I would like to tell you a story regarding one patient which I have encountered in the ward during my Obstetrics and Gynaecology (O&G) posting. She is an elderly woman who was diagnosed with endometrial adenocarcinoma or simply, cancer of the cervix. I was assigned to take her history so that it can be presented and eventually I would have scored my O&G posting. She is a warm and cheerful woman who presented with per vaginal bleeding for the past 3 months. I would have guessed and listed some of the possible reason for her symptoms but the thing is, I realized that since I was so afraid of screwing up, I've become less humane and more like a robot. Being empathetic is not an easy skill to acquire; I know now.
Let me tell you regarding her symptoms. She had a multiple per vaginal bleeding episodes for the past couple of months and as she was 65 years old, we called it a postmenopausal bleed. I would assume that most of you are familiar with the menstrual cycle, if you are not, I would cover about it tomorrow. To make it simple, women usually bleed once a month for a few days from the age whereby they were sexually matured (typically, it is between 9 to 15 years old); it’s the hallmark of a normal menstrual cycle. When a woman reaches a certain age, they would stop producing a mature ovum and basically stop bleeding as a result of lacking a certain hormone. The age varies with people but according to one of my lecturer's, according to a research/survey done by him, an average Malaysian woman would cease to menstruate when she is 50.2 years old. This is called as the menopause period; basically, mark the time whereby women can reproduce.
Causes of Abnormal Uterine Bleeding
In 2011, the Federation Internationale de Gynecologie et d’Obstetrique (FIGO) has published a clinical guideline to help fellow clinicians in establishing some differential diagnoses pertaining to people who presented with abnormal uterine bleed. This abbreviation does not only explain regarding the cause of postmenopausal bleed but also for people who have heavy menstrual bleeding or postcoital (post sexual intercourse) vaginal bleed. The list of differential diagnoses was abbreviated to PALM COEIN which was called afterwards as the PALM COEIN classification system. Let me babble about the theoretical side before telling you the life lesson I have learned from this. We would benefit greatly from this, you and I, both!
The abbreviation was divided into two words, PALM and COEIN, the former being structural causes for abnormal uterine bleeding and the latter being non-structural causes for abnormal uterine bleeding. PALM stands for "Polyp", "Adenomyosis", "Leiomyoma" and "Malignancies". It is pretty straightforward and I would assume that you know a bit about polyps. It's simply a hypertrophied which increases the surface area of a certain location which eventually exposed certain blood vessel to physical insult and cause bleeding. Although it sounds harmless, it can later develop into malignancies if it is not managed properly. Adenomyosis, I understand this disease poorly but basically, it is due to the presence of stromal and glands which was supposed to be found in the endometrial lining, but instead, in the myometrial layer of the uterus. It can influence uterine contractility which would cause abnormality in per vaginal bleeding.
Leiomyoma, or usually known as uterine fibroid is one of the commonest cause of abnormal uterine bleeding in the whole world. In Malaysia, according to the Ministry of Health, approximately 20% of women are affected by this disease and 3% out of that figure would have some fertility problems. Some people with fibroids would be asymptomatic depending on the location of it, but some would experience irregularity in their menstrual cycle and some would have heavy menstrual bleeding. There is some disagreement when we are talking about "heavy menstrual bleeding", generally it was accepted by the whole wide world, theoretically, women who lost more than 80 mills of blood would be treated as a heavy menstrual bleeding case but in a clinical setting, it would be difficult. This is due to the fact that, the volume of blood loss doesn't necessarily correlate with the amount of haemoglobin loss so it is a poor predictor of when people would present to their respective general practitioner with those complaints.
Some people would experience anaemic symptoms even without losing 80 mills of blood and some would seem fine even losing more than 80 mills. Regardless, fibroids will usually affect people who were in their reproductive age. It’s quite rare that this kind of a benign tumour to be found in people who were pre-menarche or post-menopausal. This can be due to the fact that people who were in their reproductive age produce a higher concentration of oestrogen and progesterone at a certain time in their menstrual cycle. This reason was supported by the fact that there was a lot of oestrogen and progesterone receptor at the surface of fibroids.
There are some reasons why fibroid can cause some sort of irregularities or causing you to bleed more than usual:
- It increased the uterine surface area
- It increased blood flow into the uterine surface
- It influenced myometrial contractility
- Some types of fibroids are associated with endometrial ulceration
- It can compress blood supply to the endometrium and myometrium
What about malignancies? Well, this is the reason why my patient presented to the hospital which I’m currently studying in. She was diagnosed with endometrial adenocarcinoma which caused her to bleed when she was not supposed to. After underwent a few procedures obtaining some tissue from her endometrial lining, it was found that she had the malignancy but only in the early presentation, which was quite fortunate. It didn’t affect her lymph nodes and subsequently, an aggressive removal of the uterus was done to ensure no recurrence and she is currently well.
What about the non-structural causes? Well, this one is a bit straightforward. The abbreviation “COEIN” stands for “Coagulopathy”, “Ovulatory dysfunction”, “Endometrial causes”, “Iatrogenic causes” and “Not yet classified”.
Coagulation is one of the important components during cessation of menstrual bleeding. Obviously, we can’t bleed forever. Platelet aggregation is an important component of this physiological process and this is aided by von Willebrand factors. Pretty standard, blood will start to clot and aggregate to seal the source of bleeding and any factor which could disrupt this process would be reduced; plasminogen for example. Any disease related to abnormalities of the aforementioned agent needed for the cessation of menstrual bleeding would cause abnormal uterine bleed; for example haemophilia, deficiency in certain clotting factors, vitamin K deficiency etc. Ovulatory dysfunction, on the other hand, concerned with irregularities of the oestrogen and progesterone hormone which is important in the menstrual cycle. Any imbalance in either of this hormone would result in an abnormal menstrual bleeding episode, for example, people who are diagnosed with Polycystic Ovarian Syndrome (PCOS) which produce a high level of androgen which would be converted into oestrogen in peripheral tissues.
Endometrial causes concerned with the order of the bleeding episode during menstruation. 1 in 5 healthy people would experience heavy menstrual bleeding and this is normal and usually resolved a few days after it started. Regardless, some people would experience a bout of bleeding caused by an abnormal angiogenesis which produces fragile vessels which will easily bleed. Iatrogenic would be the last possible caused by abnormal uterine bleeding (I would rather not discuss the “Not yet classified”). Some medications such as Tamoxifen would cause the formation of an abnormally thickened endometrial wall which will bleed when the time comes for that individual menstrual period. Some people would be treated with progestogen that would be able to control bleeding episode but sometimes, people still experienced heavy menstrual bleeding in an unexplained paradox phenomenon. Yes, such a bitch!
Oh, Mrs X…
Even with some financial problems in the past, she had successfully raised 5 children single-handedly when her husband divorced her 37 years ago. Can you imagine? She works 3 jobs per day to support her children’s education and now, all of them were successful. Two doctors, an engineer and two teachers, I wouldn’t need to be a psychic to know that she’s quite happy and proud of their achievements. It’s extraordinary but then again I would give some credits to the Malaysia Education System and Government for subsidizing and providing people with scholarships to make it possible for people to learn. It would be impossible otherwise.
What about now? None of them wants to take care of their mother. She was chased away from her daughter’s house and now she wasn’t sure where she would go. I realized she didn’t have any visitor and when I asked her why no one was visiting her, she just replied that all of them were busy. When the hospital staff tried to inform her family regarding her mother’s condition, it’s like they weren’t interested to know. Eventually, she was operated and some of her tissues were delivered to the Pathology Department for histopathological investigation. Otherwise, she was healthy and quite a woman for someone of her age.
I remember she advised me recently to always care for my mother. She said:
A mother can raise 5 or 7 or even 10 of her children even in the most difficult situation. She would sacrifice and would be happy as long as her children are alive and well. There’s no guarantee that 5 or 7 or 10 children would be able to take care of a single mother when they are adults and successful. It’s not that they can’t afford it but they just don’t want to. Be nice to your mother and remember, without her, you won’t be where you are right now.
I was sad, of course, but blessed and thankful. Thank you for teaching me something valuable that I can’t really learn from the textbook. I was depressed for the whole day when she was discharged but wherever she is right now, I hope she is doing fine. Please be fine!
References: [1], [2], [3], [4]
All images were taken from Pixabay
Images: [1], [2], [3], [4], [5]
