Abnormal Uterine Bleeding in a 39 year old: A Case Report

John Patrick B. Encarnacion, Neil F. Espiritu, Eunice Danica O. Fe, Richzhel V.

Fernandez, Justin Louise Q. Flavier, Eliana S. Gerzon

School of Medicine: Department of Gynecology, Angeles University Foundation

Angeles City, Pampanga

Abstract

Abnormal uterine bleeding (AUB) is a debilitating condition, which is

common in females of all ages, and etiologies include anatomic changes,

hormonal dysfunction, and infection. A structured approach for establishing the

cause using the Federation of Gynecology and Obstetrics (FIGO) PALM-COEIN

(Polyp, Adenomyosis, Leiomyoma, Malignancy (and hyperplasia), Coagulopathy,

Ovulatory disorders, Endometrial, Iatrogenic and Not otherwise classified)

classification system facilitates accurate diagnosis which guide treatment

options.1 It encompasses several descriptive terms such as heavy menstrual

bleeding (HMB) defined as menstrual bleeding exceeding 80 ml of blood loss.2

True uterine bleeding usually results from increased estrogen levels.2,3 In relation

to this, the group reports a case of AUB. Relevant discussion and considerations
of all possible etiologies are presented alongside with approach in its proposed

management and treatment.

Keywords: Abnormal Uterine Bleeding (AUB); FIGO PALM-COEIN;

Gynecology

Introduction

Abnormal uterine bleeding (AUB) is a common condition affecting 14-25%

of women of reproductive age.4 Alterations in the pattern or volume of blood flow

of menses are among the most common health concerns. Bleeding prior to

menarche is an outright abnormal finding. In children, vaginal etiology such as

vulvovaginitis is considered alongside with trauma and neoplasm.2 In

adolescence, anovulation and coagulation defects occur in higher rates in

comparison with older reproductive-aged women.5 In perimenopausal age,

anovulatory uterine bleeding from HPO axis dysfunction is a frequent finding. 2,3

Case Report

Our group presents a case of a 39-year-old, G3P3 (3003), married,

Filipino, Catholic who resides in Arayat, Pampanga and was seen at the

OB-GYN OPD with a chief complaint of heavy menstrual bleeding.

Illness began when 4 months prior to consultation, she experienced

prolonged menstruation from June 13 to July 10, 2016 in which she noted
bleeding to be red and in minimal amount. She consumed an estimated 1-3 pads

per day in a week with accompanying 3/10 dull pain localized in the hypogastric

area which is relieved when blood comes out. There were no accompanying

vaginal pruritus, dyspareunia and fever.

1 month prior to consultation, patient continued to have prolonged

menstrual bleeding. She sought consultation with a general practitioner and was

given Tranexamic Acid 500 mg capsule three times a day and was also advised

for ultrasound and Pap smear test in which she did not comply because the

bleeding stopped for 3 weeks.

1 week prior to consultation, patient followed up with the aforementioned

general practitioner with unrecalled findings in the ultrasound and a normal Pap

smear result. She was referred to Jose B. Lingad Memorial Regional Hospital

(JBLMRH) for evaluation.

4 days prior to consultation, patient noticed an increasing amount of

menstrual bleed, which totally soaked 2 white diapers per day with

accompanying dysmenorrhea described as dull and rated as 3/10 with no

management done. Foul-smelling vaginal discharge and small clots were also

noted. There is dyspareunia but no post-coital bleeding occurred. Due to

persistence of bleeding and increasing size of blood clots, she complied with the

advice to go to JBLMRH OPD for consultation.

 The patient was diagnosed with hypertension last 2003 and is maintained

on Metoprolol 50 mg BID and Losartan 5 mg OD. There were no past surgeries

and hospitalizations. There was positive history of hypertension in the maternal

side. She doesnt smoke or drink alcohol. She has finished vocational degree

and is a plain housewife. She had her menarche at 12 years old. Her usual

menses are of regular intervals of a 28 day cycle that usually last for 3 days,

consuming 3 sanitary pads per day, fully soaked and with accompanying

symptoms of dysmenorrhea. Last menstrual period was on September 24, 2016.

Previous menstrual period was estimated to be on September 5 - 8, 2016. The

first prolonged menstrual bleed was on June 13 - July 10, 2016. First sexual

contact was at 20 years old with only 1 sexual partner. There was no history of

OCP use in the past. In 2004, patient had Pap smear with normal findings. She

has no history of sexually transmitted infections.

Review of systems is unremarkable except that the patient claims weight

loss. On physical examination, patient has a blood pressure of 160/100 mmHg

and a Body Mass Index (BMI) of 28.7. She has pink palpebral conjunctiva.

Abdomen is flabby with no tenderness, mass, or nodules. Breasts are pendulous

with no tenderness, lumps, or nipple discharge. Inspection of the external

genitalia reveals normal looking pubic hair pattern with no scars, warts, and

abnormal discharges. There was no inflammation, ulceration, swelling or any

nodule in the vulva. On speculum examination, vaginal mucosa is pink and has
blood on walls. Cervix is pink, blood-tinged, and has erosion in the 12 oclock

position. Borders are smooth and there were no outgrowths noted. On bimanual

examination, there was neither adnexal mass nor tenderness upon palpation.

Salient features of the case include:

1. Prolonged heavy menstrual bleeding with small to large clots

2. Age of 39 years old

3. Multiparous

4. Dysmenorrhea

5. Obese

With all the initial findings noted, the initial impression is Abnormal Uterine

Bleeding (AUB) to consider Endometrial Hyperplasia.

Although the causes of AUB are numerous, the group identified

endometrial hyperplasia, endometrial polyp, adenomyosis, submucous myoma,

and endometriosis to be the most likely etiologies. This is due to the fact that the

bleeding is heavy and has associated dysmenorrhea. The presence of

dysmenorrhea suggests a structural abnormality. They also are associated with

aromatase expression and high tissue estrogen levels. The group primarily

considers endometrial hyperplasia because the patient is older than 35 years old

and obese, which predisposes the patient to higher estrogen production.2

Endometrial carcinoma should also be considered because its risk factors --

extended AUB, obesity, and non-smoking status of the patient are present.2
 We cannot completely rule out the aforementioned because diagnostic

procedures are necessary to confirm the etiology of the case. This is partly

because the bleeding pattern has limited value in diagnosing the underlying

bleeding cause.2

Discussion

Abnormal uterine bleeding (AUB) encompasses any significant deviation

from normal frequency, regularity, heaviness (volume or amount) and duration of

menstrual bleeding. The normal limits for the four main clinical dimensions of

menstruation and the menstrual cycle are outlined in Table 1.6

The PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and

hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and

not yet classified) classification system was approved by the International

Federation of Gynecology and Obstetrics (FIGO) to classify the possible

etiologies of AUB. In general, the components of the PALM group are discrete

(structural) entities that can be measured visually with imaging techniques and/or

histopathology, whereas the COEIN group is related to entities that are not

defined by imaging or histopathology (non-structural).7

The endometrium consists of two distinct zones, the functionalis layer and

the basalis layer. The basalis layer lies in direct contact with the myometrium,

and is less hormonally responsive. It serves as a reservoir for regeneration of the

functionalis following menses. In contrast, the functionalis layer lining the uterine

cavity undergoes dramatic change throughout the menstrual cycle and is

sloughed off during menstruation.2

The endometrium changes throughout the menstrual cycle in response to

hormones. During the first part of the cycle, estrogen is made by the ovaries.

Estrogen causes the lining to grow and thicken to prepare the uterus for

pregnancy. Following ovulation, progesterone begins to increase. Progesterone

prepares the endometrium to receive and nourish a fertilized egg. If pregnancy

does not occur, estrogen and progesterone levels decrease.8 The decrease in

progesterone leads to the release of lytic matrix metalloproteinases that break

down the stroma and vascular architecture of the functionalis layer. Subsequent

bleeding and sloughing of this layer constitute menstruation. Once the lining is

completely shed, a new menstrual cycle begins.2

In the case of endometrial hyperplasia, it is most often caused by excess

estrogen without progesterone. If ovulation does not occur, progesterone is not

made and the lining is not shed. The endometrium may continue to grow in

response to estrogen. The cells that make up the lining may crowd together and

may become abnormal. This condition is called endometrial hyperplasia.8

To complement the historical inventory and physical findings, the following

diagnostic tests are recommended to identify the etiology of AUB. A complete

blood count (CBC) is indicated to identify anemia and the degree of blood loss.
Wet Prep examination and cervical cultures are used to exclude infectious

causes of AUB. Diagnostic Pap smear evaluation is indicated to identify

abnormal cells. Endometrial biopsy is done to identify infection or neoplastic

lesions such as endometrial hyperplasia or cancer. For premenopausal women,

transvaginal sonography (TVS) and saline infusion sonography (SIS) are

performed to exclude structural sources of abnormal bleeding.2 In between the

two, SIS typically permits superior detection of intracavitary masses and

differentiation of lesions as being endometrial, submucous, or intramural. More

so, it is performed using an endoscope of 3 to 5 mm in diameter that is inserted

into the endometrial cavity. The uterine cavity is distended with saline for

visualization. Since endometrial hyperplasia is a histologic diagnosis, Pipelle

office endometrial biopsy (EMB) or outpatient dilatation and curettage (D&C) are

suitable choices for endometrial sampling. The former is associated with few

complications, performed quickly, and is well tolerated by the patient. In fact,

American College of Obstetricians and Gynecologists (ACOG) recommends it for

women older than 45 years with AUB or those younger than 45 with chronic

estrogen exposure and persistent AUB.2

The ACOG enumerated factors that need to be considered in deciding the

type of treatment for abnormal uterine bleeding. These include cause of the

bleeding, age and desire to have children.9

 In addition, the Journal of Obstetricians and Gynecologists Canada

(JOGC) suggests that once malignancy and significant pelvic pathology have

been ruled out, medical treatment should be considered as the first line

therapeutic option. Regular, heavy menstrual bleeding can be successfully

treated with both hormonal and nonhormonal options. Irregular or prolonged

bleeding is most effectively treated with hormonal options such as cyclic

progestins, combined hormonal contraceptives, and the

levonorgesterel-releasing intrauterine system that regulate cycles, decreasing the

likelihood of unscheduled and potentially heavy bleeding episodes while

protecting the endometrium from unopposed estrogen and the risk of hyperplasia

or carcinoma.10

Non-hormonal Treatments. NSAIDs reduce total prostaglandin

production through the inhibition of cyclooxygenase, shifting the balance between

prostaglandins and thromboxanes to promote uterine vasoconstriction thereby

reducing menstrual blood loss by 33% to 55%. NSAIDs also have the added

benefit of improving dysmenorrhea for up to 70% of patients. Contraindications

include hypersensitivity, pre-existing gastritis, and peptic ulcer disease.

Antifibrinolytics such as Tranexamic acid is a plasminogen activator inhibitor that

reversibly binds to plasminogen to reduce local fibrin degradation without

changing blood coagulation parameters.10

 Hormonal Treatments. Combined Hormonal Contraceptives (CHCs)

including the oral contraceptive pill, contraceptive patch, and vaginal ring provide

excellent cycle control, significantly reducing menstrual losses up to 40-50% and

improving symptoms of dysmenorrhea. The progesterone component provides

ovulation suppression and inhibits ovarian steroidogenesis to create endometrial

atrophy, while estrogen provides support to the endometrium to reduce the

likelihood of unscheduled breakthrough bleeding. Contraindications to CHCs,

include history of thrombosis or stroke, uncontrolled hypertension, migraine with

neurologic symptoms, coronary artery disease, liver disease, and a history of

breast cancer.10

Cyclic progestins, such as Medroxyprogesterone acetate or Norethindrone

(Norethisterone) are a recognized treatment for anovulatory bleeding. About 50%

of women with irregular cycles will achieve menstrual regularity with this regimen

with the added benefit of protecting the endometrium from the effects of

unopposed estrogen. Common side effects from oral progestins include breast

tenderness, water retention, weight gain, headaches, and acne.10

Depot medroxyprogesterone acetate (DMPA), while providing excellent

contraception, is often used in clinical practice for treating heavy menstrual

bleeding. DMPA suppresses ovulation and ovarian steroidogenesis, reducing the

estrogen-mediated stimulation of the endometrium and ultimately causing

endometrial atrophy. Side effects include irregular breakthrough bleeding or

spotting, breast tenderness, nausea, weight gain, mood disturbance, and a small

reduction in bone mineral density that is reversible upon cessation.10

Levonorgestrel-releasing intrauterine system is a procedure in which a 32

mm device administers 20 g of levonorgestrel directly to the endometrium each

day, inducing endometrial atrophy and reducing mean uterine vascular density. It

has been found to reduce menstrual losses significantly and has recently been

approved in the treatment of idiopathic menorrhagia. It has also been found to

improve dysmenorrhea and pelvic pain due to endometriosis.10

Danazol induces endometrial atrophy by inhibiting ovarian steroidogenesis

through suppression of the pituitary-ovarian axis. Danazol is associated with

significantly more adverse effects than other medical therapies, specifically

including weight gain, acne, and androgenic effects.10

Gonadotropin-releasing hormone (GnRH) agonists induce a reversible

hypogonadal state. Endometrial atrophy and amenorrhea are usually achieved

among premenopausal women within 3 to 4 weeks. In addition to effectively

treating heavy menstrual bleeding, GnRH agonists provide relief from

dysmenorrhea associated with adenomyosis and endometriosis. Long-term use

of GnRH agonists is limited by significant adverse effects, including bone pain,

loss of bone density, and hypoestrogenic effects including hot flashes, night

sweats, and vaginal dryness. Add-back therapy with low dose estrogen and
progestins will minimize adverse effects, and should be administered if therapy is

to extend beyond 6 months.10

Surgical Management. JOGC listed surgical indications for women with

AUB. These include (1) failure to respond to medical therapy, (2) inability to

utilize medical therapies (due to side effects, contraindications), (3) significant

anemia, (4) impact on quality of life, and (5) concomitant uterine pathology such

as large uterine fibroids, endometrial hyperplasia. The surgical options

recommended include dilation and uterine curettage, hysteroscopic polypectomy,

endometrial ablation, myomectomy and hysterectomy. However, endometrial

ablation techniques carry the risks of uterine perforation, infection, hemorrhage,

and bowel or bladder injury.10

Conclusion

Abnormal Uterine Bleeding (AUB) is a common condition found in

reproductive females. It can be caused by different etiologies as presented by the

PALM-COEIN classification. The patients signs and symptoms may be

non-specific and may suggest different etiologies. Therefore, a patient presenting

with AUB needs further work-ups to determine the etiology of her condition. It is

important to have the work-ups accomplished before making a diagnosis

because not doing so may lead to misdiagnosis and this will affect both the

management and treatment for the underlying cause of AUB.

Acknowledgement

The authors would like to acknowledge the efforts of the Gynecology

professors, especially Dra. Malou Mercado and Dr. Angelo Tolentino, who helped

them throughout their journey in making this case report. Through their guidance,

the researchers were able to have the opportunity to examine real gynecological

cases. The knowledge that they gained from this case report will surely be of use

in their future endeavors.

References

1) Whitaker L, Critchley, HOD. Abnormal uterine bleeding. Best Practice &

Research. Clinical Obstetrics & Gynaecology. 2016; 34: 5465.

2) Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Corton M.

ed. New York: McGraw-Hill Education; 2016.

Williams gynecology. 3rd

3) Lentz GM, Lobo RA, Gershenson DM, Katz, VL. Comprehensive gynecology.

6th ed. Philadelphia, PA: Elsevier, Inc.; 2012.

4) Fraser IS, Langham S, Uhl-Hochgraeber K. Health-related quality of life and

economic burden of abnormal uterine bleeding. Expert Rev Obstet Gynecol.

2009; 4: 179189.
5. Ahuja SP, Hertweck SP. Overview of bleeding disorders in adolescent females

with menorrhagia. J Pediatr Alosc Gynecol. 2010; 23: 15.

6) Philippine Obstetrical and Gynecological Society, Inc. Clinical practice

guidelines on abnormal uterine bleeding. Available from:

https://www.scribd.com/doc/273678483/POGS-CPG-Abnormal-Uterine-Bleedine.

[Accessed: 14th October 2016].

7. Munro M, Critchley C, Broder M, Fraser I. FIGO classification system

(PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of

reproductive age. Obstet Gynecol Int J. 2011; 113(1): 3-13.

8. American College of Obstetrician and Gynecologists. Endometrial hyperplasia.

Available from:

https://www.acog.org/-/media/For-Patients/faq147.pdf?dmc=1&ts=20161015T07

13567192. [Accessed: 14th October 2016].

9. American College of Obstetricians and Gynecologists. Abnormal uterine

bleeding (FAQ sheet). Available from:

http://www.acog.org/-/media/For-Patients/faq095.pdf. [Accessed: 14th October

2016].

10. Singh S, Best C, Dunn S. Abnormal uterine bleeding in pre-menopausal

women. J Obstet Gynaecol Can. 2013; 35(5): 12-20. Available from:

https://sogc.org/wp-content/uploads/2013/07/gui292CPG1305E.pdf. [Accessed:

14th October 2016].

Appendix

Table 1

Normal limits for menstrual parameters in the mid-reproductive years.

Clinical Dimensions of Descriptive Terms Normal Limits

Menstruation and (5th - 95th percentiles)

Menstrual Cycle

Frequency of menses Frequent < 24

(days) Normal 24-38

Infrequent > 38

Regularity of menses Absent -

(cycle to cycle variation Regular Variation of 2 to 20 days

over 12 months; in days) Irregular Variation of >20 days

Duration of flow (days) Prolonged > 8.0

Normal 4.5-8.0

Shortened < 4.5

Volume of monthly blood Heavy > 80

loss (ml) Normal 5-80

Light < 5