Abnormal Uterine Bleeding .

Abnormal uterine bleeding refers to any bleeding from the uterus that is irregular in timing, volume, or duration. It can occur at any age but is most common for women in their 30s–50s and around perimenopause.

Abnormal uterine bleeding can significantly impact quality of life, causing heavy, prolonged, or unpredictable bleeding. Fortunately, a wide range of effective investigations and treatments are available.

Causes

Polyps

Polyps are benign overgrowths of the endometrium or cervix that can cause irregular bleeding or spotting between periods; they are often detected on ultrasound or during hysteroscopy and can be easily removed with a minor procedure.

Adenomyosis

Adenomyosis occurs when endometrial tissue grows into the muscle of the uterus, most commonly affecting women who have had children, and typically causes heavy, painful periods and chronic pelvic pain; it is diagnosed on pelvic ultrasound or MRI and managed with medical therapy or, if symptoms are severe, hysterectomy.

Fibroids

Fibroids are very common non-cancerous growths of the uterus that can cause heavy periods, flooding, clots, and pressure symptoms; they may be submucosal (inside the cavity), intramural (within the muscle), or subserosal (on the outer surface), and management depends on symptoms, size, location, and fertility wishes, with options ranging from medical therapy to uterine artery embolisation, myomectomy, or hysterectomy.

Hyperplasia and malignancy

Malignancy and hyperplasia include endometrial hyperplasia (with or without atypia) and endometrial cancer, which are more common in women with risk factors such as obesity, PCOS, or a family history; these conditions require urgent assessment, with endometrial sampling essential to confirm the diagnosis, and treatment tailored to the specific findings.

Non-structural causes of abnormal uterine bleeding include issues with blood clotting, irregular ovulation, abnormal endometrial function, medication-related bleeding, and a small group of rare conditions that don’t fit elsewhere.

Investigations

Evaluation is personalised based on symptoms, age, and risk factors.

Blood Tests

•   Full blood count (to check for anaemia)

• Iron studies

• Pregnancy test (if relevant)

• Thyroid function

• Coagulation studies if a bleeding disorder is suspected

• Hormonal tests in selected cases

Pelvic Ultrasound Scan

Ultrasound is the first-line imaging test, assessing the uterus, endometrium, and ovaries, and detecting conditions such as polyps, fibroids, or adenomyosis, with transvaginal ultrasound generally providing the best detail

Endometrial Sampling

A small sample of the uterine lining taken in clinic or at hysteroscopy

• Recommended for:

  • women aged ≥45

  • persistent or heavy bleeding

  • risk factors for endometrial cancer

• Helps diagnose hyperplasia or malignancy

Hysteroscopy

A hysteroscopy uses a small camera inserted through the cervix to directly view the uterine cavity and can diagnose and treat polyps or submucosal fibroids in the same procedure, which can be performed under local or general anaesthetic.

Management Options

Treatment depends on the cause, your symptoms, and future fertility wishes. Many women benefit from a combination of treatments.

Non-Hormonal Options

Tranexamic acid – reduces bleeding by 40–60%
NSAIDs (eg. ibuprofen, mefenamic acid) – reduce bleeding and help with period pain

Hormonal Options

• Combined oral contraceptive pill

• Progesterone-only pills or injections

• Cyclic progesterone therapy

Mirena® (Levonorgestrel Intrauterine System)

• One of the most effective treatments for heavy bleeding

• Reduces bleeding by up to 90%

• Also provides reliable contraception

• Useful for adenomyosis and endometrial protection in perimenopause

GnRH Agonists/Antagonists

• Temporarily switch off ovarian hormone production

• Used short-term to shrink fibroids or control severe bleeding

• Often used before surgery to improve anaemia or reduce fibroid size

Uterine Artery Embolisation (UAE)

Uterine artery embolisation (UAE) is a minimally invasive radiology procedure that blocks blood flow to fibroids, causing them to shrink and improving symptoms. It is a good option for women who wish to avoid surgery and who are not planning future pregnancy.

Surgical Options

Surgery is tailored to symptoms, fertility goals, and the underlying cause.

Endometrial Ablation

Endometrial ablation destroys the lining of the uterus to reduce heavy bleeding and is suitable for women who have completed their family, but it is not appropriate if malignancy or hyperplasia is suspected or if the uterus is significantly enlarged.

Myomectomy

Myomectomy is the surgical removal of fibroids while preserving the uterus, and can be performed hysteroscopically, laparoscopically, or through open surgery, making it an ideal option for women who wish to retain fertility or avoid hysterectomy.

Hysterectomy

A hysterectomy is the complete removal of the uterus and is the definitive treatment for abnormal uterine bleeding, recommended for women with severe symptoms, fibroids, or adenomyosis who have completed their family. It can be performed vaginally, laparoscopically, or via an open approach, depending on the size of the uterus and individual clinical factors.