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  • A clinical history of a menstrual cycle pattern outside the normal parameters.

  • The normal menstrual cycle is generally 21–35 days in length with a menstrual flow lasting 2–7 days and a total menstrual blood loss of 20–60 mL.


Abnormal bleeding affects ≤30% of women at some time during their lives. Common terminology and the bleeding patterns associated with each term are listed in Table 34-1. ACOG recently adopted a classification system known by the acronym PALM–COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified). The recommendation of ACOG is to classify abnormal uterine bleeding (AUB) as heavy menstrual bleeding (HMB) or intermenstrual bleeding (IMB) in addition to a letter denoting the cause in order to achieve uniformity in nomenclature and eliminate the terminology of dysfunctional uterine bleeding (DUB).

Table 34–1.Patterns of vaginal bleeding.
Committee on Practice Bulletins—Gynecology. Diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012;120(1):197–206.
[PubMed: 22914421]


A. Symptoms and Signs

1. History

The physician should try to establish whether the patient’s pattern is cyclic or anovulatory. If the patient menstruates every 21–35 days, her cycle is consistent with an ovulatory pattern of bleeding. To confirm ovulation, patients can check their basal body temperature, cervical mucus, and luteinizing hormone (LH) levels. Basal body temperature can be checked using a basal body temperature thermometer, which allows for a precise measurement of the patient’s temperature within a narrower range than a standard thermometer. After ovulation the ovary secretes an increased amount of progesterone, causing an increase in temperature of approximately 0.5°F over the baseline temperature in the follicular phase. The luteal phase is often accompanied by an elevation of temperature that lasts 10 days. Patients can also be taught to check the consistency of their cervical mucus, watching for a change from the sticky, whitish cervical mucus of the follicular phase to the clear, stretching mucus of ovulation. Finally, the patient can use an enzyme-linked immunosorbent assay (ELISA) testing kit to check for the elevation of LH over baseline that occurs with ovulation. The patient should be asked to describe the current vaginal bleeding in terms of onset, frequency, duration, and severity. Age, parity, sexual history, previous gynecological disease, and obstetrical history will further assist the physician in focusing the evaluation of the women with vaginal bleeding. The physician should ask about medications, including contraceptives, prescription medications, and over-the-counter (OTC) medications and supplements. The ...

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