Uterine Bleeding, Abnormal Premenopausal

Key Features

Essentials of Diagnosis

• Accurate diagnosis of abnormal uterine bleeding depends on appropriate categorization and diagnostic tests

• Pregnancy should always be ruled out as a cause of abnormal uterine bleeding in women of reproductive age

• The evaluation of abnormal bleeding depends on the age and risk factors of the patient

General Considerations

• Normal menstrual bleeding

  • Frequency varies individually from 24 to 38 days

  • Lasts an average of 5 days (range, 2–8 days)

  • Mean blood loss of 40 mL

• Menorrhagia

  • Blood loss of over 80 mL per cycle

  • Frequently produces anemia

• Metrorrhagia: bleeding between periods

• Polymenorrhea: bleeding that occurs more often than every 21 days

• Oligomenorrhea: bleeding that occurs less frequently than every 35 days

• A classification system for causes of abnormal uterine bleeding uses the acronym PALM-COEIN

  • Polyp

  • Adenomyosis

  • Leiomyoma

  • Malignancy

  • Coagulopathy-Hyperplasia

  • Ovulatory dysfunction

  • Endometrial

  • Iatrogenic

  • Not yet classified

• Abnormal uterine bleeding in women aged 19–39 years is often a result of

  • Pregnancy

  • Structural lesions

  • Anovulatory cycles

  • Use of hormonal contraception

  • Endometrial hyperplasia

Clinical Findings

Symptoms and Signs

• Obtain

  • A history of the duration and amount of flow, associated pain, and relationship to the last menstrual period (LMP). The presence of blood clots or the degree of inconvenience caused by the bleeding may be useful indicators

  • A history of pertinent illnesses (such as recent systemic infections or other significant physical or emotional stressors, such as thyroid disease or weight change)

  • A history of all medications or herbal remedies that might cause abnormal uterine bleeding

  • A history of coagulation disorders in the patient or family members

• Perform a careful physical examination to look for findings predisposing to insulin resistance

  • Excessive weight

  • Signs of polycystic ovary syndrome

  • Thyroid disease

  • Bleeding disorder

• Perform pelvic examination to rule out

  • Vulvar, vaginal, or cervical lesions

  • Pregnancy

  • Uterine myomas

  • Adnexal masses

  • Adenomyosis

  • Infection

Differential Diagnosis

• Ovulation bleeding (spotting episode between menses)

• Anovulatory cycle (dysfunctional uterine bleeding)

• Polycystic ovary syndrome (type of anovulatory cycle)

• Pregnancy

• Ectopic pregnancy

• Spontaneous abortion

• Uterine leiomyomas (fibroids)

• Endometrial polyp

• Cervicitis or pelvic inflammatory disease

• Adenomyosis (uterine endometriosis)

• Cervical cancer

• Cervical polyp

• Endometrial hyperplasia

• Endometrial cancer

• Hypothyroidism

• Hyperprolactinemia

• Diabetes mellitus

• Bleeding disorder, eg, von Willebrand disease

Diagnosis

Laboratory Tests

• Complete blood count

• Pregnancy test

• Thyroid function tests

• Vaginal or urine samples should be obtained for polymerase chain reaction or culture to rule out Chlamydia infection

• If indicated, cervical cytology should also be obtained

• For adolescents with heavy menstrual bleeding and adults with a positive screening history, coagulation studies (eg, prothrombin time, activated partial thromboplastin time, platelet count) should be considered

Imaging Studies

• Transvaginal ultrasound is ...