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Click here to view next page of this article Abnormal Uterine BleedingAbnormal 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 of abnormal uterine bleeding. 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. Diagnosis of Abnormal Bleeding 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 (yon 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 latrogenic secondary to sex steroid use (eg, oral contraceptive) Nongenital tract: bladder, kidney, colon, or rectum Terminology of Abnormal Vaginal Bleeding 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 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 and pregnancy is usually Chronic anovulation is more likely attributable to an endogenous disorder like polycystic ovary syndrome or other androgen disorders. Acute anovulation can be caused by stress, intercurrent illness, medication use (eg, spironolactone), or endocrine disturbances (eg, prolactinoma, adrenal hormone excess, thyroid hormone problems). The major focus of the patient evaluation should be to identify any underlying cause of the ovulatory dysfunction. This will involve the measurement of various hormones (eg, gonadotropins, androgens, adrenal and thyroid hormones), 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 status. The presence of anemia, Ovulatory Bleeding: Not Cycle Related Ovulatory bleeding that is not cycle related comprises a heterogeneous group of disorders that causes intermenstmal 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. Postcoital bleeding requires evaluation of the cervix for infection (eg, chlamydia, gonorrhea) and a Pap test to determine neoplasia. The physical |