Basics
Description
- Abnormal uterine bleeding is an alteration in pattern or volume of normal menses
- Typical blood loss during a normal menstrual cycle is 30-80 mL
- Normal interval between menses 28 (+/- 7) days
- 2 classifications
- Dysfunctional uterine bleeding (DUB)
- Hormonally related
- Anovulatory and ovulatory categories
- Not due to organic or iatrogenic causes
- Diagnosis of exclusion
- Organic uterine bleeding
- Bleeding related to systemic illness or disease of the reproductive tract
Etiology
- Anovulatory (most common):
- Unopposed estrogen stimulation of proliferative endometrium
- Alteration of neuroendocrine function due to:
- Polycystic ovarian syndrome (PCOS)
- Very low calorie diets, rapid weight change, intense exercise, anorexia
- Psychological stress
- Obesity
- Drugs
- Hypothyroidism
- Primary hypothalamic dysfunction
- Ovulatory:
- Inadequate uterine PGF2α
- Increased uterine contractility
- Excessive uterine prostacycline
- Diminishes platelet function and increases uterine vasodilation
Anovulatory bleeding common in adolescence owing to immaturity of the hypothalamic-pituitary-ovarian axis �
Diagnosis
Signs and Symptoms
History
- Abnormal uterine bleeding in the absence of systemic or structural disease
- Most common in perimenarcheal, perimenopausal women
- Typically painless
- Anovulatory presentations:
- Metrorrhagia:
- Irregular bleeding between periods
- Menorrhagia:
- Regular periods with excess flow (>80 mL) or >7 days of bleeding
- Oligomenorrhea:
- Periods with intermenstrual cycles >35 days
- Menometrorrhagia:
- Excessive bleeding with and between menses
Physical Exam
- Acne, hirsutism, obesity suggest PCOS
- Mild to moderate bleeding on pelvic exam
- Pallor, tachycardia, hypotension, orthostasis in severe cases
- Evaluate for trauma, foreign bodies
It is rare for women to be hemodynamically unstable simply from DUB; if such instability is present, concern is for ectopic pregnancy or other cause for hemorrhage. �
Essential Workup
Pregnancy test �
Diagnosis Tests & Interpretation
Lab
- Pregnancy test, CBC, PT/PTT
- May send iron studies, TSH, LH, FSH, prolactin level, cervical cultures for routine follow-up by primary medical doctor (PMD)/gynecology
Imaging
Pelvic ultrasound may show uterine, tubal, or ovarian abnormality; may be needed to rule out other organic or iatrogenic causes on differential diagnoses. �
Diagnostic Procedures/Surgery
- Dilation and curettage (D&C) may be required for heavy bleeding unresponsive to other interventions
- Refer for endometrial biopsy if >35 yr of age
Differential Diagnosis
Organic/Iatrogenic
- Pregnancy complications:
- Threatened, incomplete, or spontaneous abortion
- Ectopic pregnancy
- Molar pregnancy
- Infectious:
- Vaginitis
- Cervicitis
- Pelvic inflammatory disease (PID)
- Coagulopathies:
- von Willebrand disease
- Idiopathic thrombocytopenic purpura
- Platelet defects
- Thalassemia
- Medications:
- Warfarin
- Aspirin
- Oral contraceptives
- Tricyclic antidepressants
- Major tranquilizers
- Systemic illness:
- Adrenal, hepatic, renal or thyroid dysfunction, diabetes mellitus, other endocrinopathies
- Anatomic lesions:
- Fibroids
- Endometriosis
- Polyps
- Endometrial hyperplasia
- Neoplasm
- Intrauterine devices
- Trauma
Hormone related
See anovulatory and ovulatory etiologies �
Treatment
Pre-Hospital
IV crystalloid boluses as needed for hypotension, tachycardia secondary to heavy bleeding �
Initial Stabilization/Therapy
ABCs: �
- Packed RBCs for significant bleeding unresponsive to crystalloids
Ed Treatment/Procedures
- Observation usually adequate if bleeding mild
- IV crystalloid, packed RBCs for continued bleeding, or hemodynamic instability
- Gynecology consultation if bleeding is severe and unresponsive to crystalloids, medications:
- D&C may be necessary for hemodynamic instability
- Endometrial ablation or hysterectomy for continued heavy bleeding unresponsive to other measures
Medication
- Conjugated estrogen (Premarin) for heavy bleeding, hemodynamic instability:
- 2.5 mg PO q6h
- 25 mg IV, repeat in 3 hr if needed
- Ibuprofen 400-800 mg PO q8h (reduces prostaglandin synthesis)
- IV dosing has not been shown to be superior to oral route:
- Medroxyprogesterone acetate 5-10 mg/d PO is added when bleeding subsides
- Oral contraceptive pills:
- Ethinyl estradiol 35 μg and norethindrone 1 mg PO QID for 1 wk
- Antifibrinolytic agents:
- Tranexamic acid: 1,300 mg PO TID � 5 days
- May be used in conjunction with OCPs
- Use limited by GI effects and allergy
- Medications may be deferred in mild cases with referral to gynecology
- Transdermal or long-acting estrogens are other options
Follow-Up
Disposition
Admission Criteria
- Significant blood loss
- Continued bleeding
- Hemodynamic instability requiring aggressive resuscitation and/or operative intervention
Discharge Criteria
Most patients can be discharged with gynecology referral once bleeding is controlled and patient is hemodynamically stable. �
Issues for Referral
Endometrial biopsy if >35 yr old: �
- Follow-up with either gynecologist or primary care physician is necessary for patients with DUB
- Must evaluate for ongoing blood loss or potential malignancy as cause
Pearls and Pitfalls
- DUB is a diagnosis of exclusion
- Only 2% of endometrial carcinoma occur before age 40 yr
- If hemodynamic instability, unlikely diagnosis of DUB
Additional Reading
- Casablanca �Y. Management of dysfunctional uterine bleeding. Obstet Gynecol Clin North Am. 2008;35:219-234.
- LaCour �DE, Long �DN, Perlman �SE. Dysfunctional uterine bleeding in adolescent females with endocrine causes and medical conditions. J Pediatr Adolesc Gynecol. 2010;23:62-70.
- Lentz �G, Lobo �R, Gershenson �D, et al. Comprehensive Gynecology. 6th ed. Philadelphia, PA: Mosby; 2012.
- Lethaby �A, Farquhar �C, Cooke �I. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000;(4):CD000249.
- Pitkin �J. Dysfunctional uterine bleeding. BMJ. 2007;334:1110-1111.
See Also (Topic, Algorithm, Electronic Media Element)
- Amenorrhea
- Vaginal Bleeding
Codes
ICD9
- 626.2 Excessive or frequent menstruation
- 626.6 Metrorrhagia
- 626.8 Other disorders of menstruation and other abnormal bleeding from female genital tract
- 626.1 Scanty or infrequent menstruation
- 626.5 Ovulation bleeding
ICD10
- N92.0 Excessive and frequent menstruation with regular cycle
- N92.1 Excessive and frequent menstruation with irregular cycle
- N93.8 Other specified abnormal uterine and vaginal bleeding
- N91.5 Oligomenorrhea, unspecified
- N92.3 Ovulation bleeding
SNOMED
- 19155002 Dysfunctional uterine bleeding (finding)
- 64996003 intermenstrual bleeding - irregular (finding)
- 386692008 Menorrhagia (finding)
- 52073004 Oligomenorrhea (finding)
- 266603000 Ovulation bleeding (finding)
- 27585009 Anovular menstruation (finding)
- 314631008 menometrorrhagia (finding)