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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 with a diagnosis.
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 to serve as an adequate screening test and should be done whenever there is any question of
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
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. experience periovulatory symptoms. Cervical mucus, under the influence of the midcycle surge in estradiol, becomes thin and copious just before ovulation and becomes thick and viscid just after ovulation in response to progesterone secretion. Some women also have transient unilateral pelvic discomfort at midcycle, referred to as mittelschmerz and thought to be due to peritoneal irritation associated with ovulation.
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, abnormal vaginal bleeding, dysfunctional uterine bleeding, disfunctional
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Differential Diagnosis of Abnormal Bleeding |
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Pregnancy Ectopic pregnancy Trophoblastic disease Abnormal intrauterine pregnancy Anovulatory Transient anovulation Polycystic ovary syndrome Androgen disorder Ovarian tumor Adrenal tumor Thyroid disorder Ovulatory: Menorrhagia Idiopathic Endometrial polyp Submucous leiomyoma Coagulopathy (von Willebrand's disease, iatrogenic cause, hematologic malignancies) Intrauterine device Ovulatory: Not Cycle Related Injury Intravaginal foreign body Endometritis Cervicitis Cancers of endometrium, cervix, vagina, or vulva Iatrogenic secondary to sex steroid use (eg, oral contraceptive) Nongenital tract: bladder, kidney, colon, or rectum |
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Terminology of Abnormal Vaginal Bleeding |
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Ovulatory Menorrhagia/hypermenorrhea--heavy flow (>80 mL), longer flow (>7 days), or both Intermenstrual bleeding--bleeding between otherwise-normal menses Midcycle bleeding--bleeding at time of expected ovulation Premenstrual spotting--light bleeding preceding regular menses Polymenorrhea--periods too close together (<21 days) Anovulatory Metrorrhagia--irregular bleeding at frequent intervals Menometrorrhagia--irregular heavy bleeding Oligomenorrhea--bleeding at intervals of >40 days Amenorrhea--no bleeding for at least 90 days |
Patient Evaluation
ANOVULATORY BLEEDING
Anovulatory episodes are commonly associated with normal events in a woman's reproductive life cycle. After menarche, girls may not establish regular ovulatory cycles for several months. At the other end of the spectrum, some women develop anovulatory cycles as their ovarian function declines with the approach of menopause. Reestablishment of ovulation after interrupting events such as use of hormonal contraception
OVULATORY BLEEDING: MENORRHAGIA
Menorrhagia is defined as menstrual blood loss in excess of 80 mL per menstrual period. However, objective measurement is not practical, so the diagnosis must be made indirectly. Complicating matters is the poor association between a woman's characterization of the amount of blood loss and the amount as measured in the laboratory. Although evaluation should include assessment for anemia, many women with measured blood losses consistently in excess of 80 mL per menstrual period are able to maintain normal hemoglobin
OVULATORY BLEEDING: NOT CYCLE RELATED
Ovulatory bleeding that is not cycle related comprises a heterogeneous group of disorders that causes intermenstrual bleeding, including infection, neoplasms, genital trauma, and nongynecologic sources. Usually, bleeding in this category will be of recent onset, and the history will be suggestive of the cause.