Abnormal uterine bleeding: causes, diagnosis, and treatment

DOI

https://dx.doi.org/10.18565/aig.2021.1.170-177

Dubrovina S.O., Kirevnina L.V., Lesnoy M.N.
1) Rostov State Medical University, Ministry of Health of the Russian Federation, Rostov-on-Don, Russia; 2) A.K. Eramishantsev City Clinical Hospital, Moscow Healthcare Department, Moscow, Russia

Abnormal uterine bleeding (AUB) is one of the most common complaints encountered in gynecological practice. AUB negatively affects the physical, emotional, sexual, and professional aspects of women’s lives. The paper highlights the current view on the tactics of managing patients with AUB according to the current FIGO classification system. Patient management requires an individual approach to tailoring treatments to individual needs, taking into account not only the etiology of this abnormality, but also the somatic problems of the women and their reproductive plans. After verifying the diagnosis of the abnormality, a physician must pay attention to its pathogenetic validity, when choosing a therapy option, and to the advisability of using one or another method. The paper analyzes various hormonal drugs for AUB, including progestogens and hormonal contraceptives. If there is a need to prevent unwanted pregnancy, oral or intrauterine hormonal contraceptives may be recommended. However, when choosing a drug, in addition to its exerted effects, the safety profile should be taken into account, by assessing the benefit-risk ratio individually for each patient. One of the most preferred and pathogenetically grounded treatments is the use of progestogens. Among them, dydrogesterone occupies a special place due to its high efficacy in reducing the volume of blood loss, as well as its favorable safety profile, which makes it currently the most suitable drug for the treatment and secondary prevention of AUB.
Conclusion. Correctly chosen hormone therapy for women who need it makes it possible to improve patients’ health and to minimize the risks of adverse events.

abnormal uterine bleeding

causes

diagnosis

progestogens

combined oral contraceptives

Full text (in Russian)

Munro M.G., Critchley H.O., Broder M.S., Fraser I.S.; FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int. J. Gynaecol. Obstet. 2011; 113(1): 3-13. https://dx.doi.org/10.1016/j.ijgo.2010.11.011.
Чернуха Г.Е., Немова Ю.И. Диагностика и медикаментозная терапия маточных кровотечений с позиций международных рекомендаций. Акушерство и гинекология: новости, мнения, обучение. 2013; 2: 12-7. [Chernukha G.E., Nemova Yu.I. Diagnostics and medical therapy of uterine bleeding from the standpoint of international recommendations. Obstetrics and Gynecology: News, Opinions, Training. 2013; 2: 12-7. (in Russian)].
Benetti-Pinto C.L., Japur de Sá Rosa-E-Silva A.C., Yela D.A., Júnior J.M.S. Abnormal uterine bleeding. Rev. Bras. Ginecol. Obstet. 2017; 39(7): 358-68. https://dx.doi.org/10.1055/s-0037-1603807.
Neena Y., Honey B. Clinico-pathological correlation of hysterectomy specimens for abnormal uterine bleeding in rural area. J. Evol. Med. Dent. Sci. 2013; 2(39): 7506-12. https://dx.doi.org/10.14260/JEMDS/1329.
Чернуха Г.Е., Асатурова А.В., Иванов И.А., Думановская М.Р. Структура патологии эндометрия в различные возрастные периоды. Акушерство и гинекология. 2018; 8: 129-34. [Chernukha G.E., Asaturova A.V., Ivanov I.A., Dumanovskaya M.R. Endometrial lesion’s pattern in different age groups. Obstetrics and Gynecology. 2018; 8: 129-34. (in Russian)].https://dx.doi.org/10.18565/aig.2018.8.129-134.
Jairajpuri Z.S., Rana S., Jetley S. Atypical uterine bleeding-Histopathological audit of endometrium A study of 638 cases. Al Ameen J. Med. Sci. 2013;6(1): 21-8.
Abbott J.A. Adenomyosis and abnormal uterine bleeding (AUB-A) pathogenesis, diagnosis, and management. Best Pract. Res. Clin. Obstet. Gynaecol. 2017; 40: 68-81. https://dx.doi.org/10.1016/j.bpobgyn.2016.09.006.
Wise M.R., Jordan V., Legas A., Showell M., Wong N., Lensen S., Farquhar C.M. Obesity and endometrial hyperplasia and cancer in premenopausal women. Am. J. Obstet. Gynecol. 2016; 214(6): 689. e1-689. e17. https://dx.doi.org/10.1016/j.ajog.2016.01.175.
Esmer A.C., Akbayir O., Goksedef B.P.C., Gunduz N., Kisacık S., Dagdeviren H. et al. Is there an appropriate cutoff age for sampling the endometrium in premenopausal bleeding? Gynecol. Obstet. Invest. 2014; 77(1): 40-4. https://dx.doi.org/10.1159/000356959.
Iram S., Musonda P., Ewies A.A.A. Premenopausal bleeding: when should the endometrium be investigated? A retrospective non-comparative study of 3006 women. Eur. J. Obstet. Gynecol. Reprod. Biol. 2010; 148(1): 86-9. https://dx.doi.org/10.1016/j.ejogrb.2009.09.023.
Wouk N., Helton M. Abnormal uterine bleeding in premenopausal women. Am. Fam. Physician. 2019; 99(7): 435-43.
Giannella L., Mfuta K., Setti T., Cerami L.B., Bergamini E., Boselli F. A risk-scoring model for the prediction of endometrial cancer among symptomatic postmenopausal women with endometrial thickness >4 mm. Biomed. Res. Int. 2014; 2014: 130569. https://dx.doi.org/10.1155/2014/13056.
Özdemir S., Çelik Ç., Gezginç K., KIreşi D., Esen H. Evaluation of endometrial thickness with transvaginal ultrasonography and histopathology in premenopausal women with abnormal vaginal bleeding. Arch. Gynecol. Obstet. 2010; 282(4): 395-9. https://dx.doi.org/10.1007/s00404-009-1290.
Committee on Practice Bulletins – Gynecology. Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet. Gynecol. 2012; 120(1): 197-206. https://dx.doi.org/10.1097/AOG.0b013e318262e320.
Ray S., Ray A. Non-surgical interventions for treating heavy menstrual bleeding (menorrhagia) in women with bleeding disorders. Cochrane Database Syst. Rev. 2016; (11): CD010338. https://dx.doi.org/10.1002/14651858.CD010338.pub3.
Cicinelli E., Trojano G., Mastromauro M., Vimercati A., Marinaccio M. et al. Higher prevalence of chronic endometritis in women with endometriosis: a possible etiopathogenetic link. Fertil. Steril. 2017; 108(2): 289-95.https://dx.doi.org/10.1016/j.fertnstert.2017.05.016.
Sweet M.G., Schmidt-Dalton T.A., Weiss P.M., Madsen K.P. Evaluation and management of abnormal uterine bleeding in premenopausal women. Am. Fam. Physician. 2012; 85(1): 35-43.
Chang I.J., Hong G.Y., Oh Y.L., Kim B.R., Park S.N., Lee H.-H. et al. Eﬀects of menopausal hormone therapy on uterine myoma in menopausal women. J. Menopausal Med. 2013; 19(3): 123-9. https://dx.doi.org/10.6118/jmm.2013.19.3.123.
Srinivasan V., Martens M.G. Hormone therapy in menopausal women with ﬁbroids: Is it safe? Menopause. 2018; 25(8): 930-6. https://dx.doi.org/10.1097/GME.0000000000001105.
Frascà C., Degli Esposti E., Arena A., Tuzzato G., Moro E., Martelli V., Seracchioli R. Can in-bag manual morcellation represent an alternative to uncontained power morcellation in laparoscopic myomectomy? A randomized controlled trial. Gynecol. Obstet. Invest. 2018; 83(1): 52-6.https://dx.doi.org/10.1159/000477171.
Farquhar C., Brown J. Oral contraceptive pill for heavy menstrual bleeding. Cochrane Database Syst. Rev. 2009; (4): CD000154. https://dx.doi.org/10.1002/14651858.CD000154.pub2.
NICE. Heavy menstrual bleeding: assessment and management. NICE guideline NG88. Publ. 14 March 2018, Last updated: 31 March 2020. Available at: www.nice.org.uk/guidance/ng88
Ярмолинская М.И., Адамян Л.В. Гормональные контрацептивы и эндометриоз: современный взгляд на проблему. Проблемы репродукции. 2020; 26(3): 39-45. [Yarmolinskaya M.I., Adamyan L.V. Hormonal contraceptives and endometriosis: modern view on the problem. Problems of Reproduction. 2020; 26(3): 39-45.(in Russian)].
Edelman A., Micks E., Gallo M.F., Jensen J.T., Grimes D.A. Continuous or extended cycle vs. cyclic use of combined hormonal contraceptives for contraception. Cochrane Database Syst. Rev. 2014; (7): CD004695. https://dx.doi.org/10.1002/14651858.CD004695.pub3.
Elmaoğulları S., Aycan Z. Abnormal uterine bleeding in adolescents. J. Clin. Res. Pediatr. Endocrinol. 2018; 10(3): 191. https://dx.doi.org/10.4274/jcrpe.0014.26.
Wiegratz I., Stahlberg S., Manthey T., Sänger N., Mittmann K., Lange E. et al. Effect of extended-cycle regimen with an oral contraceptive containing 30 mcg ethinylestradiol and 2 mg dienogest on bleeding patterns, safety, acceptance and contraceptive efficacy. Contraception. 2011; 84(2): 133-43.https://dx.doi.org/10.1016/j.contraception.2011.01.002.
Matteson K.A., Rahn D.D., Wheeler T.L., Casiano E., Siddiqui N.Y., Harvie H.S. et al.; Society of Gynecologic Surgeons Systematic Review Group. Nonsurgical management of heavy menstrual bleeding: a systematic review. Obstet. Gynecol. 2013; 121(3): 632-43. https://dx.doi.org/10.1097/AOG.0b013e3182839e0e.
Madden T., Secura G.M., Nease R.F., Politi M.C., Peipert J.F. The role of contraceptive attributes in women’s contraceptive decision making. Am. J. Obstet. Gynecol. 2015; 213(1): 46. e1-46. e6. https://dx.doi.org/10.1016/j.ajog.2015.01.051.
Tricotel A., Collin C., Zureik M. Impact of the sharp changes in the use of contraception in 2013 on the risk of pulmonary embolism in France. J. Thromb. Haemost. 2015; 13(9): 1576-80. https://dx.doi.org/10.1111/jth.13053.
Dragoman M.V., Tepper N.K., Fu R., Curtis K.M., Chou R., Gaffield M.E. A systematic review and meta-analysis of venous thrombosis risk among users of combined oral contraception. Int. J. Gynaecol. Obstet. 2018; 141(3): 287-94. https://dx.doi.org/10.1002/ijgo.12455.
Lidegaard Ø. Severely biased review of studies assessing the risk of venous thrombosis in users of drospirenone-containing oral contraceptives. BJOG. 2018; 125(8): 929-31. https://dx.doi.org/10.1111/1471-0528.15211.
Плавинский С.Л., Баринова А.Н., Озолиня Л.А. Нежелательные последствия использования гормональных средств. Анализ фармакоэпидемиологических исследований и баз спонтанных отчетов. Вопросы гинекологии, акушерства и перинатологии. 2019; 18(6): 92-9. [Plavinskiy S.L., Barinova A.N., Ozolinya L.А. Adverse outcomes of using hormonal drugs. An analysis of pharmacoepidemiological research works and spontaneous reporting databases. Questions of Gynecology, Obstetrics and Perinatology. 2019; 18(6): 92-9. (in Russian)].
Lindberg M., Foldemo A., Josefsson A., Wiréhn A.-B. Differences in prescription rates and odds ratios of antidepressant drugs in relation to individual hormonal contraceptives: a nationwide population-based study with age-specific analyses. Eur. J. Contracept. Reprod. Health Care. 2012; 17(2): 106-18.https://dx.doi.org/10.3109/13625187.2012.658925.
Gregory S.T., Hall K., Quast T., Gatto A., Bleck J., Storch E.A., DeBate R. Hormonal Contraception, depression, and Academic Performance among females attending college in the United States. Psychiatry Res. 2018; 270: 111-6. https://dx.doi.org/10.1016/j.psychres.2018.09.029.
World Health Organization. Reproductive health. Medical eligibility criteria for contraceptive use. WHO; 2017.
Соловьева А.В., Чегус Л.А. Аномальные маточные кровотечения у женщин в репродуктивном возрасте и пременопаузе. Акушерство и гинекология. 2020; 8: 29-38. [Solovyeva A.V.: Chegus L.A. Abnormal uterine bleeding in women of reproductive age and premenopause. Obstetrics and Gynecology. 2020; 8: 29-38 (in Russian)]. https://dx.doi.org/10.18565/aig.2020.8.29-38.
Bradley L.D., Gueye N.-A. The medical management of abnormal uterine bleeding in reproductive-aged women. Am. J. Obstet. Gynecol. 2016; 214(1): 31-44. https://dx.doi.org/10.1016/j.ajog.2015.07.044.
Abnormal uterine bleeding in pre-menopausal women. SOGC Clinical practice guideline no. 292. May 2013.
Karakus S., Kiran G., Ciralik H. Efﬁcacy of micronised vaginal progesterone versus oral dydrogestrone in the treatment of irregular dysfunctional uterine bleeding: a pilot randomised controlled trial. Aust. N. Z. J. Obstet. Gynaecol. 2009; 49(6): 685-8. https://dx.doi.org/10.1111/j.1479-828X.2009.01093.x.
Дубровина С.О. Рациональный подход к гормональной терапии у женщин старше 40 лет. Акушерство и гинекология. 2019; 7: 112-6. [Dubrovina S.O. Rational approach to hormonal therapy among women after 40 years. Obstetrics and Gynecology. 2019; 7: 112-6. (in Russian)]. https://dx.doi.org/10.18565/aig.2019.7.112-116.
Hickey M., Higham J.M., Fraser I. Progestogens with or without oestrogen for irregular uterine bleeding associated with anovulation. Cochrane Database Syst. Rev. 2012; (9): CD001895. https://dx.doi.org/10.1002/14651858.CD001895.pub3.
Ашрафян Л.А., Антонова И.Б., Ивашина С.В., Бабаева Н.А., Алешикова О.А., Баранов И.И. Оптимизация диагностической тактики у пациенток с аномальными маточными кровотечения в периоды пери- и постменопаузы. Акушерство и гинекология: новости, мнения, обучение. 2019; 7(1): 24-30. [Ashrafyan L.A., Antonova I.B., Ivashina S.V., Babayeva N.A., Aleshikova O.A, Baranov I.I. Diagnostic tactics optimization in patients with abnormal uterine bleeding during peri- and postmenopause. Obstetrics and Gynecology: News, Opinions, Training. 2019; 7 (1): 24-30. (in Russian)]. https://dx.doi.org/10.24411/2303-9698-2019-11003.
Тен А.Р., Обоскалова Т.А., Лаврентьева И.В., Воронцова А.В. Особенности ведения женщин различных возрастных групп с аномальными маточными кровотечениями. Пермский медицинский журнал. 2016; 33(5): 32-7. [Ten A.R., Obskalova T.A., Lavrentyeva I.V., Vorontsova A.V. Features of management of women of different age groups with abnormal uterine bleeding. Perm Medical Journal. 2016; 33(5): 32-7.(in Russian)].
Committee on Practice Bulletins – Gynecology. Practice bulletin no. 136: management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet. Gynecol. 2013; 122(1): 176-85. https://dx.doi.org/10.1097/01.AOG.0000431815.52679.bb.
Marjoribanks J., Lethaby A., Farquhar C. Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst. Rev. 2003; (2): CD003855. https://dx.doi.org/10.1002/14651858.CD003855.
Abdel-Aleem H., d’Arcangues C., Vogelsong K.M., Gafﬁeld M.L., Gülmezoglu A.M. Treatment of vaginal bleeding irregularities induced by progestin only contraceptives. Cochrane Database Syst. Rev. 2013; (7): CD003449. https://dx.doi.org/10.1002/14651858.CD003449.pub4.
Министерство здравоохранения Российской Федерации. Клинические рекомендации. Менопауза и климактерическое состояние у женщины. МКБ10: N95.1 ID: КР117. М.: Российское общество акушеров-гинекологов; 2016. [Ministry of Health of the Russian Federation. Clinical recommendations. Menopause and menopausal condition in women. ICD 10: N95. 1 ID: KR117. Moscow: Russian Society of Obstetricians and Gynecologists; 2016. (in Russian)].
Савельева Г.М., Сухих Г.Т., Серов В.Н., Радзинский В.Е., Манухин И.Б., ред. Гинекология. Национальное руководство. 2-е изд. М.: ГЭОТАР-Медиа; 2020. 1008 с. [Savelyeva G.M., Sukhikh G.T., Serov V.N., Radzinsky V.E., Manukhin I.B., ed. Gynecology: national guidelines. 2nd ed. M.: GEOTAR-Media, 2020. 1008 p. (in Russian)].
Villa P., Amar I.D., Shachor M., Cipolla C., Ingravalle F., Scambia G.Cardiovascular risk/benefit profile of MHT. Medicina (Kaunas). 2019; 55(9): 571. https://dx.doi.org/10.3390/medicina55090571.
Vinogradova Y., Coupland C., Hippisley-Cox J. Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ. 2019; 364: k4810.https://dx.doi.org/10.1136/bmj.k4810.

Received 22.10.2020

Accepted 25.12.2020

Svetlana O. Dubrovina, Doctor of Medicine, Full Professor, Senior Research Officer, Rostov State Medical University, Ministry of Health of the Russian Federation.
E-mail: s. dubrovina@gmail.com. ORCID: 0000-0003-2424-2672. 344022, Russia, Rostov-on-Don, per. Nakhichevanskii, 29.
Lilia V. Kirevnina, Ph.D. of Medical Sciences, obstetrician-gynecologist, City clinical hospital named after A.K. Eramishantsev, Moscow.
12932715, Russia, Moscow, Lenskaya str., 15.
Maxim N. Lesnoy, 6th year student, Rostov State Medical University, Ministry of Health of the Russian Federation. 344022, Russia, Rostov-on-Don, per. Nakhichevanskii, 29.

For citation: Dubrovina S.O., Kirevnina L.V., Lesnoy M.N. Abnormal uterine bleeding: causes, diagnosis, and treatment.
Akusherstvo i Ginekologiya/Obstetrics and Gynecology. 2021; 1: 170-177 (in Russian)
https://dx.doi.org/10.18565/aig.2021.1.170-177

Abnormal uterine bleeding: causes, diagnosis, and treatment

Dubrovina S.O., Kirevnina L.V., Lesnoy M.N.

Keywords

References

About the Authors

Similar Articles