Abnormal premenopausal bleeding

Abnormal premenopausal bleeding refers to any bleeding that deviates from the normal menstrual cycle before menopause. These deviations include menstrual bleeding that’s abnormally infrequent (oligomenorrhea), abnormally frequent (polymenorrhea), excessive (menorrhagia or hypermenorrhea), deficient (hypomenorrhea), or irregular (metrorrhagia [uterine bleeding between menses]). Rarely, menstrual symptoms aren’t accompanied by external bleeding (cryptomenorrhea). Premenopausal bleeding may merely be troublesome or can result in severe hemorrhage; the prognosis depends on the underlying cause. Abnormal bleeding patterns often respond to hormonal or other therapy.

Causes and incidence

Causes of abnormal premenopausal bleeding vary with the type of bleeding:

❑ Oligomenorrhea and polymenorrhea usually result from anovulation due to an endocrine or systemic disorder.

❑ Menorrhagia usually results from local lesions, such as uterine leiomyomas, endometrial polyps, and endometrial hyperplasia. It may also result from endometritis, salpingitis, and anovulation.

❑ Hypomenorrhea results from local, endocrine, or systemic disorders, or from blockage due to partial obstruction by the hymen or to cervical obstruction.

❑ Cryptomenorrhea may result from an imperforate hymen or cervical stenosis.

❑ Metrorrhagia usually results from slight physiologic bleeding from the endometrium during ovulation but may also result from local disorders, such as uterine malignancy, cervical erosions, polyps (which tend to bleed after intercourse), or inappropriate estrogen therapy. Complications of pregnancy can also cause premenopausal bleeding. Such bleeding may be as mild as spotting or as severe as menorrhagia. (See Causes of abnormal premenopausal bleeding, page 954.)

Signs and symptoms

Bleeding not associated with abnormal pregnancy is usually painless, but it may be severely painful. When bleeding is associated with abnormal pregnancy, other symptoms include nausea, breast tenderness, bloating, and fluid retention. Severe or prolonged bleeding causes anemia, especially in patients with underlying disease such as blood dyscrasia and in patients receiving anticoagulants.

Diagnosis

The typical clinical picture confirms abnormal premenopausal bleeding. Special tests identify the underlying cause:

❑ Serum hormone levels reflect adrenal, pituitary, or thyroid dysfunction.

❑ Urinary 17-ketosteroids reveal adrenal hyperplasia, hypopituitarism, or polycystic ovarian disease.

❑ Endometrial sampling rules out malignant tumors and should be performed in all patients with premenopausal bleeding who are older than age 35.

❑ Pelvic examination, Papanicolaou (Pap) test, and patient history rule out local or malignant causes.

❑ Complete blood count rules out anemia.

If testing rules out pelvic and hormonal causes of abnormal bleeding, a complete hematologic survey (including platelet count and bleeding time) is appropriate to determine clotting abnormalities.

Treatment

Treatment depends on the type of bleeding abnormality and its cause. Menstrual irregularity alone may not require therapy unless it interferes with the patient’s attempt to achieve or avoid conception or leads to anemia. When it requires treatment, clomiphene induces ovulation. Electrocautery, chemical cautery, or cryosurgery can remove cervical polyps; dilatation and curettage, uterine polyps. Organic disorders (such as cervical or uterine malignancy) may necessitate hysterectomy, radium or X-ray therapy, or both of these treatments, depending on the disease’s site and extent. Of course, anemia and infections require appropriate treatment.

Special considerations

❑ If the patient complains of abnormal bleeding, tell her to record the dates of the bleeding and the number of tampons or pads used per day. This helps to assess the cyclic pattern and the amount of bleeding.

❑ Instruct the patient to report abnormal bleeding immediately to help rule out major hemorrhagic disorders, such as occur in abnormal pregnancy.

❑ To prevent abnormal bleeding due to organic causes, and for early detection of malignancy, encourage the patient to have a Pap smear and a pelvic examination annually.

❑ Offer reassurance and support. The patient may be particularly anxious about excessive or frequent blood loss and passage of clots. Suggest that she minimize blood flow by avoiding strenuous activity and occasionally lying down with her feet elevated.

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Book Source Details

• Book Title: Professional Guide to Diseases (Eighth Edition)
• Author(s): Springhouse
• Year of Publication: 2005
• Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.

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Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X

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