Abnormal uterine bleeding (AUB) is defined as any bleeding that significantly deviates from the usual menstrual pattern. Normal menstruation varies among women in the amount and duration of blood flow and by the intervals between menstrual cycles. The average range of intervals between cycles is 21 and 35 days; the duration of normal menses is 3 to 7 days; blood lost during a normal cycle varies from 25 to 80 mL
- Uterine bleeding can be divided into two major categories: organic and dysfunctional.
- Dysfunctional uterine bleeding (DUB) is abnormal bleeding from the uterine endometrium that is unrelated to anatomic lesions of the uterus.
- In perimenopausal women, hypothalamic-pituitary dysfunction results in less predictable ovulation.
- Without adequate progesterone, the endometrium becomes unstable and fragile.
- Anovulatory bleeding can often be diagnosed by the patient’s history of erratic bleeding that is painless and unpredictable in volume.
- If endometrial proliferation or hyperplasia without atypia is found on endometrial biopsy, progestin-based medical management is indicated with follow-up evaluation after 3 to 4 months.
- Organic causes can be subdivided into systemic disease and reproductive tract disease.
- Endometrial polyps and uterine fibroids are very common causes of anatomic conditions causing AUB in the perimenopausal period.
- Endometrial atrophy is the most common cause of postmenopausal bleeding.
- All postmenopausal bleeding is considered abnormal and needs evaluation.
Definitions of Abnormal Bleeding
- Amenorrhea: Absence or abnormal cessation of the menses
- Hypermenorrhea: Menorrhagia, prolonged or profuse menses
- Hypomenorrhea: A diminution of the flow or a shortening of the duration of menstruation
- Menorrhagia: Excessively profuse or prolonged menstruation
- Metrorrhea: Irregular, acyclic bleeding from the uterus, particularly between periods
- Menometrorrhagia: Irregular or excessive bleeding during menstruation and between menstrual periods
- Oligomenorrhea: Scanty menstruation; menses occurring at intervals greater than 35 days
- Polymenorrhea: The occurrence of menstrual cycles of greater than usual frequency—usually at intervals less than 21 days
- Frequency, duration, and amount of bleeding
- Current pregnancy?
- Contraceptive history
- Systemic diseases (Box 8-1)
- List of medications
- Any recent surgical or gynecologic surgery
|BOX 8-1 Systemic Diseases That Can Cause Abnormal Bleeding|
| 1.Blood Dyscrasia
von Willebrand’s disease
Increased fibrinolysin (endometrium)
| 2. Hepatic Disease
Impaired synthesis of coagulation factors
Impaired metabolism of sex steroids (i.e., estrogen)
Impaired synthesis of sex hormone—binding globulin
|3 .Renal Disease|
| Impaired excretion of estrogens
| 4. Iatrogenic Causes
Anticoagulants, digitals, oral contraceptives (breakthrough bleeding), aspirin, intrauterine device (IUD)
| Hypothyroidism or hyperthyroidism
- Physical examination.
- A complete physical examination, including a careful pelvic examination, should be performed. There are many anatomic causes of nonuterine bleeding (Box 8-2) and anatomic uterine abnormalities (Box 8-3).
- Examination should include the following:
|BOX 8-2 Anatomic Causes of Nonuterine Bleeding|
|Neoplasia (polyps or carcinoma)|
|Ectropion and eversion|
|Neoplasia (carcinoma, sarcoma)|
|Infections or inflammations|
|BOX 8-3 Anatomic Uterine Abnormalities|
|1. Endometrial hyperplasia|
|2. Endometrial or cervical carcinoma|
|4. Polyps: endometrial and endocervical|
|5. Infections: endometritis, cervicitis, vaginitis|
|6. Foreign bodies (e.g., IUD, tampon)|
|7. Pregnancy abnormalities|
|8. Estrogen-producing ovarian tumors|
|9. Medications: hormone replacement therapy, oral contraceptives|
- Presence or absence of ecchymotic lesions on the skin
- Inspection of vulva and vagina
- Inspection and palpation of cervix and uterus
- Determination of the size and shape of uterus
(10) Palpation of adnexa for mass and to check for ovarian pathology
- Diagnostic studies: Some of the following may be indicated depending on the history and findings on physical exam.
- Hemoglobin and hematocrit
- Serum iron level and serum ferritin level
- Chemistry profile including liver function tests
- Serum human chorionic gonadotropin (HCG)
- Thyroid profile
- Coagulation profile
- Luteal phase progesterone
- Prolactin, follicle-stimulating hormone (FSH), luteinizing hormone (LH)
- Serum androgens
- Stool for occult blood
- Urinalysis for hematuria
- Papanicolaou smear
- Pelvic ultrasound; include measurement of endometrial thickness
- Hysterogram or hysteroscopy
- Endometrial sampling
In most patients, abnormal uterine bleeding is a recurrent problem and long-term management depends on correct diagnosis for treatment
(see Box 8-3). Systemic and anatomic causes should be managed with their specific treatments.
- Estrogen-progestin contraceptives
- Oral contraceptives containing low doses of estrogen (<35 ug ethinyl estradiol)
- First-line therapy for healthy, nonsmoking perimenopausal women with AUB
- Variable effectiveness for women with fibroids
- Vaginal ring releasing etonogestrel and ethinyl estradiol
- Continuous progestin-only contraceptives
- Depot injection of medroxyprogesterone acetate (Depo-Provera)
- Levonorgesterol intrauterine device (1UD) (Mirena)
- Postmenopausal estrogen plus progestin therapy (EPT) (with sufficient progestin sufficient to inhibit ovulation)
- 17beta estradiol 1 mg plus 0.5 mg Norethindrone acetate (Activella)
- Ethinyl estradiol 5 (am plus 1 mg Norethindrone acetate (Femhrt)
- Other therapies
- Cyclic oral progestogen alone
- Parenteral estrogen
- Gonadotropin-releasing hormone (GnRH) agonists such as leupro- lide acetate (Lupron)
- Dilation and curettage (D&.C)
- This surgical procedure is now considered obsolete for the treatment of AUB because it can miss localized disease such as polyps.
- D&C does not completely remove intracavitary tissue.
- Endometrial ablation
- Endometrial histologic evaluation should take place before endometrial ablation.
- Some approaches do not involve visualization of the endometrial cavity and may not effectively treat AUB caused by anatomic lesions such as submucous fibroids or polyps.
- Used to be the only definitive treatment for AUB.
- Postoperative complication rate is approximately 30%.