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A 46-year-old woman comes to your office because she is concerned about heavy vaginal bleeding. Her menstrual cycle has not changed, but over the past year, she has noticed increasingly heavy periods, requiring many more pads than she previously used, and the passage of blood clots. Over the past 3 months, she has become very tired as well, prompting her visit today.

  • What additional questions would you ask to learn more about her bleeding?
  • What questions would you use to classify her bleeding?
  • How can you determine whether her bleeding is ovulatory or anovulatory?
  • Can you narrow the diagnosis using specific questions about her history?
  • How can you use the patient history to distinguish between worrisome and nonworrisome sources of bleeding?

Abnormal vaginal bleeding is one of the most common clinical problems in women's health. Statistics regarding the frequency of various causes of abnormal vaginal bleeding are not available. Abnormal vaginal bleeding may be categorized as independent of or related to hormonal cycles. Normal menstrual bleeding lasts an average of 4 days (ranging from 2 to 7 days) and involves loss of about 30 to 60 mL of blood. Vaginal bleeding related to the menstrual cycle is considered abnormal if it varies from normal menstrual bleeding in volume, frequency, or timing. Otherwise, abnormal vaginal bleeding may result from hormonal abnormalities or structural abnormalities anywhere along the genital tract. The likely source depends on the age and reproductive status of the woman.

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Dysfunctional uterine bleeding (DUB)Abnormal uterine bleeding that is hormonal in nature and not due to structural or systemic disease.
MenometrorrhagiaIrregular or excessive bleeding during menstruation and between periods.
MenorrhagiaBleeding of excessive flow and duration that occurs at regular intervals.
MetrorrhagiaBleeding that occurs at irregular intervals.
OligomenorrheaBleeding that occurs at intervals > 35 days.
Ovulation bleedingA single episode of spotting between regular menstrual periods.
PolymenorrheaBleeding that occurs at intervals < 21 days.
Positive likelihood ratio (LR+)The increase in the odds of a particular diagnosis if a given factor is present.

The etiology of abnormal vaginal bleeding depends on the age and reproductive status of the patient. Although the vast majority of abnormal bleeding is dysfunctional uterine bleeding, this is a diagnosis of exclusion. Pregnancy, abnormalities of the reproductive tract, systemic diseases, and medications (eg, oral contraceptive pills [OCPs]) may all cause abnormal vaginal bleeding; clinicians must consider these diagnoses before assigning a diagnosis of DUB.

Differential Diagnosis

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Complications related to pregnancy

Normal intrauterine pregnancy

Ectopic pregnancy

Gestational trophoblastic disease

Spontaneous abortion (threatened, incomplete, or missed)

Placenta previa

Retained products of conception after therapeutic abortion

Abnormalities of the reproductive tract67% of women referred for hysteroscopy1

Benign lesions (cervical, endometrial, adenomyosis)

Malignant lesions (cervical, endometrial)

Infection (cervicitis, endometritis)

Trauma (laceration, abrasion, foreign body)


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