Investigation and treatment of irregular menstrual bleedingIn a woman's life cycle there are many similarities between the beginning of child-bearing age and its end. One of the striking features of these two periods is an irregular menstrual cycle. The reason for this irregularity is also similar, and in most cases stems from the occurrence of menstrual cycles without ovulation. However, while an adolescent girl can in the majority of cases wait and watch the cycle work itself out spontaneously, at the ends of childbearing age, pathological causes of irregular bleeding are more common, and so each case should be individually decided as to when and which investigation/s should be performed.
A regular cycle at reproductive age is defined as a menstrual cycle of between 21 and 35 days that lasts for 2-7 days. One characteristic of menopause is that menstruation does not appear every month on a regular basis and a particular month may be "skipped". Despite the chance of pregnancy at this age being low, in any case of irregular bleeding the possibility of early pregnancy, that could be intrauterine, ectopic or a miscarriage, should be ruled out.
The basic investigationBasic investigation of irregular bleeding includes detailed anamnesis, physical examination, ultrasound examination and basic blood tests. In general, the blood tests which are designed to rule out bleeding due to gynecological problems can be sent prior to referral to the gynecologist. These tests include a complete blood count including platelets, coagulation, HCG, TSH to negate pregnancy and sometimes, when there is doubt about menopausal symptoms, FSH and LH (on day 3 of menstruation).
The anamnesis details are of great value and can direct the doctor the correct diagnosis. For example, a woman who has noticed that her irregular bleeding occurs most often after intercourse may direct us to cervical-related pathology. However, for a 50-year-old woman complaining of hot flashes, night sweats, and a significant shortening of the interval between menstrual cycles, her doctor may be satisfied with the first stage of the investigation and can explain that we are talking about phenomena that characterize menopause.
The physical examination entails examination of the vulva, vagina, cervix and a bi-manual examination of the pelvic organs. From the physical examination it is possible to obtain information about lesions in the vulva, vagina or cervix opening, to feel the size of the uterus and a uterine fibroids, and to diagnose sensitivity or a cystic finding based on the treatment. As part of this test, a Pap smear is also performed as a review scan for pre-malignant or malignant cervical lesions.
The ultrasound test has become an integral part of the physical examination in recent years. The examination is usually performed in two stages. The first stage is performed abdominally with a full bladder and then, after emptying the bladder, a vaginal examination is carried out. The transabdominal examination is used to receive a more comprehensive picture of the pelvic organs, when checking a lump that comes out from above the pelvis, or when it is not possible to perform a vaginal examination as with girls who are virgins. The transabdominal examination requires a full bladder and sometimes, when the abdominal wall is thick or there is interference by intestinal loops it is more difficult to distinguish details. However, the vaginal examination allows a much closer look at the pelvic organs and more accurate identification of the organs and pathology (if any) in the pelvis. For example, when there are uterine fibroids a disturbance in the normal arrangement of the uterine muscle fibers is seen and a picture is otained of a round finding, darker than its surroundings; the fibroid.
The ultrasound test contributes many details, which sometimes are not diagnosed on physical examination. It is possible to obtain a description of the endometrium, whether it is uniform and regular, and what its thickness is. A thick and irregular endometrium may indicate pathology and direct us for further clarification. It is also possible to get more information on the findings of the uterine cavity, uterine characteristics, its size, and the presence of fibroids, properties of the ovaries and ovarian tumors, and fluid or another finding in the pelvis. If a cyst or other ovarian finding is revealed, it is possible to perform a Doppler scan and to characterize the dimensions of the blood flow in the finding. Malignant tumors are characterized by being rich in blood vessels with low resistance. Sometimes, when there is a need for accurate demonstration of the finding in the uterine cavity, it is possible to perform a more accurate test called hydrosonography. In this test, a fine catheter is inserted into the uterus and physiological fluid is pumped through it into the uterine space. The fluid causes the expansion of the space which allows accurate diagnosis of the boundaries of a fibroid or polyp and the extent of their bulge into the space. There are exceptional cases, which outside of ultrasound testing require more sophisticated imaging tests such as computerized tomography (CT) or magnetic resonance imaging (MRI).
Supplementary investigationIf the basic investigation reveals abnormal findings (for example, thickened endometrium or suspected polyp), or if the irregular bleeding continues and the abovementioned investigation is not sufficient, we must continue to make further inquiry. Additional means of clarification are hysteroscopy, endometrial biopsy in the clinic through a flexible plastic tube with a side opening at the tip inserted through the cervix to the uterus that allows removal of some uterine lining for pathological examination (Pipelle), and sometimes full scraping, under anesthesia in an operating room.
Hysteroscopy is a test that allows direct observation into the cervical canal, uterine cavity, and the openings of the fallopian tubes, using optics of a few millimeters in diameter inserted through the vagina into the uterus. It is customary to divide hysteroscopy into diagnostic hysteroscopy - when the test is performed alone without surgical intervention, and operative hysteroscopy - surgical procedures performed using a hysteroscope, such as the removal of a polyp, directed biopsy, or removal of a fibroid.
Hysteroscopy is considered the most reliable test for examining the cervical canal and uterine cavity. Compared to other imaging tests like ultrasound and uterus x-ray, with hysteroscopy a picture is obtained directly from the uterine space, so it is considered as the gold standard test of the uterine cavity. Many studies have shown that in a comparison between curettage (D & C) and hysteroscopy, curettage may miss about a third of cases where there are findings in the uterine space that will be diagnosed by hysteroscopy. In parallel with the technological advancement that has occurred in recent years, endoscopic equipment has been developed so that by using finer optics it is possible to obtain a sharp and accurate picture from the space. Therefore, today it is also possible to perform hysteroscopy in clinic without anesthesia.
Endometrial biopsy is performed in the clinic with a suction curette that has a diameter of about 3 mm, which is inserted through the cervix into the uterine space, and through which parts of the uterine lining are aspirated. After setting in paraffin, the lining will be transferred for pathological examination. The biopsy is performed without expanding the cervical canal and is usually painless so there is no need for anesthesia. However, its efficacy is similar to the effectiveness of curettage under anesthesia, and in approximately 98% of cases curettage under anesthesia and endometrial biopsy have similar efficacy in diagnosing endometrial pathology. Both tests are not sensitive enough when it comes to specific pathology such as polyps.
The treatmentIn all those cases where the investigation reveals a clear cause for the irregular bleeding, the finding should be treated directly. However, in more than 60% of cases no obvious cause for the irregular bleeding is revealed and we define the bleeding as dysfunctional uterine bleeding. The treatment means at our disposal in these cases include:
Medication treatment - treatment with drugs is in most cases based on combined hormonal preparations, similarly to birth control pills that contain estrogen and progesterone at different doses and compositions. It has been found that when irregular bleeding is caused by a lack of ovulation, the success of this treatment is very high, however, in ovulating cycles the success rate of drug therapy is much lower.
Treatment by an intrauterine device that secretes progesterone - the uniqueness of this device, called "Mirena", is that it secretes progesterone of the type levonorgestrel in a local way and of a minimal amount, with very little absorption into the systemic blood system. It should be emphasized that the device of this type was not originally intended for regulating irregular periods, but for menorrhagia - abnormally heavy and prolonged menstrual bleeding. However, sometimes, after installing Mirena, a woman develops amenorrhea for a few months, and so the problem of the bleeding is solved. In any case, it must be emphasized that there is always a period of about a month from the time of installation where bleeding may still be irregular and the woman must be patient during this time, otherwise it may be that this method is not suitable for her.
Minimally invasive treatments - the most "effective" treatment for solving the problem of irregular bleeding is surgical removal of the uterus (hysterectomy). Hysterectomy ensures that the bleeding stops, and indeed has historically been one of the traditional treatments. However, in recent years more and more women have become interested in minimally invasive treatment as a substitute for hysterectomy. The advantage of minimally invasive interventions over surgery is that opening the stomach is generally avoided and the hospitalization and recovery period are much shorter than with laparotomy.
One of the possibilities for minimally invasive surgery involves burning or peeling of the endometrium by hysteroscopy. The operation is performed transvaginally using a resectoscope. Sometimes a woman is treated before surgery with injection of a GnRH analogue to make the lining thinner and to shorten the operation time. The surgery can usually be performed as an outpatient and there is a rapid return to full activity. A candidate for this surgery must have completed her childbearing program, her endometrium must have been sampled and found to contain no pathology, and she should have been explained that the success of the operation, which is defined as avoidance of hysterectomy, is anticipated in 80% of cases. Today there is already more sophisticated technology which requires less surgical skill and has a similar success rate, called intrauterine treatment> Here, a balloon made of silicone is inserted into the uterus and fluid is injected into it that is heated to a temperature of about 87 degrees.
Catheterization and blocking the uterine arteries as a treatment for irregular uterine bleeding for fibroids - in this method, angiography of the iliac arteries is performed and transparency of the blood vessels that supply the blood to the uterus and fibroids. After inserting the catheter to the uterine arteries, tiny particles are injected through it that cause its blockage. This procedure is done radiology department and involves hospitalization of a day or two for observation and pain relief. To date, thousands of catheterizations such as these have been performed around the world with a high success rate of 90%. In light of the rare complication of damage in the blood flow to the ovaries too, we perform this operation only for women who have completed their childbearing plans.
Written by Dr. Asher Shushan, Department of Obstetrics and Gynecology, Hadassah Ein Kerem, Jerusalem