Abnormal Uterine Bleeding
Abnormal Uterine Bleeding: Excerpt from In a Page: Signs and Symptoms
Uterine bleeding is abnormal when the pattern (amount and/or duration) is irregular. Menorrhagia indicates regular but excessive uterine bleeding; metrorrhagia indicates irregular and, often, more frequent uterine bleeding; and menometrorrhagia indicates irregular and excessive uterine bleeding during menstruation and between cycles.
Differential Diagnosis
- Endometrial hyperplasia
–Endogenous estrogen excess (e.g., obesity,
tumor)
–Exogenous estrogen
–DUB is a diagnosis of exclusion (usually
not cyclic, occurs irregularly throughout the menstrual cycle)
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Polycystic ovarian syndrome
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Hypo- or hyperthyroidism
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Endometrial atrophy
–Caused by long-term progestin or oral contraceptive use
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Anatomic or structural lesions
–Uterine leiomyoma (fibroids)
–Foreign body (often intrauterine device)
–Cervical or uterine polyps
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Pelvic infection (cervicitis, pelvic inflammatory disease)
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Hypothalamic lesion
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Hyperprolactinemia
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Medications (e.g., exogenous estrogen, phenothiazines, reserpine)
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Coagulation disorders
–Platelet dysfunction: Thrombocytopenia, leukemia, medications (e.g., aspirin, NSAIDs)
–Clotting factor abnormality: Von Willebrand's disease, hemophilia, hepatic or renal disease, anticoagulant use
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Complications of pregnancy
–Spontaneous abortion (miscarriage)
–Ectopic pregnancy
–Placenta previa
–Placental abruption
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Endometrial cancer
–Risk factors include older age, chronic anovulation, obesity, hypertension, DM, and unopposed estrogen
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Systemic disease (e.g., HIV, hepatic disease, renal disease)
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Nonuterine bleeding
–Vaginal (tear, trauma, or cancer)
–Cervical (trauma or cancer)
–Urinary (UTI or cancer)
–Rectal (bleeding, trauma, fissure, or cancer)
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Other malignancy (ovarian or uterine tumor, sarcoma)
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Endometrioma
Workup and Diagnosis
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History, physical, pelvic, and rectal examinations
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Pap smear
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- Initial labs may include β-hCG (qualitative and, if positive, quantitative); CBC with differential; TSH, LH, FSH, estradiol, testosterone, prolactin, and DHEA-S levels
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Consider PT/PTT, peripheral smear, clotting factor assays, liver function tests, serum progesterone, and BUN/creatinine to evaluate for coagulopathy, hepatic, or renal disease
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Pelvic ultrasound may reveal adnexal or uterine masses or other pathology
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Transvaginal ultrasound is more accurate than pelvic ultrasound in evaluating the endometrium
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Endometrial biopsy and progesterone challenge test are helpful in the evaluation of estrogen excess
–Administration of medroxyprogesterone for 10 days results in withdrawal bleeding if adequate estrogen is present
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CT scan may be helpful if malignancy is suspected
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Hysteroscopy for evaluation of endometrium and uterine cavity
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Diagnostic dilatation and curettage is more invasive but offers more information than endometrial biopsy
Treatment
- Acute life-threatening bleeding must be treated emergently with IV estrogen, IV fluids and/or blood replacement, curettage, and possible ligation of uterine artery or hysterectomy
- Nonacute bleeding is often treated with oral contraceptives to regulate bleeding; consider dosage change if already on oral contraceptives
–Estrogen/progesterone (avoid if contraindicated)
–Cyclic progesterone (will not prevent pregnancy)
–Other medications include tranexamic acid, danazol,
GnRH agonists, megestrol, intrauterine progesterone, and fibrinolytic agents
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Surgery may be indicated for anatomic causes and/or if fertility is not desired
–Endometrial ablation
–Hysterectomy
-
Treat underlying etiologies (e.g. thyroid hormones for hypothyroidism, chemotherapy for leukemia, withdraw offending medications)
Book Source Details
- Book Title: In a Page: Signs and Symptoms
- Author(s): Scott Kahan, Ellen G. Smith
- Year of Publication: 2004
- Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: In a Page: Signs and Symptoms
Authors: Scott Kahan, Ellen G. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2004
ISBN: 1-4051-0368-X
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» Next page: Urethral Prolapse (The 5-Minute Pediatric Consult)
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