Abnormal uterine bleeding is an overarching term that is defined as bleeding from the uterine corpus that is irregular in volume, frequency, or duration in absence of pregnancy (Table 96-1).1 Vaginal bleeding is a common complaint in the ED, and differential diagnoses include pregnancy, structural abnormalities (e.g., polyps, fibroids), endometritis, coagulopathies, trauma, and various other causes. The prevalence of abnormal bleeding is estimated at 9% to 14% in the general population. Although vaginal bleeding may present as an acute or chronic problem, this chapter will focus on the ED evaluation and management of abnormal uterine bleeding.
TABLE 96-1FIGO Terminology for Bleeding* |Favorite Table|Download (.pdf) TABLE 96-1 FIGO Terminology for Bleeding*
|Type ||Definition |
|Abnormal uterine bleeding ||Bleeding that is abnormal in regularity, volume, frequency, or duration. Bleeding may be acute or chronic and is present for at least 6 months. |
|Heavy menstrual bleeding (heavy uterine bleeding [HUB] replaces menorrhagia) ||Excessive menstrual bleeding that interferes with a woman's physical, emotional, social, and quality of life. Note that the definition is menstrual bleeding deemed excessive by the patient regardless of duration, frequency, or timing. |
|Amenorrhea ||Bleeding that is absent for >6 months. |
|Prolonged menstrual bleeding ||Menstrual bleeding that is absent for >6 months. |
|Intermenstrual bleeding (replaces metrorrhagia) ||Bleeding episodes between normally timed menstrual periods. |
|Irregular menstrual bleeding ||Unpredictable onset of menses, with cycle variations >20 days over a period of 1 year. |
|Postmenopausal bleeding ||Any bleeding that occurs >12 months after cessation of menstruation. |
In North America, average age of menarche is 12.5 years of age, approximately 2 years after the development of thelarche (breast budding). Early cycles are often anovulatory and irregular due to the immaturity of the hypothalamic-pituitary axis. Regular ovulatory cycles develop on average 2 years after the start of menarche.
The normal menstrual cycle is 28 days and is divided into four phases: menses, follicular, ovulation, and luteal or secretory. Figure 96-1 depicts hormonal and endometrial changes associated with a normal menstrual cycle.
The hormonal, ovarian, endometrial, and basal body temperature changes and relationships throughout the normal menstrual cycle. E2 = prostaglandin E2; FSH = follicle-stimulating hormone; LH = luteinizing hormone; P = progesterone. [Reproduced with permission from Patel DR, Greydanus DE, Baker RJ: Pediatric Practice Sports Medicine. © 2009, McGraw-Hill, New York, NY.]
In response to the rising estrogen levels, the pituitary gland secretes follicle-stimulating hormone and luteinizing hormone, which stimulates the release of the mature oocyte. The residual follicular capsule forms the corpus luteum. During the luteal ...