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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?
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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 40’s 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
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Thyroid disease
Prolactinomas
Coagulation defects
Renal, liver failure
Differential diagnosis
• Trauma
• Foreign bodies
Differential diagnosis
• Medications
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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
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Pregnancy test
CBC
TSH
Prolactin
(Liver function tests)
(Coagulation panels)
(Androgen profile)
• Testosterone, DHEAS, Hydroxyprogesterone
Evaluation (cont)
• Cytopathology
– Pap
– Endometrial biopsy
• Imaging studies
• Surgical
– D&C hysteroscopy
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)