Scan 7).
With initial insertion of the hysteroscope the endocervical canal with it crypts and columnar mucosa is identified (Scan 6).
As the cavity is distended the fundal area is viewed (Scan 13).
One tubal ostia is identified (Scan 12).
For treatment of irregular heavy bleeding due to anovulation, progestins such as medroxyprogesterone acetate (Provera) may be used for controlled monthly withdrawal bleeding. Otherwise hyperplasia and adenocarcinoma could develop. Oral contraceptive agents also result in monthly withdrawal bleeding and that bleeding is usually light. If there has been severe prolonged bleeding with little residual endometrium remaining, intravenous Premarin 20-25 mg every 4-6 hours may be effective to temporarily stabilize the basal endometrium. Anti-prostaglandins may also decrease heavy blood flow but not if it is due to fibroids. If the patient is anemic, iron therapy and nutritional support are important and GnRH agonists or Danocrine maybe used to suppress bleeding temporarily.
Preoperatively the GnRH agonists, progestins or Danocrine will suppress the endometrium and thereby allow treatment of anemia and decrease the risk of hemorrhage during hysteroscopic procedures. Surgical treatments also include laparoscopic myomectomies, laparotomy myomectomies, uterine dilation and curettage (D&C), hysterectomy, and selective pelvic arterial embolization.
DUB & OP H-S
Operative hysteroscopy is useful to remove an imbedded IUD, to resect polyps or submucosal fibroids, for endometrial ablation, to lyse intrauterine adhesions and to resect uterine septum.
Distending media for hysteroscopy include C02, 32% dextran 70, D5W, sorbitol and saline. Close monitoring of input/output of media as well as electrolytes are important with prolonged procedures.
Instrumentation includes flexible and rigid instruments, polyp snares, laser fibers, and resectoscope electrocautery loop or ball.
Dextran 70 is the distending medium used in this hysteroscopy (Scan 8).
The end of the operative hysteroscope is pictured revealing 4 ports: fiberoptic, instrument port, inflow and outflow ports. (Scan 11).
An alberan is shown in this slide and acts as a lever to direct flexible instruments to the point of interest in the uterine cavity (Scan 10).
Complications include uterine perforation especially at the cornua ostia junction and simultaneous laparoscopy may be useful. Other viscera may be injured and hemorrhage may occur.
Hyponatremia, hyperglycemia, shock, DIC and ARDS are also possible complications. Contraindications
Contraindications to hysteroscopy are acute pelvic inflammatory disease, active uterine bleeding, pregnancy and significant cardiac or pulmonary disease.
Prior studies have demonstrated that with hysteroscopy histologic diagnoses are provided in 20% of women who have an immediately preceding normal D&C, and 10% of hysterectomy specimens have endometrial polyps despite negative preoperative D&C's.
Through the hysteroscope is seen an endometrial polyp which was missed during a preceding D&C (Scan 14).
Hysteroscopy can be used to biopsy the most suspicious areas in patients with endometrial hyperplasia and to determine cervical involvement with endometrial adenocarcinoma (Scan 15).
Submucosal fibroids are found on hysteroscopy in 9-16% of women with abnormal bleeding and a negative D&C.
Submucosal fibroids are seen through the H-Scope in these 3 slides (Scans 16, 17, 21).
Submucosal fibroids removed through the H-Scope should be sent to surgical pathology (Scan 20).
Adenomyosis is noted (Scan 19).
Intrauterine synechiae are identified (Scans 18, 23, 24).
An embedded Cu 7 IUD is being removed hysteroscopically (Scan 22).
Before hysteroscopic endometrial ablation, tubal ligation and pre- and postoperative hormonal suppression with danazol, progestin or GnRH agonists should be considered. Ablation may be accomplished with electrocautery, laser and with balloon thermal techniques.
Indications for Endometrial Ablation
Endometrial ablation is indicated for DUB unresponsive to hormonal therapy, anticoagulant induced bleeding, polyps and fibroids unresponsive to local excision, especially when there is a medical contraindication to hysterectomy. The procedure is 80% successful in controlling the abnormal bleeding.