Metrorrhagia, also referred to as abnormal uterine bleeding, refers to vaginal bleeding among women that is not in sync with their normal menstrual period. An example of metrorrhagia can be seen when a woman experiences a heavier, prolonged period of bleeding more often than the normal menstrual duration of 21 days, or farther apart than 35. The condition can normally be related to a hormonal imbalance and typically can be found among pre-menopausal women. Hormone treatment using estrogen, the progestin pill, use of the levonorgestrel IUD or a daily birth control pill typically helps to relieve the symptoms of metrorrhagia. In rare cases, a hysterectomy might be needed when other treatments do not work.
Pathophysiology of Metrorrhagia
The normal menstrual cycle is 28 days and starts on the first day of menses. During the first 14 days (follicular phase) of the menstrual cycle, the endometrium thickens under the influence of estrogen. In response to rising estrogen levels, the pituitary gland secretes follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which stimulate the release of an ovum at the midpoint of the cycle. The residual follicular capsule forms the corpus luteum.
After ovulation, the luteal phase begins and is characterized by production of progesterone from the corpus luteum. Progesterone matures the lining of the uterus and makes it more receptive to implantation. If implantation does not occur, in the absence of human chorionic gonadotropin (hCG), the corpus luteum dies, accompanied by sharp drops in progesterone and estrogen levels. Hormone withdrawal causes vasoconstriction in the spiral arterioles of the endometrium. This leads to menses, which occurs approximately 14 days after ovulation when the ischemic endometrial lining becomes necrotic and sloughs.
Terms frequently used to describe abnormal uterine bleeding:
- Menorrhagia – Prolonged (>7 d) or excessive (>80 mL daily) uterine bleeding occurring at regular intervals
- Metrorrhagia – Uterine bleeding occurring at irregular and more frequent than normal intervals
- Menometrorrhagia – Prolonged or excessive uterine bleeding occurring at irregular and more frequent than normal intervals
- Intermenstrual bleeding – Uterine bleeding of variable amounts occurring between regular menstrual periods
- Midcycle spotting – Spotting occurring just before ovulation, typically from declining estrogen levels
- Postmenopausal bleeding – Recurrence of bleeding in a menopausal woman at least 6 months to 1 year after cessation of cycles
- Amenorrhea – No uterine bleeding for 6 months or longer
Abnormal uterine bleeding is a diagnosis of exclusion. It is ovulatory or anovulatory bleeding, diagnosed after pregnancy, medications, iatrogenic causes, genital tract pathology, malignancy, and systemic disease have been ruled out by appropriate investigations. Approximately 90% of dysfunctional uterine bleeding cases result from anovulation, and 10% of cases occur with ovulatory cycles.
Anovulatory dysfunctional uterine bleeding results from a disturbance of the normal hypothalamic-pituitary-ovarian axis and is particularly common at the extremes of the reproductive years. When ovulation does not occur, no progesterone is produced to stabilize the endometrium; thus, proliferative endometrium persists. Bleeding episodes become irregular, and amenorrhea, metrorrhagia, and menometrorrhagia are common. Bleeding from anovulatory dysfunctional uterine bleeding is thought to result from changes in prostaglandin concentration, increased endometrial responsiveness to vasodilating prostaglandins, and changes in endometrial vascular structure.
In ovulatory dysfunctional uterine bleeding, bleeding occurs cyclically, and menorrhagia is thought to originate from defects in the control mechanisms of menstruation. It is thought that, in women with ovulatory dysfunctional uterine bleeding, there is an increased rate of blood loss resulting from vasodilatation of the vessels supplying the endometrium due to decreased vascular tone, and prostaglandins have been strongly implicated. Therefore, these women lose blood at rates about 3 times faster than women with normal menses.
Causes of metrorrhagia
There are many reasons why women may have metrorrhagia. They include:
- Hormone imbalance (the imbalance is sometimes caused by improper use of hormone medicine, such as birth control pills)
- Polyps, which are growths on the cervix (the opening of the uterus) or inside the uterus; polyps are usually noncancerous.
- Fibroids, which are noncancerous growths in the uterus
- Infection or inflammation of the uterus, cervix, or vagina
- Erosion of the cervix (loss of the surface skin of the cervix)
- Use of an IUD (intrauterine device) or birth control pills
- Endometriosis (uterine tissue growing outside the uterus)
- Adhesions (scar tissue) inside the uterus
- Dry vaginal walls from decreased estrogen after menopause
- Chronic medical problems (for example, thyroid problems, diabetes, and blood-clotting problems)
- Some medications, such as blood thinners
- Cancer of the cervix or other parts of the uterus and vagina
The following factors may contribute to the occurrence of metrorrhagia:
- Excessive physical activity
- Drug and alcohol abuse
- Anorexia and bulimia
- Thyroid problems
- Females that have begun menstruating can experience metrorrhagia.
- It is especially concerning for post-menopausal women because the risk of malignancy increases with age.
Vaginal bleeding is common in the first three months of taking oral contraceptives. Estrogen and progestin are the oral contraceptives that can cause bleeding. Sometimes, the risk is also increased due to progesterone, but the situation can be improved by the addition of estrogen.
- Soaking through one or more sanitary pads or tampons every hour for several consecutive hours
- Needing to use double sanitary protection to control your menstrual flow
- Needing to wake up to change sanitary protection during the night
- Bleeding for longer than a week
- Loss of libido
- Hot flashes
- Dyspareunia (painful intercourse)
- Pelvic pain
- Painful urination
- Smelly vaginal discharge
Complications of Metrorrhagia
In most cases, occasional light bleeding between periods does not carry major health risks, besides being inconvenient. However, frequent, consistently heavy spotting or bleeding between periods can have negative consequences on a woman’s health.
Iron-deficiency anemia may be triggered by significant blood loss on a monthly basis as well as poor nutrition, which is one of the causes of bleeding between periods. It is said to affect up to 20% of women of reproductive age and has been linked to infertility, depression, heart problems, and other complications.5
Another complication of metrorrhagia that is not properly treated is the progression of the condition that causes it. While most conditions can have detrimental effects on a woman’s well-being and daily functioning, leaving some without treatment can be life-threatening. This includes PID, certain STDs, coagulation disorders, or cancers.
Diagnosis of Metrorrhagia
Your healthcare provider will ask about your medical history and menstrual cycles. Your provider may ask you to keep a diary of bleeding and non-bleeding days, including notes about how heavy the bleeding was. You may also have a physical exam.
Sometimes, a blood test or procedure are necessary, these include:
Endometrial biopsy: Your physician takes a sample of tissue from the inside of the uterus. The tissue is then examined under a microscope.
Ultrasound scan: Sound waves are used to get pictures of the uterus, ovaries, and pelvis. The ultrasound probe may be placed on your lower abdomen or into your vagina.
Hysteroscopy: Your physician inserts a thin metal tube with a tiny camera through the vagina and cervix and into the uterus. This allows your provider to see the inside of the uterus.
Sonohysterogram: An ultrasound scan done after fluid is injected through a tube into your uterus. This test allows your provider to look for problems with the lining of the uterus, such as fibroids.
Some of these procedures may be done in your healthcare provider’s office. Others may be done in an outpatient clinic.
Check first that the source of bleeding is not from the urine or rectum, but from the vagina. This can be confirmed with the help of a tampon.
- A bed rest is a must in case of heavy bleeding. Don’t forget to take note of the number of tampons or pads you have used.
- Avoid taking aspirin. Excessive vaginal bleeding may be caused by aspirin intake.
- Hormonal treatment may be needed in case of hormonal imbalances.
- Antibiotics are required for bacterial infection.
- Hysterectomy (surgical removal of the uterus) may be required in some cases.
Once the root cause of metrorrhagia is identified, the next main focus is its treatment. The basic goal of any treatment is to provide comfort and cure to the affected person. Treatment may include the following:
- Hospitalization – When bleeding progresses to hemorrhage or becomes uncontrolled, the doctor will recommend hospitalization to monitor and observe the patient along with carrying out diagnostic tests.
- Oral Contraceptives – These can help in providing a regular menstrual cycle. They can help maintain women’s hormonal levels.
- Dilation and Curettage – The doctor performs this procedure when the cause of bleeding is an incomplete abortion. The components left behind in the body can harm the mother, so they are removed through D&C.
- Iron Supplements – Women who suffered severe blood loss should be given iron supplements.
- Estrogen-Gestagen Therapy – For 10 days, estrogen-gestagen therapy may be given to treat hormonal problems. When estrogen levels are corrected, menstrual cycles are corrected as well.
- Hysteroscopy – For polyp removal.
- Hysterectomy – For the removal of the uterus.
- Surgery, radiation, and chemotherapy – If cancer is detected, surgery, radiation, chemotherapy, or a combination of these treatments is done.
As such, metrorrhagia treatment can encompass a variety of approaches, from optimizing one’s lifestyle practices and using alternative medicine to relying on pharmacological options.
- A nutritious diet rich in iron and phytoestrogenic foods – like lentils or soy – can help women regulate their cycles and maintain a healthy weight, which is essential to menstrual health.
- Regular exercise that focuses on losing excess weight and strengthening the body can restore period regularity and improve overall health.
- Stress-relief techniques can help reduce the negative effects of accumulated cortisol on menstrual health and their role in causing intermenstrual bleeding.
- Nutritional supplements, like iron, might be necessary for those whose spotting between periods put them at risk of developing anemia.
- Phytoestrogenic supplements, like chaste berry, can be used short-term to supply the body with plant-based estrogenic compounds that work to promote hormonal balance.
- Hormone-regulating supplements, like Macafem Healthy Periods, can be safely used long-term to stimulate the endocrine glands from within toward optimal hormone production.
- It is help is helpful to keep a record of your menstrual periods.
- You should note any changes in your menstrual pattern, including abnormal bleeding, and bring your records to your doctor’s appointment.
- Females over the age of 18 or who are sexually active should receive annual Pap smear tests and pelvic examinations.