Monday, 2 December 2013

Hemorrhaging: Vaginal bleeding - The Cause and Risk Factors

Hemorrhaging is also known as bleeding or abnormal bleeding as a result of blood loss due to internal.external leaking from blood vessels or through the skin.
Vaginal bleeding
Vaginal bleeding is defined a condition of abnormal vaginal bleeding or spotting between periods as a result of hormonal imbalances (abnormal uterine bleeding), pregnancy, menopause, diseases, bleeding disorders, medications, etc. Researchers at the 2nd Department of Obstetrics and Gynecology, University of Athensuggested that the occurrence of irregular, prolonged or heavy abnormal uterine bleeding is one of the most urgent gynecological problems in adolescence and the diagnosis of dysfunctional uterine bleeding should be used only when all other organic and structural causes of abnormal vaginal bleeding have been ruled out(1).
Causes and Risk factors
1. Causes
a. Hormonal imbalance  
Menstrual bleeding that falls outside the range of normal is often a cause of great concern, before treating with hormonal interventions or blood products, PCOS, should always be ruled out with clinical signs of hyperandrogenism, obesity, or insulin resistance. Attention must also be paid to signs or a family history of a bleeding disorder, as vWD is commonly associated with excessive uterine bleeding(2). Ovulatory abnormal uterine bleeding, or menorrhagia, may be caused by thyroid dysfunction, coagulation defects (most commonly von Willebrand disease), endometrial polyps, and submucosal fibroids. Transvaginal ultrasonography or saline infusion sonohysterography may be used to evaluate menorrhagia(2a).

b. Von Willebrand disease
Von Willebrand disease is defined as a hereditary condition of  coagulation abnormality. There is a report of a 17 year old woman presented with severe anaemia due to menorrhagia. On investigation, she was shown to have abnormalities of her haemostatic mechanism consistent with von Willebrand's disease Type I, although there was no family history of this disorder(3).

c. cervical cancer
In the study to determine the presentation, pathological findings, treatment, and outcome of patients with cervical sarcom, f 1804 patients in the study with cervical malignancies, 8 cervical sarcomas were identified. All patients presented with vaginal bleeding and discharge(4).

d. Birth control pill
The Pill normally is prescribed by your doctor to reduce the heavy period blood for woman as well as in treating of period pain, or for contraceptive purpose ( 21 days on and 7 days off). Oral contraception is the dominant method of contraception for women in the world wide, in Canada there is more than 43% of sexually active women use it. It is defined as medications taken by mouth to prevent unwanted pregnancy. Bleeding and spotting is normal for the first six months for women starting any oral contraceptive combination pill because our body needs time to adjust to the new medication(5).

e. Endometrial hyperplasia
Endometrial hyperplasia is a condition of over growth of endometrial cell causing too thick of the endometrium of that can lead to abnormal bleeding. Researchers at the Department of Pathology, Aarhus University Hospital found that the mean (+/-s.d.) endometrial thickness was significantly different in patients with hyperplasia 11.5 mm (+/-5.0), polyps 11.8 mm (+/-5.1), sub-mucous myomas 7.1 mm (+/-3.4) and in patients without these abnormalities(abnormal uterine bleeding) 8.37 (+/-3.9) (p<0.001)(6).

f. Intrauterine device (IUD)
Researchers at the School of Medicine, Zhejiang University, in the study of the expression of angiopoietin-1 and -2 in the endometrium of women with abnormal bleeding induced by an intra-uterine device, found that  Immunohistochemical analysis showed elevated Ang-2 protein levels in secretory phase endometrium from IUD patients compared with the control women. These results suggest that the angiopoietin/Tie-2 system promotes vascular remodelling in the endometrium and that changes in the expression of Ang-1, Ang-2 and Tie-2 may contribute to abnormal uterine bleeding in some IUD users(7).

h. Miscarriage or ectopic pregnancy
h.1. Miscarriage 
Miscarriage is defined as the loss of an embryo before the 20th week of pregnancy as it is incapable of surviving independently. In medical terminology, miscarriage is a type of abortion, as it refers to the pregnancy ends with the death and removal or expulsion of the fetus, regardless of whether it is spontaneous or medically induced abortion. In US alone, over 15% of pregnancy ends in miscarriage.
Most common symptoms of miscarriage. 50% of bleeding during 20 weeks of pregnancy ends in miscarriage(8).
h.2. Ectopic pregnancy
Ectopic pregancy is defined as a condition in which the fertilized implant in somewhere else other than in the uterus. In most case, ectopic pregnancy occurrs in the one of the Fallopian tube, causinf tubal pregnancy. Ectopic pregnancy will end up in miscarriage as the fertilized can not survive outside of uterus. Bleeding occurs between 6 - 8 weeks of pregnancy may be a sign of miscariage due to the implant egg inability to survive out side of uterus(9).

i. Amenorrhea, age, PID, fibroids and ovarian masses
In the document sonographically identifiable causes of vaginal bleeding in secondarily amenorrhoeic women of child bearing age, showed that 75(73.2%) patients had pregnancy-related conditions, 14(13.7%) had normal, non-pregnant uteri while the remaining 13 (12.8%) had other gynaecological conditions namely pelvic inflammatory disease (PID), uterine fibroids and ovarian masses. Though pregnancy-related conditions are the major causes of vaginal bleeding in amenorrhoeic women of childbearing age, PID, fibroids and ovarian masses are possible findings(10).

j. Polycystic ovary syndrome
Polycystic Ovarian Syndrome is defined as endocrinologic diseases caused by undeveloped follicles clumping on the ovaries that interferes with the function of the normal ovaries as resulting of enlarged ovaries, leading to hormone imbalance( excessive androgen), resulting in male pattern hair development, acne,irregular period or absence of period, weight gain and effecting fertility. It effects over 5% of women population or 1 in 20 women(11).

h. Etc.

2. Risk factors
a. Physical, psychological and environmental factors
questionnaire survey was conducted on 14,752 women by trained doctors, when pregnant women came for the first antenatal examination, including sociodemographic characteristics, prior adverse pregnancy outcomes, diseases history, life event stress, adverse environmental exposure and detailed information on VB(12).

b. Age
The rate of postmenopausal vaginal bleeding during the study period peaks at the age of 55-59 years (25.9/1000 postmenopausal women/year) and declines thereafter(13).

c. Medical conditions and medication
People who have had medical conditions such as thyroid and pituitary disorders, diabetes, cirrhosis of the liver, and systemic lupus erythematosus or taken certain medication such as steroids or blood thinnersare at incresed risk of vaginal bleeding(14)

d. Inherited bleeding disorders (IBDs) 
Inherited bleeding disorders (IBDs) are by definition life-long. Women with IBDs are more likely to suffer HMB, to be symptomatic, and to present with bleeding in association with gynaecological problems. Heavy and/or abnormal menstrual bleeding increases with age due increased anovulatory cycles and gynaecological pathologies in older women(15).

d.  Etc.
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