Clinical bleeding patterns and management techniques of abnormal uterine bleeding at a teaching and referral hospital in Western Kenya

Abnormal uterine bleeding (AUB) among women has a global prevalence of between 3–30% [ 1 ] accounting for about one third of outpatient gynaecology visits. This condition affects the quality of life for women with socioeconomic and psychological consequences [ 1 ]. Its occurrence is dependent on temporal and quantitative regulation of reproductive hormones (hypothalamic-pituitary-ovarian axis). The menstrual flow mediated by prostaglandins occurs following degeneration of the corpus luteum. Currently, the use of PALM-COEIN (Polyps; Adenomyosis; Leiomyoma; Malignancy and Hyperplasia; Coagulopathy; Ovulatory dysfunction; Endometrial; Iatrogenic; and Not yet classified) classification reduces the general inconsistency in the description of AUB in clinical and research settings. Although the PALM-COEIN classification guideline is the gold standard for AUB diagnosis; it is not commonly used in many clinical settings leading to a lack of standardization in the diagnosis of women with AUB. There is limited documented studies on the bleeding patterns and management guidelines for women with AUB in Kenya. There is need to determine the proportions of women presenting with AUB at MTRH to plan for various management options. Knowledge of clinical presentation patterns of AUB will be used in putting in place control strategies. Evaluation of management strategies and their conformity to guidelines will create new knowledge on what aspects to be modified. Clinical bleeding patterns are determined by the heaviness, duration of flow, regularity, and frequency. The causes of AUB can either be structural (PALM) or non-structural (COEIN) [ 2 ]. Management on the other hand includes the diagnostic techniques and therapeutic interventions offered to the affected women [ 3 ]. Diagnosis could be through laboratory, radiological and other imaging techniques [ 4 ]. Clinical management for women with AUB is either medical or surgical. Medical management is the first line therapeutic option once malignancy and pelvic pathology have been ruled out [ 5 ]. On the other hand, Surgical Management includes both minimal invasive techniques such as endometrial ablation for heavy menstrual bleeding [ 6 ] and invasive techniques such as hysterectomy and myomectomy. Hysterectomy is the definitive solution with high rates of patient satisfaction [ 7 ]. This study aimed to determine the clinical bleeding patterns and management of AUB among women in their reproductive age. Specifically, it determined level of adherence to PALM-COEIN diagnostic guidelines for uterine bleeding, diagnostic tests ordered, medical and surgical management offered for women presenting with abnormal uterine bleeding.

The study enrolled a total of 108 women with AUB as per the flow chart on Fig 1 . The mean age of the study participants was 31.46 years (SD ± 11.17). Most 64.8% (n = 70) of them had attained secondary level of education with 24.1% (26) having attended university/college level of education. Only 10.2% (n = 11) were formally employed while more than half (57.4%; n = 62) of all the participants living outside Eldoret. Prolonged bleeding was the most common (41.7%) bleeding pattern followed by heavy (35.2%), frequent (20.4%), intermenstrual (18.5%) and infrequent (8.3%) bleeding as ( Table 1 ). Management of women with AUB was categorized in terms of diagnosis and cost of management. Out of the 108 participants enrolled, only 16.7% (n = 18) were diagnosed as per the PALM-COEIN criteria. However, there was no statistically significant difference (p-value = 0.364) in abnormal uterine bleeding between the groups that were diagnosed as per the PALM-COEIN criteria versus those that were not ( Table 2 ). (p-value = 0.364). All the study participants had a pregnancy test done. This was followed by a complete blood count (CBC) test among nearly half (45.3%; n = 49), coagulation profile (25.9%; n = 28) and Thyroid Stimulating Hormone (TSH) at 12% (n = 13). Additional hormonal profile laboratory tests were conducted based on menstrual cycle pattern (regular versus irregular). Overally, follicle stimulating hormone (FSH) was the most commonly (13%) ordered among all the study participants with 13.2% of the women with regular menstrual cycles being subjected to it. This was followed by a TSH test that was commonly ordered for women with irregular (15%) compared to those with regular (10.3%) cycles. Prolactin hormone test was the least frequently ordered. Estradiol and progesterone hormone tests were not ordered at all. There were no statistically significant relationships reported between menstrual cycle patterns ( Table 3 ). Biopsy sampling was categorized by the participants age and whether it was done. Among women aged 35 years or less (n = 72), none of them had a biopsy specimen collected. On the other hand, those aged more than 35 years, only 8.3% (n = 3) had biopsy sampling done. As per the PALM-COEIN classification, all women presenting with polyps, endometrial causes and non-classified abnormal uterine bleeding had a pelvic ultrasound done. Leiomyoma was the most commonly presenting cause of endometrial bleeding, of which more than two thirds (68.8%; n = 33) of the women presenting with it had a pelvic ultrasound ordered. Higher proportions of pelvic ultrasound requests were reported among those with adenomyosis (77.8%; n = 7), malignancy/hyperplasia (84.6%; n = 11), ovulation dysfunction (83.3%; n = 10) and iatrogenic (91.7%; n = 11) causes of abnormal uterine bleeding ( Fig 1 ). Even though 8.3% (n = 9) of the participants presented with adenomyosis; none of them got an MRI scan done. Majority of the women presenting with AUB were treated medically. Analgesics were given to nearly all (92.6%; n = 100) the study participants while more than three quarters (78.7%; n = 85) received antibiotics. Tranexamic acid (TXM) was prescribed to more than half (61.1%; n = 66) of the study participants, followed by haematinics (39.8%; n = 43) while blood transfusion and combined oral contraceptives (COCs) were given to 6.5% (n = 7) and 5.5% (n = 6) respectively. No participant was given levonorgestrel intrauterine system (LGIUS), Progesterone only Pills (POP), androgens and gonadotropin releasing hormone (GnRH) agonists as ( Fig 2 ). Surgical management was offered to 21.3% (n = 23) of all the study participants, majority (69.6%; n = 16) of whom got myomectomy done. This was followed by abdominal hysterectomy at 17.5% (n = 4). The less frequent procedures were dilatation and curettage (D&C), polypectomy and oophorectomy at 4.3% (n = 1) each. No participant got uterine artery embolization (UAE), endometrial Ablation and vaginal or laparoscopic hysterectomy ( Fig 3 ).

We report that prolonged bleeding was the most common bleeding pattern followed by heavy bleeding among women of reproductive age seeking care at a teaching hospital in Western Kenya. There were low proportions (16.7%) of adherence to PALM-COEIN classification as a diagnostic guideline for women with abnormal uterine bleeding. These findings create a need for clinical evaluation of abnormal uterine bleeding among women who present with prolonged bleeding. More training and development of in-hospital clinical care algorithms should be done to ensure adherence to PALM-COEIN guidelines in the diagnosis of abnormal uterine bleeding. Medical management should be opted for as the first line of management for women presenting with abnormal uterine bleeding. Abnormal uterine bleeding affects women of reproductive age. The recommended diagnostic guideline is using the PALM-COEIN classification. There is limited documented studies on the bleeding patterns and management guidelines for women with AUB in Kenya. Management of AUB has been reported to be costly by studies done in other settings, further complicating patient management and outcomes. Prolonged and heavy bleeding are the most common abnormal uterine bleeding patterns in Western Kenya. This study shows that the PALM-COEIN diagnostic criteria is not commonly used in Western Kenya. The study further compares PALM-COEIN diagnostic criteria with the management offered for women with AUB in Western Kenya.

This was a cross-sectional study among women presenting with abnormal uterine bleeding at Moi Teaching and Referral Hospital in Western Kenya from April 2018 to April 2019. The facility is the second largest tertiary hospital in Kenya catering for patients in Western and North Rift Valley regions of the country. A census was conducted among all the reproductive age (18–45 years) women seeking care for abnormal uterine bleeding. This was defined as an episode of bleeding in a woman of reproductive age, who is not pregnant and is of sufficient quantity to require immediate intervention to prevent further blood loss. If the bleeding prolonged over a six-month period, it was referred to as chronic abnormal uterine bleeding. Patient’s history and clinical information from medical records were collected. These included: the diagnostic tests done, final diagnosis made, and treatment given. Data analysis was conducted using statistical package for social sciences (SPSS) version 22 software. Descriptive statistics were used to summarize categorical variables such as level of education and marital status. Continuous variables such as age, duration of bleeding among others were summarized using mean and the corresponding standard deviation if the Gaussian assumptions hold. Otherwise they were summarized using median and the corresponding inter quartile range (IQR). Gaussian assumptions were assessed using histograms and the normal probability plots. Inferential statistics techniques using Pearson chi-square test was conducted to determine the level of statistical significance between predictor and outcome variables. The study’s ethical approval was obtained from the Institutional Research and Ethics Committee of Moi University and Moi Teaching and Referral Hospital.

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