Abnormal bleeding affects up to 30% of women at some time during their lives. Evaluating vaginal bleeding involves an examination of the patient's menstrual cycle. 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. During the normal menstrual cycle the endometrium is exposed initially to estrogen, followed by ovulation and production of progesterone as well as estrogen, and finally the withdrawal of estrogen and progesterone causing menstruation. Different diseases are associated with certain patterns of vaginal bleeding, although there is a wide variation in presentation within each. Common terminology used to discuss vaginal bleeding includes menorrhagia, metrorrhagia, menometrorrhagia, hypermenorrhea, polymenorrhea, and oligomenorrhea. The bleeding patterns associated with each term are listed in Table 33-1.
Table 33-1. Patterns of Vaginal Bleeding. |Favorite Table|Download (.pdf)
Table 33-1. Patterns of Vaginal Bleeding.
|Descriptive Term||Bleeding Pattern|
|Menorrhagia||Regular cycles, prolonged duration, excessive flow|
|Menometrorrhagia||Irregular cycles, prolonged duration, and excessive flow|
|Hypermenorrhea||Regular cycles, normal duration, andexcessive flow|
Throughout their lifetimes there are normal changes in most women's menstrual patterns. Just as anovulation is common during the years following menarche, the perimenopausal patient usually experiences changes in her menstrual cycle related to decreasing, irregular anovulation. Although age plays an important role in constructing a differential diagnosis in a patient presenting with vaginal bleeding, many of the causes can occur in any adult woman.
Albers JR: Abnormal uterine bleeding. Am Fam Physician 2004;69: 1915-1926.
Taking a history of a patient presenting with vaginal bleeding should begin with an exploration of the patient's usual bleeding pattern. 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. The patient takes her temperature orally as soon as she awakens in the morning and records it on a chart. 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. In addition, patients can 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 ...