Abnormal Uterine Bleeding

Uterine bleeding is abnormal if the bleeding pattern is irregular.

defined as

polymenorrhea (less than 22 days between cycles)

oligomenorrhea (more than 35 days between cycles)

hypermenorrhea or abnormal duration (more than 7 days of bleeding)

menorrhagia or abnormal amount (more than 80 mL blood loss during menses).

Menometrorrhagia is an all encompassing term used to describe irregular or excessive bleeding, or both, during menstruation or between menstrual cycles.

Dysfunctional uterine bleeding is the term used to describe abnormal bleeding caused by hormonal abnormalities in the absence of pregnancy, tumor, infection, or coagulopathy (no demonstrable organic lesion). Occurs most often in anovulatory women in whom significant amounts of ovarian estrogen are produced. In adolescents who are not pregnant, abnormal uterine bleeding is almost always the result of a hormonal abnormality (anovulation) or coagulopathy. DUB must be a diagnosis of exclusion. Anovulatory bleeding tends to occur at less frequent intervals, while organic lesions tend to cause bleeding more frequently than cyclic menses.

Three major categories are:

Estrogen breakthrough bleeding

Estrogen withdrawal bleeding

Progestin breakthrough bleeding

Most abnormal vaginal bleeding in adolescents results from anovulatory cycles, normally occurring in the 1st yr of menarche.

Organic lesions are found in about 9% of 10-20-yr-old young women

the most common including

ectopic pregnancy

threatened abortion

endometritis

hormonal contraceptives.

severe cases that require hospitalization

coagulation disorders

(idiopathic thrombocytopenic purpura, von Willebrand disease, leukemia),

Glanzmann disease

Hypothyroidism

thalassemia major

Fanconi syndrome

rheumatoid arthritis

Diagnostic Evaluation

History

the temporal pattern

the duration

the amount of bleeding

contraceptive and sexual practices

the use of hormonal medication

physical examination

determine intravascular volume status (orthostatic hypotension, tachycardia). pelvic examination assesses whether the bleeding is vaginal or uterine, provides a thorough evaluation of uterine size, and indicates whether the uterus is enlarged, irregular, or tender. Examination of the skin for ecchymoses or petechiae may provide evidence of underlying coagulopathy.

SIGNS AND SYMPTOMS

Uterine bleeding:

Unrelated to menses

In excess of normal menstrual flow

Occurring in an irregular pattern

Rarely painful

Absence of:

Other systemic symptoms

Unusual bleeding from other areas

Urinary or gastrointestinal irregularities

Sustained aspirin or anticoagulant use

Use of hormonal preparations

Evidence of thyroid disease

Galactorrhea

Pregnancy (especially ectopic)

Evidence for reproductive tract malignancy

LABORATORY FINDINGS.

hemoglobin and hematocrit

most important elements in the initial evaluation

CBC will also detect thrombocytopenia

establish the severity of the bleeding

Hg >9 g/dL or a Hct of 27% considered severe

Hg 9-11 g/dL and Hct 27-33% considered moderate

Hg > 11 g/dL and Hct > 33% considered mild

Hospitalization if

Adolescent and Hg< 7 gm/dL or Hg < 10 gm/dL with significant postural blood pressure changes or excessive heavy bleeding.

For sexually active teenagers

tests for gonorrhea and Chlamydia

pregnancy test (blood hCG) – a normal beta -hCG test result rules out pregnancy

Papanicolaou smear

provides evidence for the presence of cervical cancer and endometrial cancer

endometrial biopsy specimen

direct evaluation of endometrial histology (endometrial cancer, hyperplasia, endometritis).

all perimenopausal women with abnormal uterine bleeding must have an endometrial biopsy specimen taken. They should not be treated with hormones until endometrial biopsy results are available.

Transvaginal sonography

Sensitive, not specific

if you suspect pregnancy, anatomic problems, polycystic ovarian syndrome

helpful in identifying ovarian cysts and uterine tumors

endometrial thickness <5 mm in diameter almost never associated with endometrial disease.

endometrial thickness in most patients with endometrial disease is greater than 5 mm

many women on estrogen therapy who are disease free also have endometriums >5 mm

Can identify lesions of the

uterus

leiomyomata

endometrial polyps

adenomyosis

ovarian tumors

The secondary evaluation

liver function studies

thyroid function studies (hypothyroidism or hyperthyroidism)

prothrombin time

partial thromboplastin time

bleeding time

workup for hirsutism

If these studies are not performed at the first visit, they must be performed before any estrogen therapy is initiated that might interfere with interpreting the results.

TREATMENT.

mild cases,

iron supplementation is recommended

the patient should keep a menstrual calendar to follow the subsequent flow patterns

moderate disturbances

cycling with oral contraceptives barring any contraindications

monitoring the iron status.

Severe bleeding

not requiring hospitalization

can usually be stopped with hormonal therapy, either

(1) medroxyprogesterone acetate (Provera) 10 mg/24 hr for 10-14 days;

(2) conjugated estrogen (Premarin) 2.5 mg four times a day for 21 days, plus Provera on days 17-21; or

(3) a combination oral contraceptive (OC) using two to four pills a days until the bleeding stops, then one pill/day for the remainder of the cycle.

Once a patient is hospitalized,

Premarin 20-40 mg every 4 hr up to 24 hr given intravenously is required.

the combination oral contraceptive regimen required for maintenance initiated

These estrogen doses are high, but no complications have been reported from short-term use.

IF bleeding cannot be controlled by one of these methods (rare)

an endometrial curettage may be indicated

For the woman with anovulation and dysfunctional uterine bleeding who desires fertility

ovulation induction with clomiphene citrate or gonadotropins

natural progesterone -intramuscularly (100 mg each month) or intravaginally (25 mg 3 times daily for 10 days each month).

synthetic progestins PO

Medroxyprogesterone acetate 10 or 20 mg daily for 10 to 14 days

megestrol acetate

Courses of progestin therapy are repeated every month or every other month until the patient begins to ovulate spontaneously.

SPECIFIC TREATMENTS

DUB

Even profuse bleeding in anovulatory women can almost always be successfully treated by administering one combination oral contraceptive pill every 6 hours for 5 to 7 days. Bleeding should cease within 24 hours, but patients should be warned to expect heavy bleeding 2 to 4 days after stopping therapy.

Abnormal Uterine Bleeding Caused by Infection

hyperemia

microscopically by edema and white blood cell infiltration

usually characterized by intermittent spotting, not severe hemorrhage.

Incomplete spontaneous or therapeutic abortion can cause endometrial infection from

Escherichia coli

Pseudomonas aeruginosa

Enterococcus spp.

Bacteroides spp.

broad-spectrum antibiotic therapy and dilatation and curettage.

Endometritis not associated with a recent pregnancy may be caused by

Chlamydia spp. or Mycoplasma spp.

tetracycline (250 mg orally 4 times daily for 3 weeks) or doxycycline (100 mg orally 2 times daily for 2 to 3 weeks).

Treatment of Life-Threatening Uterine Bleeding

Initial evaluation should include

CBC;

coagulation studies (prothrombin time, partial thromboplastin time);

rapid, sensitive pregnancy testing;

if indicated, endometrial curettage.

Coagulopathies require correction with the appropriate replacement products (platelets or fresh frozen plasma).

If the physical examination or ultrasonography shows the uterus to be structurally normal, if the pregnancy test result is negative, and if the dilatation and curettage does not slow bleeding, aggressive hormonal therapy may be required.

Conjugated estrogens (25 mg intravenously every 4 hours for 3 doses) have been successful in the treatment of life-threatening uterine hemorrhage that is not caused by pregnancy or tumor.

Alternatively, large dosages of a combined estrogen-progestin medication may be used. For example, 0.05 mg ethinyl estradiol plus 0.5 mg of norgestrel (Ovral) given 4 times daily for up to 7 days may slow the bleeding.

In severe cases of uterine bleeding in which conventional therapy has failed, angiographic embolization of the uterine arteries may help control the bleeding. In some patients, hysterectomy may be required to treat an episode of life-threatening uterine bleeding.