Abnormal Uterine Bleeding

Aka: Abnormal Uterine Bleeding, Dysfunctional Uterine Bleeding, Vaginal Bleeding

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II. Definitions

  1. Acute Abnormal Uterine Bleeding
    1. Episode of heavy bleeding requires immediate medical evaluation
  2. Chronic Abnormal Uterine Bleeding
    1. Six months of Abnormal Uterine Bleeding
  3. Inter-Menstrual Bleeding
    1. Bleeding between otherwise normal periods
  4. Metrorrhagia
    1. Change in Amount and Frequency of bleeding, associated with Anovulatory Bleeding
    2. Deprecated term ("imprecise")
    3. Polymenorrhea: Cycle less than 21 day cycles
    4. Oligomenorrhea: Cycle greater than 35 day cycles (>45 days in adolescents)
  5. Menorrhagia
    1. Increase in the amount of bleeding, associated with Ovulatory Bleeding
    2. Deprecated term ("imprecise")
  6. Menometrorrhagia (Metrorrhagia and Menorrhagia)
    1. Prolonged, irregularly frequent, heavy Menses
  7. Dysfunctional Uterine Bleeding
    1. Replaced by "Abnormal Uterine Bleeding"
  8. Irregular Menses
    1. Variation of Menstrual Cycle length over prior 12 months >20 days

III. Epidemiology

  1. Lifetime risk of Menorrhagia: 33%
  2. Prevalence in women of reproductive age: 10-30%
  3. Women with Menorrhagia who consult their doctors: 20%
  4. Women who have at least one Endometrial Biopsy sampling: 15%
  5. Women who have Hysterectomy by age 40 years: 10%
  6. Number of hysterectomies for Menorrhagia: 200,000/year

IV. Physiology

  1. See Menstrual Cycle

V. Causes

  1. See Abnormal Uterine Bleeding Causes

VI. Types: Anovulatory or Ovulatory

  1. Anovulatory Bleeding or Metrorrhagia (90%)
    1. Unopposed Estrogen (Progesterone deficiency)
    2. Risk of Endometrial Hyperplasia and ultimately Endometrial Cancer
  2. Ovulatory Bleeding or Menorrhagia (10%)
    1. Inappropriate endometrial response to normal cycle
    2. Shortened or prolonged life span of corpus luteum
    3. Common causes
      1. Abnormal Estrogen : Progesterone ratio (low Estrogen)
      2. Bleeding Disorder (Von Willebrand Disease)

VII. Symptoms: Bleeding History

  1. Normal cycles and bleeding
    1. Menstrual Cycle intervals: 24-38 days
    2. Variation between cycles <20 days between cycle lengths over 12 months
    3. Menstrual duration: 4.5 to 8 days
    4. Normal menstrual volume: 5-80 ml blood per cycle
  2. Anovulatory Bleeding
    1. Change in Amount and Frequency of bleeding
      1. Low Levels of Unopposed Estradiol or Estrogens
        1. Lighter and Less Frequent Menses
      2. High Levels of Unopposed Estradiol or Estrogens
        1. Prolonged periods of Amenorrhea
        2. Heavy Withdrawal Bleeding
    2. Lack of premenstrual signs
      1. Progesterone absent: no bloating or Breast Pain
  3. Ovulatory Bleeding
    1. Premenstrual Symptoms are present
    2. Normal Menstrual Cycle intervals (occur every 24 to 38 days)
    3. Change in Amount of bleeding
      1. Menorrhagia
        1. Patient describes very heavy periods
        2. Change pad or tampon every 1-2 hours
          1. Each saturated pad or tampon contains 20-30 ml blood
        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

VIII. History

  1. Approach: Key questions
    1. Pregnancy status
    2. Quantify bleeding (20-30 ml blood per saturated pad or tampon)
    3. Abdominal or Pelvic Pain
    4. Associated symtoms to suggest Hemorrhagic Shock (e.g. Shortness of Breath, Palpitations)
  2. Red Flags suggestive of serious pathology
    1. Post-coital Bleeding (e.g. Cervicitis, Cervical Cancer)
    2. Perimenopause, postmenopausal patient (Endometrial Cancer)
      1. See Postmenopausal Bleeding
      2. See Endometrial Cancer Screening
  3. Pelvic Pain
    1. Consider Pelvic Inflammatory Disease, Endometriosis, structural lesions
    2. Consider Trauma (e.g. sexual abuse)
  4. Pregnancy Symptoms
    1. See Uterine Bleeding in Pregnancy
  5. Medication changes
    1. See Medication Causes of Abnormal Uterine Bleeding
    2. See Oral Contraceptive-Related Uterine Bleeding Management
    3. Missed Oral Contraceptive pill(s)
    4. Recently started or modified medications
  6. Bleeding Disorder
    1. Von Willebrand Disease is most common
    2. Consider if onset at Menarche, Family History, bleeding from other sites (e.g. prolonged Epistaxis >10 min)
    3. Accounts for 20% of patients with Menorrhagia (esp. adolescent girls)
  7. Endocrinopathy
    1. Hypothyroidism and Hyperthyroidism symptoms
    2. Hyperandrogenism (e.g. PCOS)
    3. Hyperprolactinemia (e.g. Galactorrhea)

IX. Exam

  1. Vital Signs
    1. Assess for hemodynamic instability
  2. Findings suggestive of compensated shock (should trigger emergent stabilization)
    1. Lethargy
    2. Tachycardia
    3. Tachypnea
    4. Peripheral vasconstriction (Cyanosis)
  3. General exam
    1. Thyromegaly
    2. Obesity
      1. Associated with Polycystic Ovary Syndrome
      2. Associated with Unopposed Estrogen, Endometrial Hyperplasia and Endometrial Cancer
  4. Abdominal exam
    1. Peritoneal signs
    2. Focal abdominal tenderness
  5. Vaginal and cervical exam (by speculum or frog-legged position for children)
    1. Vaginal Lacerations or lesions
    2. Vaginitis
    3. Vaginal foreign body
    4. Cervical polyps or other lesions
    5. Cervicitis (e.g. Chlamydia)
    6. Cervical os with blood or IUD strings
  6. Pelvic exam
    1. Uterine Size
    2. Cervical motion tenderness
    3. Adnexal tenderness or masses
    4. Rectovaginal exam

X. Labs: Emergency Department

  1. Urine Pregnancy Test (bHCG) or blood qualitative Pregnancy Test
    1. Obtain in all women of reproductive age
  2. Urinalysis
  3. Chlamydia PCR screen
  4. Thyroid Stimulating Hormone (TSH)
  5. Complete Blood Count (CBC) with Platelets
    1. Consider point-of-care Hemoglobin if significant blood loss
    2. Consider that Hemoglobin will not reflect full extent of blood loss
  6. Comprehensive metabolic panel (includes liver and Kidney tests)
  7. Coagulation profile (INR, PTT)
  8. Type and cross match

XI. Labs: Ambulatory - Selected based on Menorrhagia versus Metrorrhagia

  1. Initial testing
    1. Urine Pregnancy Test (bHCG) or blood qualitative Pregnancy Test
    2. Pap Smear
    3. Chlamydia PCR screen
    4. Thyroid Stimulating Hormone (TSH)
    5. Serum Prolactin
    6. Complete Blood Count (CBC) with Platelets
    7. Consider Ureaplasma culture
  2. Additional Testing to Consider
    1. Glucose to Insulin Ratio
    2. Hyperandrogenism labs
    3. Coagulation studies
      1. ProTime (PT)
      2. Partial Thromboplastin Time (PTT)
      3. Platelet Closure Time (Von Willebrand's Disease suspected)

XII. Diagnostics: Evaluation over age 35-45 years

  1. Background
    1. Prior recommendations used age cut-off of 35 years, however Endometrial Cancer is uncommon age <45 years
    2. As of 2019, Age over 45 years with Abnormal Uterine Bleeding indicates evaluation
      1. Consider in age >=35, if persistent or refractory Abnormal Uterine Bleeding, or known Unopposed Estrogen
  2. Combination approach may be best
    1. Endometrial Cancer Screening
      1. Endometrial Biopsy (preferred first line) or
      2. Dilatation and Curretage
    2. Structural evaluation
      1. Transvaginal Ultrasound (preferred first line) or
      2. Hysteroscopy
  3. Non-Invasive investigation
    1. Transvaginal Ultrasound
      1. Time Ultrasound to end of Menses when endometrium is thinnest (if still menstruating)
      2. Endometrial Biopsy for stripe >5 mm
      3. Cancer is very unlikely if stripe <4 mm (Negative Predictive Value 99.3%)
      4. Incomplete imaging in 10% of cases
        1. Occurs most commonly if prior uterine procedures, fibroids, Obesity or atypical uterine positioning
        2. Saline infusion improves sensitivity (but with an increased False Positive Rate)
    2. Endometrial Biopsy
      1. See Endometrial Biopsy for efficacy
      2. Sensitive and specific for Endometrial Cancer
        1. Misses Endometrial Polyps and focal lesions
      3. Insufficient samples are common (no glandular cell)
        1. Requires other study (non-diagnostic)
  4. Invasive procedures (performed by gynecology)
    1. See Endometrial Cancer Screening
    2. Dilatation and Curettage
      1. No significant advantage over Endometrial Biopsy
    3. Saline Infusion Sonography
    4. Hysteroscopy
      1. Insufflation with carbon dioxide or warmed saline
        1. Risk of tumor dissemination
      2. Flexible 3 mm hysteroscope (Same size as Pipelle)
      3. Improves diagnosis with D&C and Endometrial Biopsy
        1. Identifies most structural lesions (e.g. polyps)

XIII. Evaluation: Protocols

  1. See Anovulatory Bleeding
  2. See Ovulatory Bleeding
  3. See Postmenopausal Bleeding
  4. See Endometrial Cancer Screening
  5. See Abnormal Uterine Bleeding Causes
  6. Key conditions to consider and exclude at initial presentation
    1. Pregnancy (and Ectopic Pregnancy) in women of childbearing age
    2. Sexually Transmitted Infection (especially Chlamydia) and Pelvic Inflammatory Disease
    3. Other bleeding source
      1. Gastrointestinal Bleeding (Hematochezia or melana)
      2. Hematuria
    4. Gynecologic cancer
      1. Endometrial Hyperplasia (and Endometrial Cancer) in women over age 35 years
      2. Cervical Cancer
    5. Other common conditions
      1. Hypothyroidism
      2. Coagulopathy (e.g. Von Willebrand Disease)

XIV. Management

  1. Metrorrhagia Management (Anovulatory Bleeding Management)
  2. Menorrhagia Management (Ovulatory Bleeding Management)
    1. Covers emergent protocols to stop severe uterine and Vaginal Bleeding

XV. Resources: Patient Education

  1. Information from your Family Doctor
    1. http://www.familydoctor.org/handouts/470.html

XVI. References

  1. Mace (2013) Crit Dec Emerg Med 27(2): 13-21
  2. Nelson (1997), Fam Prac Recert 19(8):14
  3. Apgar (2013) Am Fam Physician 87(12): 836-43 [PubMed]
  4. Bradley (2016) Obstet Gynecol 214(1): 31-44 [PubMed]
  5. Buchanan (2009) Am Fam Physician 80(10): 1075-88 [PubMed]
  6. Sweet (2012) Am Fam Physician 85(1): 35-43 [PubMed]
  7. Wouk (2019) Am Fam Physician 99(7): 435-43 [PubMed]

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