Can stress-induced disruptions in sleep and appetite cause abnormal uterine bleeding?

Stress-Induced Sleep and Appetite Disruptions Do Not Directly Cause Abnormal Uterine Bleeding

Stress-induced disruptions in sleep and appetite are not direct causes of abnormal uterine bleeding (AUB), as AUB is classified according to structural and non-structural causes that do not include stress as a primary etiology.

Understanding Abnormal Uterine Bleeding

Abnormal uterine bleeding is defined as bleeding from the uterus that is abnormal in regularity, volume, frequency, or duration and occurs in the absence of pregnancy 1. The International Federation of Gynecology and Obstetrics (FIGO) has established the PALM-COEIN classification system to categorize causes of AUB:

Structural Causes (PALM)

• Polyps 1
• Adenomyosis 1
• Leiomyoma (fibroids) 1
• Malignancy and hyperplasia 1

Non-structural Causes (COEIN)

• Coagulopathy (bleeding disorders) 1, 2
• Ovulatory dysfunction 1, 3
• Endometrial disorders 1
• Iatrogenic causes (medications, intrauterine devices) 1, 3
• Not yet classified 1

Relationship Between Stress and AUB

While stress is not listed as a direct cause of AUB in the PALM-COEIN classification, it may indirectly contribute to AUB through several mechanisms:

• Stress can disrupt normal hypothalamic-pituitary-ovarian axis function, potentially leading to ovulatory dysfunction, which is a recognized cause of AUB 3
• Chronic stress may affect hormone regulation, potentially leading to anovulatory cycles that can cause irregular bleeding 4
• Sleep disruptions may affect circadian rhythms that influence hormone production and regulation 5

However, it's important to note that:

• No direct causal relationship between stress-induced sleep/appetite disruptions and AUB has been established in the medical literature reviewed 6, 1, 5
• When evaluating AUB, clinicians should focus on identifying the specific structural or non-structural causes according to the PALM-COEIN classification 1

Proper Evaluation of AUB

When a patient presents with AUB, a systematic approach should be taken:

1. Rule out pregnancy and pregnancy-related complications as these are common causes of abnormal bleeding in reproductive-age women 3, 2

2. Consider age-specific risk factors:

   • In adolescents, coagulation disorders (particularly von Willebrand disease) should be suspected 2
   • In perimenopausal women, anovulation is common but structural causes must be ruled out 4
   • In postmenopausal women, endometrial cancer is the most serious concern 6, 1

3. Evaluate for structural causes using:

   • Transvaginal ultrasound as the first-line imaging method 6, 5
   • Saline infusion sonohysterography for better detection of endometrial polyps and submucous fibroids 4
   • Hysteroscopy with biopsy when indicated 5

4. Screen for non-structural causes including:

   • Thyroid dysfunction 3
   • Coagulation disorders 2
   • Medication effects (anticoagulants, hormonal treatments) 3

Management Implications

Since stress-induced sleep and appetite disruptions are not direct causes of AUB, management should focus on identifying and treating the underlying cause according to the PALM-COEIN classification:

• For ovulatory dysfunction (which could potentially be stress-related), treatment options include progestin-only contraception, combined hormonal contraception, or antifibrinolytic agents 1

• For structural causes, appropriate interventions may include polypectomy, fibroidectomy, or other targeted treatments 3

• For heavy menstrual bleeding, options include the levonorgestrel-releasing intrauterine system, oral progesterone, or nonsteroidal anti-inflammatory drugs 3

Clinical Pearls and Pitfalls

• Pitfall: Attributing AUB solely to stress without proper evaluation for structural and non-structural causes 6, 1
• Pitfall: Missing serious underlying conditions like endometrial cancer, especially in women over 35 with recurrent anovulation 3
• Pearl: Consider endometrial biopsy in women 35 years or older with recurrent anovulation, women younger than 35 with risk factors for endometrial cancer, and women with excessive bleeding unresponsive to medical therapy 3
• Pearl: While stress management may improve overall health, it should not replace appropriate diagnostic evaluation and treatment of AUB 5, 4