Katelyn Rogers. Reproductive System. March 1st, 2010.
Abnormal Uterine Bleeding
Anne Whitworth, M.D.
Learning Objectives
Identify the causes of abnormal uterine bleeding
Demonstrate a knowledge of the evaluation of abnormal
uterine bleeding
Describe the treatments for the different causes of
abnormal uterine bleeding
Abnormal Uterine Bleeding
Definition:
-Bleeding outside of normal physiologic menstruation
-Includes both dysfunctional uterine bleeding &
structural bleeding
Normal Menstrual Cycle
Proliferative Phase/Follicular (8-14 d)
-Predominance of estrogen over progesterone and a
build up of endometrium
Secretory Phase/Luteal(14 d)
-Begins after ovulation triggers progesterone production
Marked by a reaction to the combination of estrogen and
progesterone and stabilization in the thickness of the
endometrium (Constant part)
Normal Menstrual Cycle
Pituitary gonadotropin secretion is stimulated by the
GnRH
Estradiol results in increased secretion of LH and
decreased secretion of FSH
Leading to release of the egg
Corpus luteum has negative feedback on LH and FSH
Normal Menstrual Cycle
Interval: 28 days +/- 7 days
Duration: 4-6 days (3-5 pads/tampons per day)
Blood loss: 25-69 ml (average 35 to 40 ml)
no clots, no mid cycle bleeding
Normal Menstrual Cycle
The average female will have around 400 menstrual
cycles in her life
Up to 20% of women will present to the office with the
complaint of excessive blood loss
Definitions of Abnormal Uterine Bleeding
Menorrhagia: Prolonged or excessive uterine bleeding at
regular intervals
Metrorrhagia: Uterine bleeding at irregular but frequent
intervals, amount is variable
Menometrorrhagia: Prolonged uterine bleeding at
irregular intervals (most common)
Intermenstrual bleeding: Bleeding of variable amounts
between regular menstrual periods
Polymenorrhea: Uterine bleeding at regular intervals of
less than 21d
Oligomenorrhea: Uterine bleeding in which the interval
between bleeding episodes may vary from 35 days to 6
months
Amenorrhea: No uterine bleeding for at least 6 months
Menopause: No UB for at least 1 year
Case: ectopic pregnancy – bleeding when 7 weeks
pregnant.
Causes of Abnormal Uterine Bleeding
Disruption of regularity, frequency, volume and duration
of menstrual flow
The cause can be physiologic, pathologic or
pharmocologic
Differential
Complications of Pregnancy
Pelvic Pathology
Systemic
Ovulatory vs. anovulatory
Iatrogenic (pharmacologic)
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Katelyn Rogers. Reproductive System. March 1st, 2010.
Causes of Abnormal Uterine Bleeding
Differential
1. Complications of Pregnancy
Ectopic pregnacy
Miscarriage
Placenta previa
Gestational trophoblastic disease
2. Pelvic Pathology
Benign:
Pregnancy, myoma (fibroid), adenomyosis,
endometriosis,endometrial/cervical polyp, PID,
infection,trauma, vascular abnormality, foreign body
Malignant:
Carcinoma of the reproductive tract
Endometrial hyperplasia (pre- malignant changes)
Uterine Fibroids (myoma)
Causes of Abnormal Uterine Bleeding
If no etiology in above categories then by exclusion the
diagnosis is dysfunctional uterine bleeding--it applies not
only to menorrhagia but also menometrorrhagia
Causes of Abnormal Uterine Bleeding
Dysfunctional Uterine Bleeding is a symptom and not
really a diagnosis.
-Causes 80% of menorrhagia
-Bleeding is UTERINE and mechanism is HORMONAL
Causes of DUB
DUB is usually related to one of four hormonalimbalance conditions:
-Estrogen breakthrough bleeding
-Estrogen withdrawl bleeding
-Progesterone breakthrough bleeding
-Progesterone withdrawl bleeding
Estrogen breakthrough bleeding:
This occurs when excess estrogen stimulates the
endometrium to proliferate in an undifferentiated
manner--if there is insufficient progesterone to provide
structural support the endometrium will slough at
irregular intervals (high BMIs store estrogen in fat)
Estrogen withdrawl bleeding:
This results from a sudden decrease in estrogen levels,
such as occurs after bilateral oophorectomy, cessation of
exogenous estrogen therapy or just before ovulation in
the normal menstrual cycle
3. Systemic
Ovulatory:
Coagulation disorder
Thrombocytopathy, von Willibrand’s disease, Leukemia
Systemic Lupus erythematosus
Cirrhosis
Anovulatory
Hypothyroid, hyperprolactenemia, PCOD, hypothalamic
dysfunction
(Again same causes for amenorrhea)
4. Iatrogenic
Hormone therapy
Contraceptive devices and injections (Depopervara most
common)
Medications
Antidepressants, anticoagulants, steroids
Progesterone breakthrough bleeding:
This occurs when the progesterone:estrogen ratio is high.
(progesterone only contraception)
The endometrium becomes atrophic and is prone to
frequent, irregular bleeding.
Progesterone Withdrawl Bleeding:
This occurs only if the endometrium is initially
proliferated by exogenous or endogenous estrogen
Evaluation of Abnormal Uterine Bleeding
Obtain a History:
Menstrual history
Recent cycle length and duration, blood flow, and
pattern
Color and character of flow (pain, discharge, odor)
Estimate of amount of blood loss
Use of contraception
Medical history
Thyroid disorder
Current medications
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Katelyn Rogers. Reproductive System. March 1st, 2010.
Physical Exam:
Height, weight, vital signs
Body fat distribution
Tanner staging
Pelvic examination
External-bruising, laceration, discharge, cervix
Bimanual exam- uterine size, adnexal mass or pain
Laboratory assessment:
Rule out pregnancy!
CBC, PAP, cultures
Maybe TSH, Prolactin level
Maybe coagulation studies
Chronic abnormal bleeding—medical Rx:
Observation
NSAIDS
Oral contraceptives
Progesterones
Hormone replacement
Inhibit GnRH stimulation
Danazol
Treatment-Medical
Case: pre-menopausal, abnl pap, she probably had
anovulatory. Older than 40s worry about cancer.
Further evaluation is based on menopausal status”
Premenopausal--look for cause of anovulatory bleeding
Peri and postmenopausal--need to evaluate for
endometrial hyperplasia or cancer
Tests to rule out endometrial hyperplasia or carcinoma:
Endometrial Biopsy
Ultrasound
Hysteroscopy
Evaluation- Endometrial Biopsy
Treatment –Merina IUD
Good for people with heavy flow, perimenopausal.
Treatment- Medical
Treatment
Goal of treatment is to control bleeding, prevent
recurrence, and preserve fertility (if desired)
Acute, heavy bleeding:
Hemodynamically unstable: High dose IV estrogen, or
emregent D&C (often with miscarriage)
Hemodynamically stable (& not preg): oral estrogen
Ablation
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