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ESSENTIALS OF DIAGNOSIS

ESSENTIALS OF DIAGNOSIS

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

  • The normal menstrual cycle is generally 24–38 days in length, with a menstrual flow lasting 4–8 days and a total menstrual blood loss of 5–80 mL.

GENERAL CONSIDERATIONS

Abnormal uterine bleeding (AUB), defined as premenopausal menstrual bleeding outside of the normal parameters of volume, duration, regularity, or frequency, affects 10–30% of women at some time during their lives. In 2011, the American College of Obstetricians and Gynecologists (ACOG) adopted a classification system known by the acronym PALM–COEIN, which classifies AUB by its causes: structural (polyp, adenomyosis, leiomyoma, malignancy, and hyperplasia) and nonstructural (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified). The recommendation of ACOG is to pair the term abnormal uterine bleeding with the letter denoting the cause in order to achieve uniformity in nomenclature and to eliminate the terminology of dysfunctional uterine bleeding. In addition, descriptive terms should be used instead of traditional Latin terms, such as heavy menstrual bleeding instead of menorrhagia, intermenstrual bleeding instead of metrorrhagia, and infrequent or anovulatory bleeding instead of oligomenorrhea.

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American College of Obstetricians and Gynecologists. Diagnosis of abnormal uterine bleeding in reproductive-aged women. ACOG Practice Bulletin No. 128. Obstet Gynecol. 2012;120(1):197–206. (Reaffirmed 2016).
[PubMed: 22914421]  
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Munro  MG, Critchley  HO, Border  MS, Fraser  IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. FIGO Working Group on Menstrual Disorders. Int J Gynaecol Obstet. 2011;113:3–13.
[PubMed: 21345435]  
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Wouk  N, Helton  M. Abnormal uterine bleeding in premenopausal women. Am Fam Physician. 2019;99(7):435–443.
[PubMed: 30932448]  

CLINICAL FINDINGS

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 24–38 days, the cycle is consistent with an ovulatory pattern of bleeding. Patients often report breast discomfort or premenstrual symptoms with ovulatory bleeding. Although cycles may vary in length by several days, >10 days of variance raises the suspicion of anovulatory cycles. The patient should be asked to describe the current vaginal bleeding in terms of onset, frequency, duration, and severity. Although heavy menstrual bleeding is defined by >80 mL of blood loss, in practice, it is determined by patient report of excessive bleeding. Age, parity, sexual history, previous gynecologic disease, and obstetrical history will further assist the physician in focusing the evaluation of the woman with vaginal bleeding. The physician should ask about medications, including contraceptives, prescription medications, and over-the-counter (OTC) medications and supplements. The patient should be asked about any OTC preparations she might be taking. Patients may not be aware that herbal preparations may ...

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