Abnormal Uterine Bleeding: Evaluation

September 12, 2005.

Seine Chiang, MD

1. How is abnormal uterine bleeding defined?
Duration less than 2 or greater than 7 days
Flow greater than 80 mL (or subjective impression of heavier than normal flow)
Cycle length less than 24 or greater than 35 days
Intermenstrual bleeding or postcoital spotting

2. What are the definitions of the following terms?
Dysfunctional uterine bleeding used classically to describe anovulatory bleeding
Amenorrhea absence of bleeding for at least three usual cycle lengths.
Oligomenorrhea bleeding that occurs at an interval greater than 35 days.
Polymenorrhearegular bleeding occuring at an interval less than 24 days.
Menorrhagia (also called hypermenorrhea) refers to excessive or prolonged menstrual bleeding
occurring at regular intervals. It is technically defined as blood loss greater than 80 mL per cycle
and/or menstrual periods lasting longer than 7 days. However, quantitation is not accurate nor
practical in a clinical setting.
Metrorrhagia: bleeding of normal or reduced volume that occurs at irregular intervals
Menometrorrhagia: prolonged or excessive bleeding at irregular intervals.

3. In the following cases, what are the usual causes of abnormal genital bleeding?
a. 6 week old female infant brought in by the mother for mucoid blood tinged vaginal
discharge noted in the infants diaper and upon wiping the vaginal opening.
Common Causes: Estrogen withdrawal

b. 2 year old female brought in by mother for blood noted on underwear.
Common Causes in the premenarchal (< age 9) patient: Foreign body, vulvovaginitis,
urethral prolapse. Also consider less common causes such as trauma including sexual
abuse, sarcoma botryoides, estrogen-producing ovarian tumor (ie. Granulose cell) and
precocious puberty.

c. 14 yo female presented to ER with menometrorrhagia and hypermenorrhea since
onset of menarche 6 months ago.
Common Causes in the early post-menarchal patient: anovulation due to immature
hypothalamic-pituitary axis is the cause in >90% of patients in this age group but pregnancy
should be ruled out. The remaining 10% are primarily caused by bleeding disorders,
psychogenic issues, medical illness, infection, and hormonal contraceptive use.

d. 39 yo female with 6 month history of menometrorrhagia:
Common causes in the reproductive age patient: The greatest variety of causes of AUB
occur in this age group. The 3 most important to consider are anovulation, pregnancy,
endometrial abnormalities such as polyps, fibroids, neoplasms/cancer. Other common
causes include infection, medication use (hormones), and systemic diseases such as
hypothyroidism, liver disease, chronic renal diseases).

e. 47 yo female with 6 month history of menometrorrhagia
Common causes in the perimenopause: Anovulation due to decline in ovarian function
and progesterone deficiency, anatomic abnormalities (polyps/fibroids), and cancer are the
big three to consider.

f. 70 yo female with vaginal spotting
Common causes in the postmenopause: The most common causes in this age group are
GU atrophy, disorderly proliferation of the endometrium due to peripheral estrogen
production (or exogenous hormones), and neoplasms (hyperplasia, polyps, cancer).

4. How would you evaluate a 14 yo virginal healthy female admitted with history of cyclic
menorrhagia and dysmenorrhea since onset of menarche 6 months ago and now with
vaginal bleeding x 10 days, dizziness, and severe anemia (Hgb 7)?
History and physical exam, UCG, CBC with platelet count
History suggests ovulatory menorrhagia, which is often related to underlying bleeding disorder
in this age group von Willegrand disease, hematologic malignancies, use of anticoagulants. -
Check PTT, PT, Factor VIII, and vonWillebrand antigen in addition to the basic evaluation.
In those requiring admission due to bleeding and anemia, 10-20% have underlying
coagulopathy (1/2 of these patient presenting at menarche) with 1/3 requiring transfusion. The
risk of underlying coagulation disorder is even higher in those with Hgb <10 g/dL and who
require hospitalization (approximately 25-50%).

5. How would you evaluate a morbidly obese sexually active 34 yo black female G 0 with
history of menometrorrhagia with menses every 2-3 months since onset of menarche at age
14, recent exacerbation of hirsutism, no prior use of hormonal contraception, and no known
medical problems or medication use?
History and physical exam, UCG, CBC with platelet count
History suggests long history of anovulatory cycles which is likely due to PCOS but one
must rule out other causes by checking:
i. Prolactin for prolactinemia since she has oligomenorrhea
ii. TSH for hypothyroidism
iii. DHEAS, Testosterone panel to rule out androgen secreting tumor
iv. Chem panel for systemic diseases such as chronic renal insufficiency, liver
dysfunction, and overt diabetes
Cervical cytology and cultures since she is sexually active
Endometrial biopsy is indicated for AUB evaluation in all women >35 or in women ages <35
with risk factors for endometrial neoplasm such as chronic anovulation, morbid obesity,
history of breast CA, use of tamoxifen, FHx of endometrial, ovarian, breast, or colon CA
Pelvic ultrasound if exam is abnormal or limited by her obesity exclude anatomic abn.

6. How would your differential diagnosis and evaluation differ if this were a 34 yo female G 0 of
normal weight with history of cyclic menorrhagia? Since the most common cause of ovulatory
bleeding in this age group is an anatomic abn of endometrial cavity (fibroids, polyps), the following
tests should be considered:
Pelvic ultrasound- endometrial thickness should be 4-8 mm on CD 4-6 and 8-14 mm during
the secretory phase.
Saline infusion sonohysterography to detect small endometrial lesions that might be missed
on TVS or EM Bx.
Hysteroscopy is considered the gold standard for the diagnostic evaluation for AUB but may
not be cost-effective as a first line tool.
It is important to recognize that, even in this age group, coagulation abnormalities may account for
11% of ovulatory menorrhagia (von Willebrands, abn platelets, anticoagulant use) causes and
should also be considered and evaluated.

References:
1.APGO educational series on women's health issues. Clinical management of abnormal
uterine bleeding. Association of Professors of Gynecology and Obstetrics, May 2002.
2.Dilley, A. et al. von Willebrand disease and other inherited bleeding disorders in women with
diagnosed menorrhagia. Obstet Gynecol 2001; 97:630.
3. Shwayder, JM. Pathophysiology of abnormal uterine bleeding. Obstet Gynecol Clin North
Am 2000; 27:219