Ovulatory Bleeding

Aka: Ovulatory Bleeding, Menorrhagia

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II. Pathophysiology

  1. Shortened or prolonged corpus luteum life span
  2. Abnormal relative ratio of Estrogen to Progesterone
    1. Usually due to low Estrogen levels

III. Risk Factors

  1. Increases with age

IV. Causes

  1. See Abnormal Uterine Bleeding Causes
  2. Uterine Fibroids (before Menopause)
  3. Endometrial Polyps
  4. Bleeding Disorders
    1. Von Willebrand Disease (present in 13% of women with Menorrhagia)
  5. Hypothyroidism
  6. Advanced liver disease

V. Symptoms

  1. Premenstrual Symptoms are present
  2. Menstrual Cycle intervals are normal (every 24 to 35 days)
  3. Quantifying Menstrual Bleeding amount
    1. Regular-absorbency tampons hold 6 to 9 grams (20 ml) of menstrual blood
    2. Super-absorbency tampons hold 9 to 12 grams (30 ml) of menstrual blood
    3. Heavy or Ultra Pads hold 30 to 50 ml of menstrual blood
    4. Menstrual Discs hold 60 to 80 ml of menstrual blood
    5. Menstrual Cups hold 20 to 35 ml of menstrual blood
    6. Menstrual underwear holds only 1-3 ml of menstrual blood
    7. DeLoughery (2024) BMJ Sex Reprod Health 50(1):21-6 +PMID: 37550075 [PubMed]
  4. Change in Amount of bleeding
    1. Menorrhagia
      1. Patient describes very heavy periods
      2. Change pad or tampon every 1-2 hours
      3. Blood clots >1 inch (2.5 cm)
      4. Patient passes over 80 ml blood per cycle
        1. The definition of 80 ml is no longer recommended
        2. Warner (2004) Am J Obstet Gynecol 190:1224-9 [PubMed]
    2. Prolonged bleeding
      1. Bleeding duration lasts 7 days or more per cycle

VI. Signs

  1. See Ovulation

VII. Labs: Initial

  1. Urine Pregnancy Test
  2. Complete Blood Count
  3. Thyroid Stimulating Hormone (TSH)
  4. Consider Serum Ferritin

VIII. Labs: Bleeding Disorder tests

  1. Indications
    1. Adolescents with Menorrhagia
    2. Family History of Bleeding Disorder
    3. Menses lasting 7 days or more with very heavy bleeding (flooding, associated Anemia)
    4. Excessive bleeding with other procedures (e.g. Tooth Extraction, Postpartum Hemorrhage)
    5. Women planning Hysterectomy for Menorrhagia
  2. Tests
    1. See Bleeding Disorder for protocol (esp. evaulation Von Willebrand's Disease)
    2. Complete Blood Count (CBC)
    3. ProTime (PT/INR)
    4. Partial Thromboplastic Time (PTT)

IX. Imaging

  1. Transvaginal Ultrasound
    1. Evaluate for uterine polyps and Uterine Fibroids
  2. Saline infusion Sonohysterography
    1. Indicated if Transvaginal Ultrasound is nondiagnostic

X. Evaluation

  1. See Abnormal Uterine Bleeding
  2. ACOG does not recommend routine TSH or Serum Prolactin testing for Menorrhagia
    1. Menorrhagia is most often due to fibroids or polyps
    2. Important to distinguish from annovulatory bleeding
      1. More often related to endocrine cause
  3. Consider Endometrial Cancer Screening
    1. Indicated if more than one Endometrial Cancer Risk Factors or refractory bleeding
    2. See Abnormal Uterine Bleeding
    3. See Endometrial Cancer Screening

XI. Management

  1. See Menorrhagia Management
  2. Uterine polyp
    1. Refer for hysteroscopic uterine polypectomy
  3. Uterine Fibroid
    1. See Uterine Fibroid for management options

XII. Complications

  1. Iron Deficiency Anemia
  2. Endometrial Hyperplasia and Endometrial Cancer are rarely associated with Ovulatory Bleeding (<1% risk)
    1. Consider Endometrial Cancer Screening if more than one Endometrial Cancer Risk Factors

XIII. References

  1. Nelson (1997), Fam Prac Recert 19(8):14
  2. Buchanan (2009) Am Fam Physician 80(10): 1075-88 [PubMed]
  3. Dilley (2001) Obstet Gynecol 97:630-6 [PubMed]
  4. Sweet (2012) Am Fam Physician 85(1): 35-43 [PubMed]

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