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Abnormal Uterine 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 of abnormal uterine bleeding.


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


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 (yon Willebrand's disease, iatrogenic

cause, hematologic malignancies) Intrauterine device

Ovulatory: Not Cycle Related


Intravaginal foreign body



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)


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