Abnormal uterine and vaginal bleeding

Disease Description (Causes and Symptoms)

• Definition: Uterine or vaginal bleeding outside the normal menstrual cycle (typically 24–38 days, lasting 4–8 days, with a blood volume of approximately 5–80 mL), caused by structural lesions (such as uterine fibroids, polyps, uterine malformations, or malignancies) or functional causes (such as ovulatory disorders or hormonal imbalance).
• Major causes
  • Pregnancy-related: Normal early pregnancy, miscarriage, missed miscarriage, ectopic pregnancy, etc.
  • Uterine or adnexal lesions: Uterine fibroids, endometrial polyps, adenomyosis, endometrial hyperplasia, endometrial cancer, cervical cancer
  • Infections: Cervicitis, viral diseases (e.g., herpes), condyloma, etc.
  • Endocrine abnormalities: Ovarian dysfunction (anovulation), thyroid dysfunction, diabetes, etc.
  • Medications and external factors: Oral contraceptives, hormonal medications, anticoagulants, and some herbal medicines or supplements (affecting estrogen activity)
  • Bleeding tendencies: Thrombocytopenia, coagulation disorders, liver disease, etc.
  • Other: Stress; functional uterine bleeding that occurs despite the absence of an organic lesion
• Pathophysiology summary: Hormonal imbalance caused by ovulatory dysfunction (estrogen-only stimulation → unstable endometrium), vascular bleeding from localized structural lesions (such as polyps or fibroids), and abnormalities in the blood coagulation mechanism may act in combination.
• Symptoms
  • Abnormal vaginal bleeding (irregular or excessive); in cases of heavy bleeding, risk of dizziness, tachycardia, hypotension, and syncope
  • Iron-deficiency anemia due to prolonged bleeding (fatigue, pallor, shortness of breath)
  • Pelvic pain, menstrual cramps, or foul odor/discharge (when infection is suspected)

Treatment Methods and Precautions

• General principle: Identify the cause and provide cause-specific treatment. When bleeding is severe, hemodynamic stabilization (emergency treatment) is performed first.
• Emergency treatment (in cases of severe bleeding)
  • ABC stabilization: Oxygen, securing intravenous access, fluid replacement, and transfusion if necessary
  • Consider emergency uterine hemostatic procedures or surgery (when active bleeding persists or is life-threatening)
  • High-dose hormones to temporarily stabilize the endometrium may be used (at the discretion of medical professionals)
• Medication treatment
  • Antifibrinolytic: Tranexamic acid — effective in reducing heavy menstrual bleeding
  • Nonsteroidal anti-inflammatory drugs (NSAIDs, e.g., mefenamic acid) — reduce pain and bleeding volume
  • Hormonal therapy:
    • Oral contraceptives (combined oral contraceptives) — regulate the cycle and reduce bleeding
    • Progestins (e.g., medroxyprogesterone) — stabilize the endometrium through cyclic or continuous administration
    • Levonorgestrel-releasing intrauterine system (LNG-IUS) — highly effective for heavy menstrual bleeding
  • Iron supplementation (oral or intravenous if necessary) and correction of anemia
• Procedures and surgery
  • Hysteroscopic surgery (polypectomy, partial removal of fibroids); diagnosis and treatment may be performed together through hysteroscopy
  • Uterine artery embolization (UAE) or myomectomy for uterine fibroids
  • Endometrial curettage (D&C) — used for diagnostic and therapeutic purposes
  • Endometrial ablation — when bleeding control is needed while preserving the uterus
  • Hysterectomy — definitive treatment when hormonal therapy or procedures fail, malignancy is suspected, or bleeding is severe
• Other
  • Anti-infective drugs, anticancer treatment, etc., depending on the cause
  • When a coagulation disorder is the cause, hematologic treatment and consultation with relevant specialties are necessary
• Lifestyle and self-management
  • Record the amount and pattern of bleeding (including the number of pad or tampon changes)
  • Consume iron to prevent anemia and get sufficient rest
  • Avoid strenuous exercise and heavy labor during bleeding
  • Discontinuation or adjustment of medications (such as anticoagulants or hormonal medications) must be done according to a doctor's instructions
• Precautions (points of caution and risk of complications)
  • Confirming pregnancy status before treatment is essential (especially before intrauterine procedures or endometrial biopsy)
  • Patients taking anticoagulants or with bleeding disorders should consult a specialist before treatment
  • Infection, transfusion reactions, and side effects may occur after surgical treatment
  • Long-term abnormal bleeding can cause iron-deficiency anemia and reduced quality of life, and in some cases may be a sign of malignant disease

Checklist Before an Outpatient Visit (Including Items to Bring and Example Questions)

• Items to bring (helpful for consultation and diagnosis)
  • Menstrual history from the past 3–6 months (cycle, duration, and number of pad/tampon changes)
  • List of currently used medications (including prescription drugs, OTC medications, herbal medicines, and health supplements)
  • Previous test results (blood tests, pelvic ultrasound, and prior endometrial or hysteroscopy results)
  • History of gynecologic surgery and medical history (including pregnancy and miscarriage history)
  • Information about allergies and family history of blood disorders
  • Recent pregnancy test results, if available, or the date menstruation began
• Example questions for an outpatient visit (information to tell the doctor first during the consultation)
  • Whether the bleeding suddenly became heavier, and its duration and pattern
  • Associated symptoms (dizziness, syncope, fever, foul-smelling discharge, pelvic pain, etc.)
  • Whether currently taking contraceptives, anticoagulants, or hormonal medications
  • Possibility of pregnancy or a recent history of pregnancy or miscarriage

Examples of General Questions to Ask the Doctor

• "What is the most likely cause of my current bleeding?"
• "Which tests should be performed first? (Blood tests, ultrasound, endometrial biopsy, etc.)"
• "Can the symptoms be controlled with medication? What are the side effects?"
• "My anemia is severe. Will I need any treatment other than iron supplementation?"

Examples of Condition-Specific Questions

• When wishing to become pregnant: "How will treatment of the cause of the bleeding affect my chances of becoming pregnant? What additional tests should I have when preparing for pregnancy?"
• When considering surgery: "Can the symptoms be controlled with uterus-preserving treatment (hysteroscopic surgery, uterine artery embolization, or LNG-IUS)? What are the criteria for choosing a hysterectomy?"

(When necessary, consultation with a gynecology specialist and relevant departments, as well as hematologic, endocrine, and oncologic evaluation, is recommended.)