Abnormal Uterine Bleeding

Disorders of the Menstrual Cycle

• Amenorrhea

• Dysmenorrhea

• Premenstrual Syndrome

• Abnormal Uterine Bleeding

Abnormal Uterine Bleeding: Definitions

• Menorrhagia: heavy or prolonged uterine bleeding that occurs at regular intervals. Some sources define further as the loss of ≥ 80 mL blood per cycle or bleeding > 7 days.

• Hypomenorrhea: periods with unusually light flow, often associated with hypogonadotropic hypogonadism (athletes, anorexia). Also may be associated with Asherman’s syndrome

• Metrorrhagia: irregular menstrual bleeding or bleeding between periods

• Menometrorrhagia: metrorrhagia associated with > 80 mL

• Polymenorrhea: frequent menstrual bleeding. Strictly, menses occur q 21 d or less

• Oligomenorrhea: Menses are > 35 d apart. Most commonly caused by PCOS, pregnancy, and anovulation

Abnormal Uterine Bleeding: Differential Diagnosis

• Structural

– Cervical or vaginal laceration

– Uterine or cervical polyp

– Uterine leiomyoma

– Adenomyosis

– Cervical stenosis/Asherman’s (hypomenorrhea)

• Hormonal

– Anovulatory bleeding

– Hypogonadotropic hypogonadism

– Pregnancy

– Hormonal Contraception (i.e. OCPs, Depo-Provera)

• Malignancy

– Uterine or Cervical cancer

– Endometrial hyperplasia (potentially pre-malignant)

• Bleeding disorders

– von Willebrand’s Disease, Hemophilia/Factor deficiencies, platelet disorders

Abnormal Uterine Bleeding: Workup

• History

– Timing of bleeding, quantity of bleeding, menstrual hx including menarche and recent periods, associated sxs, family hx of bleeding disorders

• Physical

– R/o vaginal or cervical source of bleeding. Bimanual may reveal bulky uterus/discrete fibroids

– Assess for obesity, hirsutism, stigmata of thyroid disease (hypothyroidism associated with anovulation), signs of hyperprolactinemia (visual field testing, galactorrhea)

– Pap smear

– Endometrial biopsy, if appropriate

• Pregnancy Test

• Imaging

– Pelvic ultrasound

– Sonohystogram or hysterosalpingogram

• Surgical

– Hysteroscopy

– D & C

Normal Menstrual Cycle

Normal Ovulatory Cycle

• Follicular development à ovulation (d14) à corpus luteal function à luteolysis

• Endometrium is exposed to:

– ovarian production of estrogen à

(proliferation)

– Combination of estrogen and progesterone à

(secretory phase)

– Estrogen and progesterone withdrawal

(desquamation and repair)

Anovulatory Bleeding

• Corpus luteum is not produced

– Ovary fails to secrete progesterone, although estrogen production continues

– Result is continuous, unopposed E stimulation of endometrium:

• endometrial proliferation without P-induced differentiation / stabilization

– Endometrium becomes excessively vascular without stromal support à fragility and irregular endometrial bleeding

Anovulatory Bleeding:
Etiologies

• Hyperandrogenic anovulation (PCOS, CAH, androgen-producing tumors)

• Hypothalamic dysfunction (stress, anorexia, exercise)

• Hyperprolactinemia

• Hypothyroidism

• Primary pituitary disease

• Premature ovarian failure

• Iatrogenic (secondary to radiation or chemo)

Anovulatory Bleeding: Adolescents (13-18 years)

• Anovulatory bleeding may be normal physiologic process, with ovulatory cycles not established until 1-2 yrs after menarche (immature HPG axis)

• Screen for coagulation disorders (PT/PTT, plts)

• May be caused by leukemia, ITP, hypersplenism

• Consider endometrial bx in adolescents with 2-3 year history of untreated anovulatory bleeding, especially if obese

Anovulatory Bleeding: Management in Adolescents

• High dose estrogen therapy for acute bleeding episodes (promotes rapid endometrial growth to cover denuded endometrial surfaces): conjugated equine estrogens PO up to 10 mg/d in 4 divided doses or IV 25 mg q 4 hrs for 24 hrs

• Treat pts with blood dyscrasias for their specific diseases, r/o leukemia

• Prevent recurrent anovulatory bleeding with:

• cyclic progestogen (i.e. Provera)

or

• low dose (≤ 35 μg ethinyl estradiol) oral contraceptive

– suppresses ovarian and adrenal androgen production and increases SHBG à decreasing bioavailable androgens

Anovulatory Bleeding: Reproductive Age (19-39 years)

• Anovulatory bleeding not considered physiologic, evaluation required

• 6-10% of women have hyperandrogenic chronic anovulation (i.e. PCOS), characterized by noncyclic bleeding, hirsutism, obesity (BMI ≥ 25)

– Underlying biochemical abnormalities: noncyclic estrogen production, elevated serum testosterone, hypersecretion of LH, hyperinsulinemia.

– h/o rapidly progressing hirsutism with virilizationà suggests tumor

• Lab testing: HCG, TSH, fasting serum prolactin

– If androgen-producing tumor is suspected, serum DHEAS and testosterone levels

– If POF suspected, serum FSH

• Chronic anovulation resulting from hypothalamic dysfunction (dx’d by low FSH level) may be due to excessive psychologic stress, exercise, or weight loss

Anovulatory Bleeding:
Reproductive Age (19-39 yrs)

When is endometrial evaluation indicated?

• Sharp increase in incidence of endometrial CA from 2.3/100,000 ages 30-34 yrs à 6.1/100,000 ages 35-39 yrs

• Therefore, endometrial bx to exclude CA is indicated in any woman > 35 yrs old with suspected anovulatory bleeding

• Pts 19-35 who don’t respond to medical therapy or have prolonged periods of unopposed estrogen 2/2 anovulation merit endometrial bx

Anovulatory Bleeding: Reproductive Age (19-39 yrs)

Medical therapies

• Can be treated safely with either cyclic progestogen or OCPs, similar to adolescents.

• Estrogen-containing OCPs

– relatively contraindicated in women with HTN or DM

– contraindicated for women > 35 who smoke or have h/o thromboembolic dz

• If pregnancy is desired, ovulation induction with clomid is initial tx of choice

– Can induce withdrawal bleed with progestogen (i.e. provera), followed by initiation of therapy with Clomid, 50 mg/d for 5 days, starting b/t days 3 and 5 of menstrual cycle

Anovulatory Bleeding:
Later Reproductive Age (40-Menopause)

• Incidence of anovulatory bleeding increases toward end of reproductive years

• In perimenopausal women, onset of anovulatory cycles is due to declining ovarian function.

• Can initiate hormone therapy for cycle control

When is endometrial evaluation indicated?

• Incidence of endometrial CA in women 40-49 years: 36.2/100,000

• All women > 40 yrs who present with suspected anovulatory bleeding merit endometrial bx after excluding pregnancy

Anovulatory Bleeding:
Later Reproductive Age (40-Menopause)

Medical therapy

• Cyclic progestogen, low-dose OCPs, or cyclic HRT are all options

• Women with hot flashes secondary to decreased estrogen production can have symptomatic relief with ERT in combination with continuous or cyclic progestogen

Anovulatory Bleeding:
Later Reproductive Age (40-Menopause)

Surgical therapy

• Surgical options include: hysterectomy and endometrial ablation

• Surgical tx only indicated when medical mgmt has failed and childbearing complete

• Some studies suggest hysterectomy may have higher long-term satisfaction than ablation

• Endometrial ablation: NovaSure, thermal balloon

– YAG laser and rollerball less widely-used currently

– 45% of women achieve amenorrhea after YAG laser or resectoscope. 12 month post-op satisfaction is 90%. Only 15% of women achieve amenorrhea after thermal balloon ablation, and 1 yr satisfaction rate still 90%

– Long-term satisfaction with ablation may be lower:

• in 3-year f/u study, 8.5% of women who had undergone ablation were re-ablated, an additional 8.5% had hyst

• In a 5-year follow up study, 34% of women who underwent ablation later had a hyst.

This post was written by: Franklin Manuel

Franklin Manuel is a professional blogger, web designer and front end web developer. Follow him on Twitter