Abnormal Uterine Bleeding

DEFINITIONS

Menstrual abnormalities include:

■ Polymenorrhea—menses with regular intervals that are too short (under 21 days)

■ Menorrhagia—menses that are too long in duration (over 7 days) and/or menses associated with excessive blood loss (> 80 mL) occurring at normal intervals

■ Hypermenorrhea—menses that are too long in duration (over 7 days) and/or menses associated with excessive blood loss (> 80 mL) occurring at regular but not necessarily normal intervals

■ Oligomenorrhea—menses with intervals that are too long (cycle lasts more than 35 days)

■ Metrorrhagia—bleeding occurring at irregular intervals; intermenstrual bleeding

■ Menometrorrhagia—combination of both menorrhagia and metrorrhagia; menses too long in duration or excessive blood loss + irregular bleeding intervals

■ Kleine regnung—bleeding for 1 to 2 days during ovulation (scant)

For an overview of bleeding, see Figure 16-1.

DIFFERENTIAL DIAGNOSES FOR MENORRHAGIA

Leiomyoma Adenomyosis Cervical cancer Coagulopathy Endometrial Hyperplasia Polyps Cancer

Menorrhagia—bleeding too long or too much. Menorrhagia is clinically signified by clots, anemia, increase in number of pads, and soiled clothing.

Metrorrhagia—the metro never comes according to schedule (bleeding at irregular intervals).

Use mnemonic LACCE for differential diagnoses of menorrhagia:

Leiomyoma

Adenomyosis

Cervical cancer

Coagulopathy

Endometrial

Hyperplasia

Polyps

Cancer

Bleeding per vagina

Premenopausal

Postmenopausal

P-hCG level

P-hCG level

Do ultrasound

(Intrauterine pregnancy shows at > 7 weeks; alternatively, you might see ectopic or nothing.

Endometrial biopsy

Consider cervical or endometrial cancer.

Check PT/PTT for coagulopathy. Physical exam or CT/ultrasound might show pelvic mass or neoplasia. Consider laparoscopy to diagnose endometriosis. Check estrogen levels to show PCOD.

With pain Ruptured ectopic pregnancy

Surgery

+/- Pain Consider

Threatened/inevitable/incomplete abortion or ectopic pregnancy

Very high p-hCG + no fetal heartbeat = gestational trophoblastic neoplasia

-Look for POC in vagina/cervical canal -Serial p-hCGs

Normal pregnancy p-hCG levels increase 66%/48 hours, whereas ectopics are lower.

FIGURE 16-1. A quick approach to bleeding.

POC in vagina/cervical canal = abortion

Mnemonic for Premenopausal metrorrhagia: Pretty PINC metro:

Polyps

Increased estrogens

Neoplasia

Contraceptive

DIFFERENTIAL DIAGNOSES FOR PREMENOPAUSAL METRORRHAGIA

Polyps

Increased estrogens Neoplasia

Contraceptive complications

DYSFUNCTIONAL UTERINE BLEEDING

Dysfunctional uterine bleeding (DUB) is abnormal uterine bleeding unrelated to anatomic lesions; usually caused by hormonal dysfunction.

DUB is a diagnosis made by exclusion after workup for other causes of abnormal uterine bleeding (caused by anatomical lesions) is negative.

Classification of DUB

DUB is classified as either anovulatory or ovulatory, though it is most often caused by anovulation:

Anovulatory DUB: Anovulation results in constant endometrial proliferation without progesterone-mediated maturation and shedding. The "overgrown" endometrium continually and irregularly sheds. Causes of anovulatory DUB include:

■ Polycystic ovaries (polycystic ovarian disease [PCOD])

■ Unopposed exogenous estrogen

Ovulatory DUB: Inadequate progesterone secretion by corpus luteum causes a luteal-phase defect and results in DUB; it often presents with polymenorrhea or metrorrhagia.

Evaluation of DUB

History

■ Thorough menstrual and reproductive history

■ Signs of systemic disease (thyroid, liver, kidney)

■ Social (extreme exercise, weight changes)

■ Presence or absence of ovulation (regularity, premenstrual body changes)

Treatment of DUB

■ High-dose oral contraceptive pills or

■ Medroxyprogesterone acetate > 10 days

Because DUB is usually caused by anovulation (PCOD, exogenous estrogens, obesity), oral contraceptives prevent DUB by mimicking the normal menstrual cycle changes to allow for endometrial maturation and sloughing. If DUB is ovulatory, nonsteroidal anti-inflammatory drugs are useful.

Only if medical treatment fails should endometrial ablation or hysterectomy be performed.

Treatment of Acute Bleeding Episodes

■ High-dose oral or IV estrogen

■ High-dose oral contraceptives

Tumors (benign and malignant) often present with menorrhagia or metrorrhagia.

Postcoital bleeds suggest trauma, infections, or cervical cancer.

POSTMENOPAUSAL BLEEDING

Always do an endometrial biopsy when encountering postmenopausal bleeding because of the strong possiblity of endometrial cancer.

Postmenopausal bleeding is vaginal bleeding more than 1 year after menopause.

Differential Diagnoses for Postmenopausal Bleeding

Endometrial Hyperplasia Cancer Cervical cancer Vulvar cancer Estrogen-secreting tumor Vaginal atrophy (most common)

Studies to Get

■ Endometrial biopsy and endocervical curettage (because of the prevalence and danger of endometrial lesions)

■ Pap smear for cervical dysplasia, neoplasia

■ Ultrasound

■ Hysteroscopy

OTHER BLEEDING TIPS

Postcoital bleeding in pregnant woman: Consider placenta previa. Postcoital bleeding in nonpregnant woman: Consider cervical cancer. Postmenopausal bleeding: Consider endometrial cancer. Premenopausal bleeding: Consider PCOD.

NOTES

NOTES

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