Menstruation 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 preceeding menopause, there may be disorders of ovulation. (Ovulation is the normal process of extrusion of ova in women). 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.

Q:What is normal menstruation?

A: 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.

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:

The normal cyclic periods are the result of normal balance between estrogen and progesterone (ovarian hormones). In the perimenopause, disruption of normal hormonal sequence results in erratic response of the endometrium (inner lining of uterine cavity). In most p e r i m e n o p a u s a l women ovary is the

major source of estrogen production. However, in obese women the excess of adipose (fat) tissue also

Q: What are the types of bleeding that occur in perimenopause?

The menstrual dysfunctions at perimenopause are of different types:

• Regular periods with excessive cyclic bleeding

• Short menstrual periods with normal or excessive bleeding

• Infrequent and delayed periods with normal or excessive and prolonged bleeding

What are the treatment options for dysfunctional uterine bleeding in women who have completed child bearing?

Q: 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 simultaneously.

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 patient.

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.

Questions and Answers compiled by:

Dr.Shobhana Mohandas. MD.DGO.FICOG.

Consultant Gynaecologist, Elite Hospital, Thrissur, Kerala.

Email: shobhanamohandas@yahoo.co.in

References:

1. Shobhana Mohandas www.thrissurgynaecology.com,

2. Preeti Galvankar,Menstrual dysfunction, Article in Poise, an Indian Menopause society publication.