18.2 Abnormal Vaginal Bleeding

Abnormal uterine bleeding (AUB) is a common gynecological condition that includes a variety of menstrual irregularities, such as menorrhagia (excessive menstrual bleeding), hypermenorrhea (prolonged menstrual bleeding), metrorrhagia (irregular menstrual cycles), menometrorrhagia (excessive or prolonged uterine bleeding that occurs more frequently or irregularly than normal), postcoital bleeding (minimal bleeding or spotting after sex), and bleeding after menopause.^[1]

Heavy menstrual bleeding is a common problem reported to health care providers, affecting one in five American women. Symptoms of heavy menstrual bleeding requiring treatment include the following^[2],[3]:

• Menstrual flow that soaks through one or more pads or tampons every hour for several hours in a row.
• Menstrual flow with blood clots the size of a quarter or larger.
• Menstrual periods lasting more than seven days.
• Menstrual flow that requires changing pads or tampons during the night.

AUB can significantly affect the quality of a woman’s life, as well as cause additional symptoms of fatigue or shortness of breath from anemia resulting from the blood loss.^[4]

Potential causes of AUB include the following^[5],[6]:

• Anovulatory dysfunction, where unopposed estrogen causes excessive buildup of the endometrium
• Hormone imbalances, such as polycystic ovarian syndrome
• Uterine fibroids
• Endometrial polyps
• Endometriosis
• Blood clotting disorders, such as von Willebrand disease, or platelet disorders
• Certain medications, such as aspirin or anticoagulants
• Intrauterine devices (IUDs)
• Ectopic pregnancy
• Miscarriage
• Pelvic inflammatory disease (PID)
• Cervical or uterine cancer
• Gestational trophoblastic disease

Diagnosing AUB begins with a comprehensive assessment of the client’s medical history, menstrual patterns, and related symptoms and often includes the following questions^[7]:

• How old were you when you got your first period?
• How long is your menstrual cycle?
• How many days does your period usually last?
• How many days do you consider your period to be heavy?
• How do your periods affect your quality of life?

The health care provider performs a physical examination, including a pelvic examination and orders laboratory tests, such as complete blood count (CBC) to assess for anemia, thyroid hormone levels to evaluate thyroid function, and coagulation panels to assess blood clotting. A pregnancy test is typically performed to rule out pregnancy as a potential cause for excessive bleeding. A Pap test may be performed to assess for infection, inflammation, or changes in cervical cells that might cause cancer. An endometrial biopsy may be performed to obtain a tissue sample of the lining of the uterus to assess for overgrowth of the endometrium. Other diagnostic tests, such as transvaginal ultrasound, sonohysterogram, or hysteroscopy, may be performed to further evaluate the uterus. During a transvaginal ultrasound, a transducer is inserted into the vaginal to obtain detailed images of the pelvic structures. A sonohysterogram is an ultrasound scan that is performed after fluid is injected into the uterus through a tube placed through the vagina and cervix. This procedure assesses problems in the lining of the uterus. Hysteroscopy is a procedure that examines the inside of the uterus and cervix using a thin, lighted tube called a hysteroscope. During a hysteroscopy, the health care provider can take a tissue sample for biopsy, remove polyps or fibroid tumors, or treat heavy bleeding by destroying tissue using an electric current, freezing temperature, heat, or chemicals.^[8],[9]

Medical treatment of AUB often includes prescription of nonsteroidal anti-inflammatory drugs (NSAIDs), iron supplements, and hormonal therapy. NSAIDS, such as ibuprofen and naproxen, decrease prostaglandin synthesis in the еոdоmеtriսm, leading to vasoconstriction and reduced blеeԁiոg. However, NSAIDS are avoided in clients already receiving an anticoagulant or who have a history of bleeԁiոg disorder because they may worsen bleеԁing. Iron supplements are prescribed for women with iron-deficiency anemia due to excessive menstrual blood loss. Hormonal therapy (e.g., medications containing estrogen and progesterone) is prescribed with oral contraceptives or the insertion of a medication-infused intrauterine device (IUD) to help regulate menstrual cycles and reduce menstrual flow. However, hormonal therapy is contraindicated for clients who are at risk for developing thrombosis, such as those who smoke.^[10]

If medical management is unsuccessful in treating menorrhagia, surgical procedures may be performed. If AUB is caused by fibroids, a myomectomy may be performed. A myomectomy is a surgical procedure that removes uterine fibroid(s) while leaving the uterus intact. A second type of procedure for fibroids is called uterine artery embolization (UAE) that blocks blood flow in the blood vessels supplying fibroid(s), causing them to shrink. For women with severe menorrhagia, an endometrial ablation may be performed to destroy the endometrial lining of the uterus. However, endometrial ablation is contraindicated for women who desire to maintain their fertility. If other treatments are unsuccessful, the definitive treatment of AUB is a hysterectomy (removal of the uterus).^[11]

Nurses teach clients about the causes of AUB, its potential impact on health, and prescribed medications, including potential side effects. Nonpharmacologic interventions are suggested to complement medical treatment, such as regular exercise and a well-balanced diet to promote hormonal balance and overall health. Stress management and relaxation techniques may also help reduce menstrual symptoms. Clients are also encouraged to track their menstrual cycles, bleeding, and associated symptoms using calendars or apps to facilitate communication with health care providers for optimal treatment.^[12]