The Merck Manual of Diagnosis and Therapy 17

th
ed, Beers MH, Berkow R, editors. Portland Merck ! "o., #nc$ 1%%%. p. 1%&% ' ().
ABNORMAL UTERINE BLEEDING
Excessive duration (menorrhagia) or amount (menorrhagia, or hypermenorrhea) of menses or both;
too-frequent menstruation (polymenorrhea); nonmenstrual or intermenstrual bleeding (metrorrhagia); or
postmenopausal bleeding (any bleeding > 6 mo after the last normal menstrual period at menopause)
*+nor,al uterine +leeding is due to organic causes in a+out -./ of patients and to functional
a+nor,ality of the hypothala,ic0pituitary0o1arian a2is 3dysfunctional uterine +leeding4 in the rest. *ge is the
,ost i,portant factor$ organic causes, including gynecologic neoplas,s, +eco,e ,ore co,,on with
ad1ancing age. Dysfunctional uterine +leeding 3see +elow4 is the ,ost co,,on cause of a+nor,al uterine
+leeding.
Infancy and childhood: 5ew+orn girls ,ay ha1e spotting for a few days +ecause the endo,etriu, is
sti,ulated in utero +y placental estrogens. *ny other +leeding fro, the reproducti1e tract is rare in childhood
and should +e in1estigated. *ccidental trau,atic lesions of the 1ul1a and 1agina are the ,ost co,,on causes.
6aginitis 3often due to a foreign +ody4, prolapse of the urethral ,eatus, and gynecologic neoplas,s can also
cause +leeding. 71arian tu,ors generally do not cause +leeding unless they are endocrinologically acti1e.
Precocious pu+erty 3see also "h. -7.4 ,ust always +e considered in childhood +leeding and can usually +e
recogni8ed +y the de1elop,ent of secondary se2ual characteristics. The cause of +leeding is unknown in ,any
cases +ut ,ay +e due to drug ingestion, "59 lesions, hypothyroidis,, or adrenal or o1arian neoplas,s.
Bleeding and 1aginal discharge are the presenting sy,pto,s in : ;)/ of cases of 1aginal adenosis and
of clear cell adenocarcino,a of the 1agina and cer1i2. These lesions ha1e +een linked to diethylstil+estrol
e2posure in utero and are diagnosed +y cytologic s,ear and +y colposcopically directed +iopsy of suspicious
areas. <nless ,alignancy is present, ,ost lesions do not re=uire treat,ent +ut should +e ,onitored periodically.
Reproductive ae: Pri,ary or secondary he,atologic disorders with a+nor,al clotting can lead to
a+nor,al +leeding throughout the reproducti1e years. He,atologic e1aluation is indicated for adolescents and
wo,en with a history suggesting clotting disorders. >or e2a,ple, dysfunctional uterine +leeding is the ,ost
co,,on presentation of 1on ?ille+rand@s disease in wo,en.
"o,plications of pregnancy are the ,ost co,,on organic causes of a+nor,al +leeding in wo,en of
reproducti1e age. 5early half of patients with uterine +leeding and sy,pto,s of pregnancy or a confir,ed early
pregnancy spontaneously a+ort the fetus. #,portant differential diagnoses include ectopic pregnancy 3see "h.
-.-4 and gestational tropho+lastic disease 3see "h. -(14. Ando,etritis and infection of retained products of
conception usually cause +leeding shortly after deli1ery or a+ortion +ut occasionally : - wk later 3see "h. -.(4.
!ulvar "leedin in the reproductive year# i# al$o#t al%ay# due to trau$a&
6aginal lesions that cause +leeding include 1aginal adenosis and ,alignancy 3see "h. -(14. 6aginitis
causes +leeding ,ore co,,only in children and post,enopausal wo,en +ecause their 1aginal ,ucosa is
thinner, +ut se1ere cases ,ay cause spotting during the reproducti1e years. Branulo,atous tissue for,ed after
surgery 3especially hysterecto,y4 ,ay cause +leeding. Biopsy ,ay +e needed to rule out ,alignancy. *lthough
cauteri8ation with sil1er nitrate or cryotherapy stops +leeding in ,ost cases, surgical resection ,ay +e re=uired
for large lesions.
"er1ical lesions causing +leeding include cer1ical cancer 3see "h. -(14, +enign cer1ical lesions,
cer1icitis 3rarely causes +leeding, e2cept in association with cer1ical ectropion, +ut ,ay cause 1aginal
discharge tinged with +lood4, cer1ical or endo,etrial polyps 3causing postcoital +leeding4, su+,ucosal ,yo,as
3causing inter,enstrual +leeding, ,etrorrhagia, or poly,enorrhea4, and condylo,ata acu,inata of the cer1i2.
*deno,yosis 3+enign in1asion of endo,etriu, into the ,yo,etriu,4 is a co,,on disorder that causes
sy,pto,s in only a s,all percentage of patients, usually late in the reproducti1e years. Menorrhagia and
inter,enstrual +leeding are the ,ost co,,on co,plaints, followed +y nonspecific pel1ic pain and +ladder and
rectal pressure. During pel1ic e2a,ination, the uterus ,ay feel enlarged, glo+ular, and softer than nor,al, and
fi+roids 3leio,yo,as4 ,ay +e present. *n MR# aids in ,aking the diagnosis +efore surgery. Hysterecto,y
relie1es sy,pto,s in all patients if the diagnosis was accurate. "ontracepti1e steroids and BnRH agonists are
not 1ery effecti1e.
>i+roids occur in as ,any as ()/ of wo,en +y age ()$ only a few are sy,pto,atic and re=uire
treat,ent. They can cause any kind of +leeding a+nor,ality 3see "h. -()4.
1
>unctional o1arian cysts are relati1ely co,,on, and : .)/ of patients present with ,enstrual
irregularities ranging fro, a,enorrhea to ,enorrhagia. #n young wo,en, cystic adne2al ,asses ,ay disappear
spontaneously. *dne2al ,asses of : . c, that persist for : 1 ,o re=uire surgical e2ploration to e2clude a
neoplas,. *ny o1arian tu,or ,ay cause uterine +leeding, +ut +leeding is co,,on only with
endocrinologically acti1e neoplas,s 3see "h. -(14.
Thyroid dysfunction ,ay +e associated with ,enstrual irregularity. Menorrhagia can result, +ut
oligo,enorrhea and a,enorrhea are ,ore co,,on.
'o#t$enopau#e: Bynecologic ,alignancies ,ust +e ruled out in any post,enopausal wo,an with
uterine +leeding 3see "h. -(14. The ,ost co,,on +enign disorders causing post,enopausal +leeding are
atrophic 1aginitis, atrophic endo,etriu,, endo,etrial polyps, and endo,etrial hyperplasia. The cause of
+leeding in atrophic endo,etriu, is unclear. Ando,etrial polyps need no further treat,ent after diagnostic
curettage, +ut patients ,ust +e o+ser1ed for recurrence. Ando,etrial hyperplasia generally should +e treated
with a progestin or hysterecto,y 3see +elow4.
39ee also Post,enopausal Bleeding in The Merck Manual of Beriatrics.4
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