Abnormal vag¡nal Bleeding,

The uterus bleeds in regular cycles called the menstrual cycles that last for 3-5 days. Menstruation occurs once every month although the cycle may vary from 21-35 days. These cyclical bleeds are triggered by a fall in the oestrogen (female sex hormones) levels in the blood.

• What is abnormal vag¡nal bleeding?
• What are the causes of abnormal vag¡nal bleeding?
• How is the diagnosis confirmed?
• What is the treatment?
• When should the doctor be consulted?

What is abnormal vag¡nal bleeding?

The uterus bleeds in regular cycles called the menstrual cycles that last for 3-5 days. Menstruation occurs once every month although the cycle may vary from 21-35 days. These cyclical bleeds are triggered by a fall in the oestrogen (female sex hormones) levels in the blood.

vag¡nal bleeding may become abnormally excessive, scanty, or irregular. All of these need evaluation because they indicate disease.

What are the causes of abnormal vag¡nal bleeding?

The bleeding may arise from the uterus, the cervix, the vag¡na or the ovaries. In the uterus the presence of fibroids or cancer cause excessive or irregular bleeding. Dysfunctional uterine bleeding (DUB) is an irregular heavy bleeding from a normal uterus, and occurs due to hormonal imbalances.

Other uterine causes include molar pregnancy, double uterus, infection of the uterus (tuberculosis) and pregnancy relayed causes such as abortion. An intrauterine copper device may be the cause if irregular bleeding.

Bleeding from the cervix may occur from erosions, inflammation (cervicitis), polyps or cancer. Bleeding may arise from the vag¡na as in vag¡nal foreign bodies. Children tend to insert small objects, which stay in the vag¡na and cause infection and bleeding. In adults, a forgotten tampon may be the cause. Other vag¡nal sources of bleeding include infections, inflammation in the elderly (senile vaginitis), and rarely, vag¡nal cancer.

Some hormone producing tumours of the ovaries can cause bleeding from the uterus. Bleeding may be less than normal in patients with hormonal imbalances, such as those that occur at around the time of menopause. Infections such as tuberculosis, as well as some drugs (antipsychotic medicines) also may be associated with scanty blood flow.

What are the symptoms?

Patients may complain of irregular periods. The cycles may have become shortened. Excessive bleeding may occur between two menstrual periods or the menstrual period itself may be profuse, or last longer than normal. Excessive bleeding may be associated with anaemia. The patients become pale, and tire easily. Those with tuberculosis or cancer may have loss of weight.

How is the diagnosis confirmed?

The doctor will first examine the patient with his fingers, and with a speculum, an instrument to look inside the vag¡na and the cervix. If the diagnosis is not clear, other tests may be needed.

An ultrasound can pick up tumours or enlargement of the ovaries or the uterus. A Papanicolou (PAP) smear picks up cells from the cervix and examination of these cells will confirm whether there is cancer or not. Dilatation and curettage (D&C) is a procedure that is usually done under anaesthesia.

The opening of the cervix is stretched, and an instrument (curette) is inserted to scrape the lining of the uterus. This provides tissue for biopsy, which may reveal an abnormality. In conditions like DUB, a D&C can even cure the condition.

If the diagnosis is still not clear, the gynaecologist may do a hysteroscopy. This is a form of endoscopy in which the uterus is visualised with a specially designed telescope, the hysterosocpe. The hysteroscopy may be diagnostic, and minor lesions such as polyps may be removed at the same time. CT scans and MRI may be required prior to treatment if cancer is suspected or diagnosed, to identify the extent of disease.

What is the treatment?

The treatment of abnormal vag¡nal bleeding depends on the underlying cause. Medicines are needed for DUB, which is usually treated with the hormone progesterone (another female sex hormone), or a hormone-like drug,Danazol.

Fibroids are treated by operation in which either only the fibroid is removed (myomectomy) or the uterus is removed hysterectomy). Hysterectomy is preferred in patients who are not keen to have more children. Anaemia is commonly present in patients with excessive bleeding, and need supplementation with iron rich foods such as meat.

When should the doctor be consulted?

All women with abnormal vag¡nal bleeding need medical consultation. Excessive bleeding should be treated early, and profuse, uncontrollable bleed may need emergency treatment. In the elderly, abnormal bleeding may indicate cancer, and a thorough investigation is essential.