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Evaluation of Common Gynecologic Symptoms

Abnormal vaginal bleeding and vulvovaginal symptoms are two of the most common gynecologic complaints. Presented here is a basic approach to evaluation.


Abnormal genital tract bleeding in the reproductive-age woman results from a wide variety of underlying conditions, and the task of the clinician is to identify the specific cause accurately and cost-efficiently. There is a high prevalence of mood disorder among women who present with menstrual complaints, and this possibility should be evaluated if clinical findings are not consistent.

Differential Diagnosis

The overall differential diagnosis of abnormal bleeding is shown in the box. Pregnancy should always be considered in the presence of abnormal bleeding. Although the history and pelvic examination will be decisive in most cases, the only definitive way to screen for pregnancy is to do a test of human chorionic gonadotropin. The urine tests available are sufficiently sensitive and specific.

Screening test and should be done whenever there is any question of pregnancy status.

Once pregnancy is excluded, abnormal bleeding can be divided into two broad categories: ovulatory and anovulatory bleeding. Of women who present with abnormal bleeding, roughly one third have anovulatory bleeding, one third have heavy ovulatory menstrual periods, and one third have bleeding from other causes associated with ovulatory cycles (eg, intermenstrual bleeding). The terminology used to describe the various abnormal bleeding pattens are shown in the box. The term should only be used to refer to anovulatory abnormal bleeding.

In most cases the assessment of ovulation can be done by history. The normal range of values for characteristics of menstrual cycle bleeding is shown in Table 8. Ovulatory cycles are characterized by a predictable (+5 days) intermenstrual interval and a consistent amount and duration of flow. The intermenstrual interval should be measured from the first day of regular bleeding (leaving out premenstrual spotting) to the first day of the next period. An important problem in the assessment of bleeding patterns.

In addition, many women experience characteristic symptoms associated with the phases of the cycle. The most common of these is lower abdominal midline cramping pain, referred to as dysmenorrhea, which typically begins on the first day of bleeding and then spontaneously resolves by the second or third day. Dysmenorrhea that is newly worse or longer lasting can be associated with the conditions that cause menorrhagia. Most women also experience premenstrual symptoms in the week before the onset of bleeding; among the most common are breast tenderness, bloating, food cravings, insomnia, and mood changes. Although negative mood symptoms such as irritability and mood lability are common, many women actually experience an increase in energy during this phase. Finally, a smaller proportion of women experience periovulatory symptoms.

Sometimes the history alone will be inconclusive regarding ovulation; in these cases additional methods can be helpful. Recording of basal body temperature can be used to determine whether the expected postovulatory rise in basal temperature is present. Serum progesterone, measured in the midluteal phase, should be greater than 2 U/mL if ovulation.

Differential Diagnosis of Abnormal Bleeding Pregnancy