Abnormal Uterine Bleeding

Peter J. Chen, M.D.

Clinical Assistant Professor

Department of Obstetrics and Gynecology
Hospital of the University of Pennsylvania

What is normal uterine bleeding?

Age of patient
Frequency
Duration
Flow

What is normal uterine bleeding?

Frequency of menses
21 days (0.5%) to 35 days (0.9%)
Age 25, 40% are between 25 and 28 days
Age 25-35, 60% are between 25 and 28 days
Teens and women over 40s cycles may be longer apart

Munster K et al, Br J Obstet Gynaecology

What is normal uterine bleeding?

Duration of menses
2 days to 8 days
Usually 4-6 days

Hallberg L et al, Acta Obstet Gynecology Scandinavica

What is normal uterine bleeding?

Flow/amount of menses

Normal volume of menstrual blood loss is 30 cc

Hallberg L et al, Acta Obstet Gynecology Scandinavica

Traditional terminologies
Menorrhagia

Regular intervals, excessive menstrual blood loss

amount >80mL

Metrorrhagia

Irregular intervals, excessive flow and duration

Oligomenorrhea

Interval longer than 35 days

Polymenorrhea

Interval less than 21 days

Cohen BJB et al, Obstetrical and Gynecologic Survey

Differential diagnosis
Pregnancy related complications
ectopic, inevitable

Differential diagnosis
Disease of the cervix
Polyp, ectropian, dysplasia, invasive
cancer

Differential diagnosis
Disease of the uterus

Infection: endometritis
Endometrial polyp, adenomyosis, hyperplasia, adenocarcinoma
Fibroids
One third of patients with symptoms

Correlation between the severity of the bleeding and the area of

endometrial surface
Sehgal N, et al American Journal of Surgery

Histologic abnormalities of the endometrium, ranging from atrophy to

hyperplasia
Deligdish, et al Journal of Clinical Pathology

Endometrial venule ectasia

Faulkner RL American J of Obstetrics and Gynecology; Farrer-Brown G, et al Journal of Obstetrics

and Gynaecology Br Common W

Differential diagnosis
Disease of the ovary
Germ cell tumors
Choriocarcinomas
Embryonal carcinoma

Sex cord-stromal tumors

Granulosa cell tumors(1-2% of all ovarian
tumors)
Peak incidence between 50 and 55 years of age

Differential diagnosis

Thyroid disease
Prolactinomas
Coagulation defects
Renal, liver failure

Differential diagnosis
Trauma
Foreign bodies

Differential diagnosis
Medications

Hormonal contraceptives
Hormone replacement therapy
Phytoestrogens, ginseng
SSRIs

Differential diagnosis
Dysfunctional uterine bleeding
Anovulatory cycles
Loss of normal regulatory mechanism
Immaturity
Dysfunction
Psychiatric medications, stress, anxiety, exercise, rapid
weight loss, anorexia nervosa

Ovarian failure
Obesity
PCOS

Evaluation
History and physical
Labs

Pregnancy test
CBC
TSH
Prolactin
(Liver function tests)
(Coagulation panels)
(Androgen profile)
Testosterone, DHEAS, Hydroxyprogesterone

Evaluation
Cytopathology
Pap
Endometrial biopsy

Imaging studies
Surgical
D&C hysteroscopy

(cont)

Treatments

Medical therapy
Hormonal

Progestin, estrogen (IV), combination OCPs

GnRH agonist

Surgical therapy
D&C
Endometrial ablation
Myomectomy/hysterectomy

Radiologic therapy
Uterine artery embolization (UAE)