Abnormal Uterine Bleeding

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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).

Abnormal uterine bleeding is due to organic causes in about 25% of patients and to functional abnormality of the hypothalamic-pituitary-ovarian axis (dysfunctional uterine bleeding) in the rest. Age is the most important factor; organic causes, including gynecologic neoplasms, become more common with advancing age. Dysfunctional uterine bleeding is the most common cause of abnormal uterine bleeding.

Infancy and childhood:
Newborn girls may have spotting for a few days because the endometrium is stimulated in utero by placental estrogens. Any other bleeding from the reproductive tract is rare in childhood and should be investigated. Accidental traumatic lesions of the vulva and vagina are the most common causes. Vaginitis (often due to a foreign body), prolapse of the urethral meatus, and gynecologic neoplasms can also cause bleeding. Ovarian tumors generally do not cause bleeding unless they are endocrinologically active. Precocious puberty must always be considered in childhood bleeding and can usually be recognized by the development of secondary sexual characteristics. The cause of bleeding is unknown in many cases but may be due to drug ingestion, CNS lesions, hypothyroidism, or adrenal or ovarian neoplasms.

Bleeding and vaginal discharge are the presenting symptoms in > 80% of cases of vaginal adenosis and of clear cell adenocarcinoma of the vagina and cervix. These lesions have been linked to diethylstilbestrol exposure in utero and are diagnosed by cytologic smear and by colposcopically directed biopsy of suspicious areas. Unless malignancy is present, most lesions do not require treatment but should be monitored periodically.

Reproductive age:
Primary or secondary hematologic disorders with abnormal clotting can lead to abnormal bleeding throughout the reproductive years. Hematologic evaluation is indicated for adolescents and women with a history suggesting clotting disorders. For example, dysfunctional uterine bleeding is the most common presentation of von Willebrand’s disease in women.

Complications of pregnancy are the most common organic causes of abnormal bleeding in women of reproductive age. Nearly half of patients with uterine bleeding and symptoms of pregnancy or a confirmed early pregnancy spontaneously abort the fetus. Important differential diagnoses include ectopic pregnancy and gestational trophoblastic disease. Endometritis and infection of retained products of conception usually cause bleeding shortly after delivery or abortion but occasionally >= 2 wk later.

Vulvar bleeding in the reproductive years is almost always due to trauma.

Vaginal lesions that cause bleeding include vaginal adenosis and malignancy. Vaginitis causes bleeding more commonly in children and postmenopausal women because their vaginal mucosa is thinner, but severe cases may cause spotting during the reproductive years. Granulomatous tissue formed after surgery (especially hysterectomy) may cause bleeding. Biopsy may be needed to rule out malignancy. Although cauterization with silver nitrate or cryotherapy stops bleeding in most cases, surgical resection may be required for large lesions.

Cervical lesions causing bleeding include cervical cancer, benign cervical lesions, cervicitis (rarely causes bleeding, except in association with cervical ectropion, but may cause vaginal discharge tinged with blood), cervical or endometrial polyps (causing postcoital bleeding), submucosal myomas (causing intermenstrual bleeding, metrorrhagia, or polymenorrhea), and condylomata acuminata of the cervix.

Adenomyosis (benign invasion of endometrium into the myometrium) is a common disorder that causes symptoms in only a small percentage of patients, usually late in the reproductive years. Menorrhagia and intermenstrual bleeding are the most common complaints, followed by nonspecific pelvic pain and bladder and rectal pressure. During pelvic examination, the uterus may feel enlarged, globular, and softer than normal, and fibroids (leiomyomas) may be present. An MRI aids in making the diagnosis before surgery. Hysterectomy relieves symptoms in all patients if the diagnosis was accurate. Contraceptive steroids and GnRH agonists are not very effective.

Fibroids occur in as many as 40% of women by age 40; only a few are symptomatic and require treatment. They can cause any kind of bleeding abnormality.

Functional ovarian cysts are relatively common, and > 50% of patients present with menstrual irregularities ranging from amenorrhea to menorrhagia. In young women, cystic adnexal masses may disappear spontaneously. Adnexal masses of > 5 cm that persist for > 1 mo require surgical exploration to exclude a neoplasm. Any ovarian tumor may cause uterine bleeding, but bleeding is common only with endocrinologically active neoplasms.

Thyroid dysfunction may be associated with menstrual irregularity. Menorrhagia can result, but oligomenorrhea and amenorrhea are more common.

Postmenopause:
Gynecologic malignancies must be ruled out in any postmenopausal woman with uterine bleeding. The most common benign disorders causing postmenopausal bleeding are atrophic vaginitis, atrophic endometrium, endometrial polyps, and endometrial hyperplasia. The cause of bleeding in atrophic endometrium is unclear. Endometrial polyps need no further treatment after diagnostic curettage, but patients must be observed for recurrence. Endometrial hyperplasia generally should be treated with a progestin or hysterectomy.

RELATED STORIES:
Disorders of the Menstrual Cycle   Abnormal Premenopausal Bleeding   Postmenopausal Vaginal Bleeding   Dysmenorrhea   Ovarian Failure   Dysfunctional Uterine Bleeding (Functional Uterine Bleeding)   Primary Dysmenorrhea (Functional Dysmenorrhea)   Secondary Dysmenorrhea (Acquired Dysmenorrhea)   Amenorrhea   Premature Ovarian Failure (Premature Menopause)   Premenstrual Syndrome (Premenstrual Tension)   Menorrhagia

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