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Abnormal Vaginal Bleeding

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.

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.

Differential Diagnosis of Abnormal Bleeding


Ectopic pregnancy

Trophoblastic disease

Abnormal intrauterine pregnancy


Transient anovulation

Polycystic ovary syndrome

Androgen disorder

Ovarian tumor

Adrenal tumor

Thyroid disorder

Ovulatory: Menorrhagia


Endometrial polyp

Submucous leiomyoma

Coagulopathy (von Willebrand's disease, iatrogenic cause, hematologic malignancies)

Intrauterine device

Ovulatory: Not Cycle Related


Intravaginal foreign body



Cancers of endometrium, cervix, vagina, or vulva

Iatrogenic secondary to sex steroid use (eg, oral contraceptive)

Nongenital tract: bladder, kidney, colon, or rectum

Terminology of Abnormal Vaginal Bleeding


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)


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 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


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