Normal and Abnormal
Uterine Bleeding
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series
Objectives for Normal and Abnormal Bleeding
 Define the normal menstrual cycle and describe its
endocrinology and physiology
 Define abnormal uterine bleeding
 Describe the pathophysiology and identify etiologies of
abnormal uterine bleeding
 Discuss the steps in evaluation of abnormal uterine
bleeding
 Explain medical and surgical management options for
patients with abnormal uterine bleeding
 Counsel patients about management options for abnormal
uterine bleeding
Normal Menstrual Cycle
Normal Menstrual Cycle
Basic functional components
 Hypothalamic-pituitary unit
 Ovaries
 Uterus-endometrium
Normal Menstrual Cycle
Proliferative (Follicular) Phase: Days 1-13
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Rise in FSH stimulates maturation of ovarian follicle
Follicles secrete estrogen as they mature
Estrogen stimulates proliferation of the endometrial lining
Endometrium reaches maximum thickness in late follicular phase
Level of estrogen peaks on day 12-13, stimulating LH surge on day 14
LH surge stimulates ovulation
Normal Menstrual Cycle
Secretory (Luteal) Phase: Days 14-28
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After ovulation, FSH and LH cause follicle to transform into corpus luteum
Corpus luteum produces progesterone which maintains endometrial lining
Microvasculature becomes well-differentiated (spiral arterioles)
In absence of fertilization the corpus luteum involutes
Fall in progesterone triggers menstruation (endometrial sloughing)
Normal Menstrual Cycle
 Normal parameters:
 Cycle interval: 24 – 35 days
 Menses: 4 – 7 days
 Blood loss: 30 – 45 mL
 Ovulatory bleeding is cyclic and predictable
Abnormal Uterine Bleeding: Definition
 Bleeding that is outside the normal parameters of the
menstrual cycle (volume, duration, or interval)
 Abnormal Uterine Bleeding (AUB):
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Polymenorrhea: regular cycle interval < 24 days
Oligomenorrhea: regular cycle interval > 40 days
Menorrhagia: regular blood loss > 80 mL or menses > 7 days
Metrorrhagia: irregular bleeding
Menometrorrhagia: heavy and irregular bleeding
AUB: Etiology
 Trauma
 Cervical laceration
 Foreign body
 Organic
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Pregnancy complication
Uterine leiomyoma
Adenomyosis
Endometrial polyp
Endometrial hyperplasia
Malignancy (cervix, uterus)
 Dyscrasias
 Von Willebrand’s Disease
 Thrombocytopenia
 Iatrogenic
 Exogenous estrogen
 Intrauterine device (IUD)
 Heparin, Coumadin
 Systemic
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Hepatic disease
Thyroid disease
Hyperprolactinemia
Renal failure
 Other
 Anovulation (DUB)
AUB: Evaluation
 History
 Detailed menstrual history (volume, duration, intervals)
 Symptoms associated with ovulation
 e.g. breast tenderness, bloating, mood changes
 Associated symptoms
 e.g. dysmenorrhea, post-coital bleeding, galactorrhea, hirsutism
 Weight changes
 Medical history and medications
 Pelvic Exam
 Cervical and vaginal lesions
 Size, shape of uterus
AUB: Evaluation
 Laboratory
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Urine pregnancy test
CBC with platelets
Coagulation studies
Thyroid studies (TSH, T4)
Prolactin
 Diagnostic Procedures
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Pap smear
Endometrial biopsy (EMB)
Transvaginal ultrasound
Hysteroscopy
Saline-infusion sonography (SIS)
AUB: Management (Medical)
 Directed at treating the underlying pathology with relief of
volume and duration of menses
 Medical management
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NSAID’s
Combination hormonal contraceptives (e.g. OCP’s, vaginal ring, patch)
Levonorgestrel IUD (Mirena)
GnRH agonists (e.g. Lupron)
Correct medical condition
AUB: Management (Surgical)
 Surgical management
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Endometrial ablation
D&C - IF clinically indicated
Myomectomy – IF leiomyomata and fertility desired
Hysteroscopic resection – IF polyp, submucous myoma
Hysterectomy (TAH, TVH, or TLH)
Dysfunctional Uterine Bleeding: Definition
 Abnormal uterine bleeding with no attributable underlying
illness or pathology
 Diagnosis of exclusion!
 Must exclude all other causes of AUB
DUB: Etiology
 Anovulation
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Polycystic ovary syndrome (PCOS)
Obesity
Adrenal hyperplasia
Luteal phase defect (rare)
DUB: PCOS
 Polycystic ovary syndrome (PCOS)
 Increased circulating androgens aromatize to estrone (E1)
 Constant, noncyclic, unopposed level of estrogen stimulates growth and
development of the endometrium
 Estrogen provides feedback to pituitary, resulting in low FSH and high LH
 Static levels of LH trigger chronic anovulation
 Without ovulation, progesterone-induced changes do not occur
 Endometrium outgrows blood supply and sloughs at irregular times in
unpredictable amounts (usually frequent and heavy)
DUB: Etiology
Progesterone
Estrogen
Estrogen
2
4
6
8 10 12 14 16 18 20 22 24 26 28
Menses
DUB/Anovulation
Ovulatory Cycle
DUB: Evaluation
 Pelvic Exam
 Cervical and vaginal lesions
 Size, shape of uterus
 Laboratory evaluation
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Urine pregnancy test
CBC with platelets
Coagulation studies
Thyroid studies (TSH, T4)
DHEAS and testosterone, if symptoms of hirsutism
Prolactin
 Procedures
 Endometrial biopsy (R/O neoplasia)
 Transvaginal ultrasound (R/O anatomic lesions)
DUB: Management (Medical)
 Massive Intractable Bleeding
 Conjugated Estrogens 25 mg IV
 Continued Management after Massive Bleeding
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Conjugated Estrogens 2.5 mg po daily x 25 days
Medroxyprogesterone acetate 10 mg for the last 10 days
Allow 5-7 days for withdrawal bleed
Administer Mirena IUD
DUB: Management (Medical)
 Management of Moderate Menometrorrhagia
1. Estrogen-Progestin Combination
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Conjugated Estrogen 1.25 mg po daily x 25 days +
Medroxyprogesterone acetate 10 mg po for last 10 days
OCP x 21 days, with 7 day withdrawal
2. Cyclic Progestin
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Medroxyprogesterone acetate 10 mg po daily x 10-15 days ea. month
Norethindrone acetate 5 mg po daily x 10-15 days ea. month
5 – 7 days menstrual withdrawal should follow cessation ea. month
3. Mirena IUD
DUB: Management (Surgical)
 Patients who do not respond to medical therapy
 Patients who do not desire future pregnancies
 Management:
 Endometrial ablation
 Hysterectomy
Bottom Line Concepts
 Abnormal menstruation is one of the most common problems dealt
with in the gynecologic clinic.
 Understanding of the physiology and endocrinology of the menstrual
cycle is imperative in a thorough evaluation and management of AUB.
 It is important to rule out unsuspected pregnancies and endometrial
cancer in the evaluation of AUB.
 Irregular bleeding that is unrelated to anatomic lesions of the uterus is
referred to as dysfunctional uterine bleeding (DUB/anovulatory).
 Before DUB can be diagnosed, anatomic causes including neoplasia
should be excluded.
 The primary goal of treatment of DUB is to ensure regular shedding of
the endometrium and consequent regulation of menses.
 In AUB from other causes it is important to correct underlying
pathology and decrease volume and duration of menses.
References and Resources
 APGO Medical Student Educational Objectives, 9th edition, (2009),
Educational Topic 45 (p96-97).
 Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010),
Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William
NP Herbert, Douglas W Laube, Roger P Smith. Chapter 35 (p315-319).
 Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and
Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone,
Calvin J Hobel. Chapter 33 (p368-370).