Abnormal Premenopausal Bleeding

Introduction

Essentials of Diagnosis

• Blood loss of over 80 mL per cycle.
  
• Excessive bleeding, often with the passage of clots, may occur at regular menstrual intervals (menorrhagia) or irregular intervals (dysfunctional uterine bleeding).
  
• Etiology most commonly dysfunctional uterine bleeding on a hormonal basis.
  

General Considerations

Normal menstrual bleeding lasts an average of 4 days (range, 2-7 days), with a mean blood loss of 40 mL. Blood loss of over 80 mL per cycle is abnormal and frequently produces anemia. Excessive bleeding, often with the passage of clots, may occur at regular menstrual intervals (menorrhagia) or irregular intervals (dysfunctional uterine bleeding). When there are fewer than 21 days between the onset of bleeding episodes, the cycles are likely to be anovular. Ovulation bleeding, a single episode of spotting between regular menses, is quite common. Heavier or irregular intermenstrual bleeding warrants investigation.

Dysfunctional uterine bleeding is usually caused by overgrowth of endometrium due to estrogen stimulation without adequate progesterone to stabilize growth; this occurs in anovular cycles. Anovulation associated with high estrogen levels commonly occurs in teenagers, in women aged late 30s to late 40s, and in extremely obese women or those with polycystic ovary syndrome.

Clinical Findings

A. Symptoms and Signs
The diagnosis of the disorders underlying the bleeding usually depends upon the following: (1) A careful description of the duration and amount of flow, related pain, and relationship to the last menstrual period (LMP). The presence of blood clots or the degree of inconvenience caused by the bleeding may be more useful indicators. (2) A history of pertinent illnesses. (3) A history of all medications the patient has taken in the past month. (4) A careful pelvic examination to look for pregnancy, uterine myomas, adnexal masses, or infection.

B. Laboratory Studies
Cervical smears should be obtained as needed for cytologic and culture studies. Blood studies should include a complete blood count, sedimentation rate, and glucose levels to rule out diabetes. Diabetes may occasionally initially present with abnormal bleeding. A test for pregnancy and studies of thyroid function and coagulation disorders should be considered in the clinical evaluation. Tests for ovulation in cyclic menorrhagia include basal body temperature records, serum progesterone measured 1 week before the expected onset of menses, and analysis of an endometrial biopsy specimen for secretory activity shortly before the onset of menstruation.