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Menstrual Bleeding
Initial screening for an underlying disorder of hemostasis in patients with excessive menstrual
bleeding should be structured by the medical history. A positive screening result* comprises the
following circumstances:
Definitions
• Menorrhagia: heavy or prolonged uterine bleeding that occurs at regular intervals. Some sources
define further as the loss of ≥ 80 mL blood per cycle or bleeding > 7 days.
• Hypomenorrhea: periods with unusually light flow, often associated with hypogonadotropic
hypogonadism (athletes, anorexia). Also may be associated with Asherman’s syndrome
• Metrorrhagia: irregular menstrual bleeding or bleeding between periods
• Menometrorrhagia: metrorrhagia associated with > 80 mL
• Polymenorrhea: frequent menstrual bleeding. Strictly, menses occur q 21 d or less
• Oligomenorrhea: Menses are > 35 d apart. Most commonly caused by PCOS, pregnancy, and
anovulation
Differential Diagnosis
• Structural
– Cervical or vaginal laceration
– Uterine or cervical polyp
– Uterine leiomyoma
– Adenomyosis
– Cervical stenosis/Asherman’s (hypomenorrhea)
• Hormonal
– Anovulatory bleeding
– Hypogonadotropic hypogonadism
– Pregnancy
– Hormonal Contraception (i.e. OCPs, Depo-Provera)
• Malignancy
– Uterine or Cervical cancer
– Endometrial hyperplasia (potentially pre-malignant)
• Bleeding disorders
– von Willebrand’s Disease, Hemophilia/Factor deficiencies, platelet disorders
Workup
• History
– Timing of bleeding, quantity of bleeding, menstrual hx including menarche and recent periods,
associated sxs, family hx of bleeding disorders
• Physical
– R/o vaginal or cervical source of bleeding. Bimanual may reveal bulky uterus/discrete fibroids
– Assess for obesity, hirsutism, stigmata of thyroid disease (hypothyroidism associated with
anovulation), signs of hyperprolactinemia (visual field testing, galactorrhea)
– Pap smear
– Endometrial biopsy, if appropriate
• Pregnancy Test
• Imaging
– Pelvic ultrasound
– Sonohystogram or hysterosalpingogram
• Surgical
– Hysteroscopy
–D&C
Etiologies
• Hyperandrogenic anovulation (PCOS, CAH, androgen-producing tumors)
• Hypothalamic dysfunction (stress, anorexia, exercise)
• Hyperprolactinemia
• Hypothyroidism
• Primary pituitary disease
• Premature ovarian failure
• Iatrogenic (secondary to radiation or chemo)
Anovulatory Bleeding:
Reproductive Age (19-39 yrs)
When is endometrial evaluation indicated?
• Sharp increase in incidence of endometrial CA from 2.3/100,000 ages 30-34 yrs à 6.1/100,000
ages 35-39 yrs
• Therefore, endometrial bx to exclude CA is indicated in any woman > 35 yrs old with suspected
anovulatory bleeding
• Pts 19-35 who don’t respond to medical therapy or have prolonged periods of unopposed estrogen
2/2 anovulation merit endometrial bx
Medical therapy
• Cyclic progestogen, low-dose OCPs, or cyclic HRT are all options
• Women with hot flashes secondary to decreased estrogen production can have symptomatic relief
with ERT in combination with continuous or cyclic progestogen
Surgical therapy
• Surgical options include: hysterectomy and endometrial ablation
• Surgical tx only indicated when medical mgmt has failed and childbearing complete
• Some studies suggest hysterectomy may have higher long-term satisfaction than ablation
• Endometrial ablation: NovaSure, thermal balloon
– YAG laser and rollerball less widely-used currently
– 45% of women achieve amenorrhea after YAG laser or resectoscope. 12 month post-op
satisfaction is 90%. Only 15% of women achieve amenorrhea after thermal balloon ablation, and 1
yr satisfaction rate still 90%
– Long-term satisfaction with ablation may be lower:
• in 3-year f/u study, 8.5% of women who had undergone ablation were re-ablated, an additional
8.5% had hyst
• In a 5-year follow up study, 34% of women who underwent ablation later had a hyst.
Duration of menstruation
–8.0 days; prolonged >8 days, shortened <4.5 days.
–8 days).
Heavy menstrual bleeding is a subjective diagnosis as it is defined by the woman based on how it interferes with her quality
of life. HMB affects 3% of premenopausal women. Pathological causes of HMB include uterine fibroids (20–30%), uterine
polyps (5–10%), adenomyosis (5%); endometriosis rarely presents as AUB, but is identified in <5% of cases of
AUB. DUB should not be used to describe HMB.
FIGO have approved this new classification system and have called it PALM-COEIN:
• structural causes for AUB: polyp; adenomyosis; leiomyoma; malignancy and hyperplasia
• non-structural causes for AUB: coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet
classified.
Causes of AUB should be classified as per the PALM-COEIN model. PALM causes (Polyps, Adenomyosis, Leiomyomas
[subserosal and other], Malignancy and hyperplasia) are structural. COEIN causes (Coagulopathy, Ovulatory dysfunction,
Endometrial, Iatogenic, Not otherwise specified) are nonstructural
Causes of vaginal bleeding in postmenopausal women
Polyps 30%
Hyperplasia 8–15%
Endometrial carcinoma 8–10%