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).

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.