Women with Menorrhagia lose blood in excess of 80 ml per month … they should consult a gynaecologist as soon as possible

In this part of the world women often tend to neglect their health. They consult a gynaecologist when they are either pregnant or are trying to become pregnant. Never for a routine checkup, not even for cervical smears. To compound, very often they see a doctor who does not have the facilities to investigate conditions like, say hysteroscopy and endometrial biopsy.

“Menstrual abnormalities are a frequent problem of women. Menorrhagia or heavy periods is blood loss in excess of 80 ml per month. Menorrhagia is one of the commonest cause of iron deficiency anaemia. Heavy periods is a very common complaints with about 30 per cent of female between age of 16-45 years suffering from this. In 50 per cent of females with proven menorrhagia no pathology is found but it is very important to exclude uterine fibroids, endometrial polyp, uterine cancer, cervical cancer (cancer of neck of the womb), and ovarian tumours,” says Dr Tazyeen Jahan Faisal, specialist obstetrician and gynaecologist, Canadian Specialist Hospital, Dubai.

Some medical problems like under or overactive thyroid gland, blood clotting abnormalities, need to be excluded. Heavy irregular periods are more common at the extremes of reproductive life, adolescence and around menopause.

“In adolescence heavy irregular period is mainly due to immature hypothalamic, pituitary and ovarian axis, impaired positive feedback, causing hormonal imbalance, which can be treated with hormones for few months. But it is important to do some blood tests and an abdominal pelvic ultrasound scan of the uterus and ovaries,” says Dr Tazyeen Faisal.

Regular periods, she says, are the result of a precise hormone balance causing regular ovulation. “In perimenopause changes in hormone levels interfere with ovulation. If ovulation does not occur, the ovary will continue making oestrogen, causing the endometrium to keep thickening. This often leads to a late menstrual period followed by irregular bleeding and spotting. This can also result in endometrial polyps, a greater thickening called ‘hyperplasia’ or in the extreme long-standing cases, cancer of the lining of the uterus.”

Endometrial hyperplasia has got a malignant potential. It can be diagnosed and treated completely if diagnosed by hysteroscopy and endometrial biopsy. “But if left untreated it can change into endometrial cancer (cancer of the lining of the womb) over a period. In two studies, it was found that significant proportion 7-20 per cent of women with marked hyperplastic changes on curettage (without hysteroscopy) had invasive cancer on hysterectomy.”

Hysteroscopy is a simple procedure used to view the inside of the uterine cavity through a telescope like device called hysteroscope. “This gives a magnified view of the uterine cavity on the screen. Any uterine pathology can be seen directly and suspicious area can be biopsied under vision. Hysteroscopy is a day surgery procedure done without general anaesthesia or under general anaesthesia and patient can go home the same day,” says Dr Tazyeen.

Uterine cancer is one of the commonest gynaecological cancers, with an incidence of 1/1000 in post menopausal females and 1/1000,000 in women less than 40 years of age. “Post-menopausal bleeding is the most common symptom in 75-80 per cent of endometrial cancer. Post-menopausal foul smelling vaginal discharge due to pyometra (pus in the uterine cavity) will reveal a uterine cancer in 50 per cent of the cases. Women who get post-menopausal spotting or bleeding have a 10-20 per cent risk of having genital cancer,” says Dr Tazyeen.

The most common type of hereditary endometrial cancer syndrome is the Hereditary Non-Polyposis Colorectal Cancer (HNPCC or Lynch Syndrome II). Multiple family members can develop cancers arising from the colon, uterus, small intestine, kidney system, or the ovaries. “The treatment should be directed according to the cause.”

Dysfunctional uterine bleeding is abnormal bleeding from the uterus not due to organic causes. After excluding serious pathologies, medical treatment (hormonal and non-hormonal) is the first line of treatment. An intrauterine contraceptive device coated with levonorgestril harmone is one of the treatment options for heavy periods where no obvious pathology is found (DUB).The local release of this hormone within the uterine cavity results in strong suppression of endometrial growth and causes decreased bloodloss each month – eventually up to 97 per cent decrease in bloodloss in nine months or as in some cases to even no periods at all without affecting the ovarian hormones, and no menopausal symptoms. If this treatment fails then surgeries like endometrial ablation or hysterectomy are the last resort.

“Early detection is the best prevention from developing invasive endometrial cancer. As the disease progresses, chances of survival decrease markedly. Treating precancerous hyperplasia with hormones (progestins), a hysterectomy, can prevent abnormal, precancer cells from developing into cancer. About 10-30 per cent of all hyperplasia cases eventually develop into cancer, if left untreated,” says Dr Tazyeen.

Abnormal uterine bleeding that is not related to the menstrual period is a common and

usually innocent symptom. However, cancer of the uterus, both of the cervix and corpus uteri present with Intermenstrual bleeding, post-coital bleeding, postmenopausal bleeding, and heavy irregular periods.

“All postmenopausal females with complaints of postmenopausal bleeding, excessive foul smelling discharge should have cervical smear, hysteroscopy and endometrial biopsy. Especially those who are obese, diabetic, hypertensive, nullipara in old age; who have had late menopause (between 51-55 years); have oestrogen producing ovarian tumours; who had received pelvic radiation; who have a family history of breast, ovary, or colon cancer and/or have less than four periods in a year due to polycystic ovarian syndrome are at higher risk of developing endometrial hyperplasia and endometrial cancer,” says Dr Tazyeen.

Women under 35 may be offered hormonal therapy as a therapeutic trial. In women over 35 and in the face of an unsuccessful empirical trial of hormones, the endometrium must be sampled. In low risk patients endometrial biopsy can be done without general anaesthesia in the clinic without any significant pain. In perimenopause and postmenopause women endometrial hyperplasia and endometrial cancer are the prime concerns. “It is very important to investigate the cause of irregular heavy periods by pelvic examination, pelvic ultrasound scan to check uterus and ovaries, cervical smear, hysteroscopy and endometrial biopsy to exclude endometrial pathology especially among ladies more than 40 years.Early endometrial cancer can be missed by blind D&C, so Hysteroscopy with endometrial biopsy should be done preferably, instead of D&C.”

Any woman with abnormal vaginal bleeding should consult her gynaecologist as soon as possible.

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