is a normal physiological event occurring in a
woman in the reproductive years.
Normal menstruation occurring
in normal quantities is reassuring to the woman,
in spite of the small inconveniences experienced during the
period. Any change from
the normal pattern gives rise to anxious moments. The reasons
for abnormal bleeding varies according to the age
of the patient. In the years
following the first menarche and in the years preceding
menopause, there may be disorders of ovulation. Ovulation is
the normal process of extrusion of ova in women). In the
reproductive years, bleeding may occur in spite
of normal ovulation. Besides
these hormonal abnormalities, tumours in the uterus
or ovaries could cause excessive or irregular uterine bleeding.
In the following section, a few of
the commonly faced situations are discussed.
is normal menstruation?
Normal menstruation means menstruation occurring once
in 28-35 days, the flow
being moderate in amount for the first 2-3 days and
petering out to a complete stop in 7 days time.
example:A young 12 year old girl who has attained
menarche (first menstruation) 6 months back comes
with bleeding coming on every 15 days.
The flow is not heavy, but it
is bothersome and the girl is not able to concentrate
in her studies. Does it need medical intervention?
is a result of the combined efforts of the uterus,
the ovaries and the brain. In
the first few years after mernarche, menstruation
tends to be a bit irregular, because the body systems
are yet to mature. In due
course of time it may mature and regular menstruation
may ensue. Meanwhile there
may be signs of anaemia like inability to concentrate, etc. Taking iron tablets
with a good nutritious diet will help in tiding
over the situation. If the
menstruation still does not become normal, taking oral
contraceptive pills for 3 months will help.
As the flow is not very heavy, probably detailed
investigations could be deferred.
example:If the same girl comes with heavy bleeding,
what could be the reason?
If the bleeding is heavy, then the girl should be evaluated
ultrasonography should be done to rule out any abnormalities
in the uterus or ovaries. A
detailed blood test should be done to rule out any bleeding
disorders or abnormalities in the blood cells. If there
are any abnormalities detected, treatment should
be given to cure the disease.
If every thing is normal, she may need treatment
with heavy doses of hormone pills.
If a woman in the reproductive age group comes with
heavy bleeding what could be the reason?
the reproductive group the causes could be
device related problems
cysts or uterine fibroids.
related problems: In a woman in the reproductive age group, unintentional
pregnancy and related problems should always be
kept in mind. It is commonly believed that pregnancy
will occur only if a woman misses her periods. But it is quite possible that even
without missing her periods, a woman may be harbouring
an abnormal pregnancy either in the uterus or even
outside the uterus, which is then called an ectopic pregnancy. Ectopic pregnancies are usually
associated with pain in the abdomen.
device related problems.
using copper containing intrauterine contraceptive
devices could have bleeding related to a foreign
body reaction to the device. Usually the first 2-3 months following
insertion of the IUD is associated with irregular
and excessive periods, but it settles on its own.
If it is excessively heavy even after that, medical
intervention may be necessary.
in all age groups, abnormal tumours in the uterus or
ovaries should be ruled out.
infections in the uterus or nearby structures (Pelvic
inflammatory disease) could also cause abnormal
bleeding. Clinical examination
can rule out gross abnormalities.
Ultrasonography is a more accurate method of ruling out
abnormalities in the pelvic organs.
In women with
no structural or pregnancy related abnormalities,
any bleeding is called dysfunctional uterine
bleeding. While in the
post menarchal or premenopausal women, these abnormalities
occur due to disorders in ovulation, in women in the reproductive
age group, bleeding occurs in spite of normal ovulation.
Quite often they can be cured by non-hormonal medical
Q:What are the abnormalities in menstruation
are expected in the woman nearing menopause?
The menstrual irregularity at perimenopause is the result of
physiologic reduction or depletion of healthy oocytes (ovarian
eggs). The remaining oocytes of the ovary are of lesser competence
and cannot sustain the normal hormone balance. In most women this
menstrual dysfunction continues till menopause (complete cessation
of menses). In the perimenopause period, the previously regular
periods tend to become irregular with changes in intermenstrual
lengths. The perimenopause is divided into two phases:
• Early perimenopause – The menstrual cycles may be short or
• Late perimenopause – Characterized by lengthened intermenstrual
periods, resulting in prolonged and irregular menstrual cycles. In
some women, the menstrual bleeding may be prolonged and heavy
requiring immediate medical attention.
• Infrequent and delayed periods with normal or
excessive and prolonged bleeding
• Irregular and non-cyclic prolonged periods with scanty or
What are the treatment options for dysfunctional uterine bleeding
in women who have completed child bearing?
In the woman nearing menopause, one has to rule out cancer of the
lining of the uterus, called the endometrium. This is done by
Ultrasonography in the early menstrual period, or by sampling the
endometrium and sending it to a pathologist. Once this has been
done, drugs are given to control the bleeding. Hormone preparations
and non hormone preparations are used by doctors depending on the
case, by doctors to control this situation. Sometimes, quick and
permanent response to medical treatment is also an indication of the
bleeding being benign in nature. Associated medical disorders like
thyroid dysfunction, diabetes mellitus, pelvic infections should be
ruled out. Iron-deficiency, anemia is a very common nutritional
disorder in Indian women and menstrual dysfunction further
aggravates this deficiency. Therefore, this needs to be treated
What are the other treatment options for women who continue to
have abnormal bleeding?
1. D&C: In women who have completed childbearing, when medical
treatment fails, a small procedure called D&C (Dilatation and
curettage) may be done. It involves widening the opening of the
uterus and putting in a curette and scraping the inner surface of
the uterus. This inner lining of the uterus is called the
endometrium. The endometrium which is thus taken out is submitted
for testing in a pathological laboratory to make sure there is no
malignancy in it. This procedure besides being diagnostic to rule
out malignancy may also be curative. Bleeding may completely stop
after this. D&C is usually done as a day care procedure and need not
involve admission to the hospital.
2. Medicated intrauterine devices: Intra-uterine devices medicated
with a hormone called progesterone are placed in the uterus. The
advantage of this IUD is that it is a simple procedure and avoids
the complications of surgical procedures. The disadvantage is that
it is a bit costly (Around Rs.7500). Although the cost may seem to
be a bit high for the average patient, it is certainly worth trying
specially in cases where surgery or anaesthesia poses a risk to the
3.Endometrial Ablation: In dysfunctional uterine bleeding the
irregular or excessive and prolonged bleeding is caused by irregular
shedding of the inner lining of the uterus called the endometrium.
This lining can be destroyed using many modalities like heat,
electricity, laser, microwaves etc. These procedures could be a boon
to the woman with DUB with risk of surgery or anaesthesia.
4.Thermal ablation: A rubber device is introduced into the uterus
and a hot solution is passed into the rubber balloon. The heat of
the solution is transmitted across the rubber balloon on to the
lining of the uterus which is desiccated. . Most of them attain
normal menstruation or decreased menstruation. Very few attain
stoppage of menstruation. It is done as a day-care procedure and can
be done under local anaesthesia and sedation or under mild general
anaesthesia. Immediately following the procedure. There
may be uterine cramps which settles with antispasmodics. Some women
may have profuse watery discharge for a month or so.
4. Hysteroscopy: An instrument called hysteroscope is inserted into
the uterus, The uterus is distended with fluid. Any small
projections into the uterus called polyps can be removed using
special equipments called resectoscopes. The endometrium can also be
ablated using this instrument.
5. Hysterectomy: If medical treatment and D&C fails, another option
is removal of the uterus. Uterus being of normal size, can be
removed through the vaginal route. Pain after surgery is minimal,
and in uncomplicated cases the hospital stay may be limited to 3 or
4 days. Hysterectomy being a major surgery should be reserved for
cases where all other means of controlling bleeding fails. Since
vaginal hysterectomy is not a very morbid procedure,& there is a
100% possibility of cure, some doctors do not wait to try methods
like medicated intrauterine devices or endometrial ablation before
going in for hysterectomy. However, it must be remembered that
hysterectomy is certainly associated with more complications
compared to the non surgical treatment modalities. In India where
there is no insurance cover for most patients, the cost of these
procedures may seem prohibitive to some patients, and probably that
is another reason why hysterectomy is preferred in many patients
with dysfunctional uterine bleeding.