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Abnormal uterine bleeding is a departure from the normal and what do we consider normal? A total volume of 30 to 60 cc. This has been evaluated by doing tests on menstrual pads from a number of women to get a total volume. Once you get above 80 cc of blood - these are the patients who have menorrhagia, menometrorrhagia - and will get into anemia situations over time. A good way of estimating blood loss is with a chart that a woman can use, to circle number of pads she uses, how much bleeding there has been on the pads and so forth. You can add them up and pretty well quantify, on a visual basis, the menstrual bleeding so that you can estimate whether or not this patient really has abnormal uterine bleeding.
Abnormal patterns; we can term them into hypomenorrhea, which is a diminished total flow, oligomenorrhea which are menses occurring less than every 35 days, menorrhagia which is a profuse flow on regular intervals. So anywhere in that 21 to 35 day interval, if she’s having a profuse flow then she’s got menorrhagia. Menometrorrhagia is an excess of flow occurring on an irregular basis. So that’s excessive and irregular. Intermenstrual spotting or bleeding is light, regular, usually about mid-cycle.
We can divide abnormal bleeding into two causes, really, or two general categories. Those that are caused by anatomic problems and those that are dysfunctional or generally hormonal in etiology. Anatomical etiologies - and I think someone probably does the presentation for you on pregnancy and complications, such as placenta previa, abruptio and so forth - cervical polyps can cause it. Leiomyomas, infection, trauma, adenomyosis and of course carcinoma. And these are anywhere in the GI tract. We can see a carcinoma of the vagina, which is fairly rare, carcinoma of the cervix. We see endocervical polyps, cervical polyps, carcinomas of the endocervix, sarcomas and carcinomas of the endometrium and myometrium. Myometrial polyps, submucous leiomyoma will cause menstrual problems and bleeding, and then ovarian dysfunctions.
Those that are dysfunctional or hormonal in etiology, we can classify into two basic parts; ovulatory, which means that the patient is releasing an egg on a monthly basis, and anovulatory problems where a patient does not ovulate on a regular basis or does not ovulate at all.
The normal physiology is the important thing that we should all keep in mind when we are evaluating the abnormal bleeding. The first phase of the menstrual cycle is what is called the follicular phase and this is dependent upon a communication between the hypothalamus sending information to the pituitary which then sends FSH and LH to the ovaries telling it to produce estrogen, which then feeds back to the hypothalamus. The estrogen also acting in concert on the ovaries with the developing follicles, produces a primary follicle that actually produces more estrogen and the estrogen also causes the endometrium to proliferate. So this is also called the proliferative phase.
The menstrual period starts 14 days after ovulation and this is important in that the amount of tissue that you see shed at the time of menstruation is related to the duration of estrogen exposure during the proliferative or follicular phase. This means that if a woman menstruates every 28 days she will shed X amount of menstrual tissue.
The normal luteal phase, like I say, ovulation occurs. The corpus luteum cyst forms and produces both estrogen and progesterone and maintains the endometrium, makes it secretory, ready for a pregnancy. In discussing it with patients I will often times say, "Well, after you ovulate the endometrium becomes very thick and lush like a garden that has flowered and bloomed."
Pre-pubertal causes usually, I think of foreign bodies because little girls and little boys explore themselves. Explore their genitalia. They like to put things …you always hear about them putting things in their nose. Little girls will put things in the vagina and they may have a foreign body. Very difficult to examine little girls, and probably there’s two easy ways to do it. Number one, if she’s a very good patient, you’ll have the mother lie down on the examining table and have the child lay on the mother’s abdomen with her knees up under her, sort of in a knee-chest position, you can sometimes spread the labia and with a light just look up the vagina to see if there’s anything up there. If I can’t get an exam done and the child is actually having bleeding and so forth, then my choice is to take them to the operating room, put them to sleep. You can do a good visual inspection and you can do a vaginoscopy with a cystoscope. It’s very simple, very easy. Sexual abuse is another thing that we think of and we look for signs of. Exogenous estrogen can be a problem. She may be picking up her mother’s birth control pills and having withdrawal menses because she takes a pill and after awhile, after a few pills that her mother didn’t happen to notice were gone, she stopped taking them and has some bleeding. Then of course we always worry about tumors, sarcoma botryoides, dysgerminomas.
During the reproductive years: this is the group we see most frequently. Pregnancy and its complications is a frequent cause. Ovulatory problems only occur in maybe up to 25% of the patients. Anovulatory problems are the ones we deal with the majority of times. The patient is having either irregular anovulation or irregular ovulation, or is totally anovulatory. That can be 75% to 90% of the patients you see. And then anatomical problems in the reproductive years are usually fairly few and far between, although we do see a fair number of patients.
The reasons many patients have the anovulatory type of bleeding, the endocrine problems we see with thyroid, pituitary. Ovarian problems: they may have polycystic ovaries. Drugs such as many of the psychiatric drugs will create problems, related back to endocrine. Many of the psychiatric drugs will raise the prolactin and cause problems. Stress can cause changes in it. We all know about nutritional problems, especially in the bulimic patients that create menstrual problems such as amenorrhea, total amenorrhea.
Thyroid problems we see both in the hyper and hypo thyroid. If the patient has any other symptoms of either, such as hyperthyroid - if she’s one of those patients that can get all her housework done and have time to go shopping and all the rest of that, then I get suspicious. They may be a little hyperthyroid, and if they are not gaining weight slowly over the decades, and you should. Your metabolism changes by about 2% every five years so that the natural history is that we gain about 5 to 10 pounds every decade of life.
Adrenal problems, hyperplasia and tumors, are things we see. Patients who have anovulatory cycling, doing laboratory testing for this is very easy. It’s a simple blood test to do and if it’s normal you can pretty well count out the adrenal tumors and so forth. The test is DHEA sulfate.
Neoplasias of the hypothalamic gland; doing serum prolactins is easy. Try and draw them in the morning. That’s when they are going to be at their highest level. Hyperprolactinemia’s are fairly frequent. You need to be careful in treating them with bromocriptine because of seizures, but I’ve only seen one patient in the 15 years I’ve been using bromocriptine that had seizures.
Ovarian problems, such as polycystic ovarian cysts syndromes. My treatment for that, I offer the patient a couple of choices. One is to withdraw menses every three months or so with Provera 10 mg for ten days, or put them on birth control pills to protect their hypothalamic pituitary axis and protect their endometrium from over-stimulation.
Renal blastomas, granulosa and thecal cell tumors and hilus cell tumors are difficult or may be very difficult to diagnose, but can cause bleeding. Chronic pelvic inflammatory disease - because of the vasculitis in the endometrium and also in the region of the ovaries - will cause bleeding. Endometriosis can be found almost anywhere and can interfere with the normal function of the endometrium and may cause abnormal bleeding just by having endometrial implants in the vagina.