In women of child-bearing age, a methodical history, physical examination, and laboratory evaluation may enable the physician to rule out causes such as pregnancy and pregnancy-related disorders, medications, iatrogenic causes, systemic conditions, and obvious genital tract pathology. Dysfunctional uterine bleeding anovulatory or ovulatory is diagnosed by exclusion of these causes. In women of childbearing age who are at high risk for endometrial cancer, the initial evaluation includes endometrial biopsy; saline-infusion sonohysterography or diagnostic hysteroscopy is performed if initial studies are inconclusive or the bleeding continues.
Women of childbearing age who are at low risk for endometrial cancer may be assessed initially by transvaginal ultrasonography. Post-menopausal women with abnormal uterine bleeding should be offered dilatation and curettage; if they are poor candidates for general anesthesia or decline dilatation and curettage, they may be offered transvaginal ultrasonography or saline-infusion sonohysterography with directed endometrial biopsy.
Medical management of anovulatory dysfunctional uterine bleeding may include oral contraceptive pills or cyclic progestins. Menorrhagia is managed most effectively with nonsteroidal anti-inflammatory drugs or the levonorgestrel intrauterine contraceptive device. Surgical management may include hysterectomy or less invasive, uterus-sparing procedures.
Abnormal uterine bleeding is a common but complicated clinical presentation. One national study 1 found that menstrual disorders were the reason for Furthermore, a reported 25 percent of gynecologic surgeries involve abnormal uterine bleeding. Except for self-limited, physiologic withdrawal bleeding that occurs in some newborns, vaginal bleeding before menarche is abnormal.
In postmenopausal women, abnormal uterine bleeding includes vaginal bleeding 12 months or more after the cessation of menses, or unpredictable bleeding in postmenopausal women who have been receiving hormone therapy for 12 months or more. This article presents a practical approach to determining the cause of abnormal uterine bleeding and briefly reviews medical and surgical management. Malignancy, trauma, and sexual abuse or assault are potential causes of abnormal uterine bleeding before menarche.
A pelvic examination possibly under anesthesia should be performed, because a reported 54 percent of cases involve focal lesions of the genital tract, and 21 percent of these lesions may be malignant.
The menstrual cycle has three phases. During the follicular phase, follicle-stimulating hormone levels increase, causing a dominant follicle to mature and produce estrogen in the granulosa cells. With estrogen elevation, menstrual flow ceases, the endometrium proliferates, and positive feedback is exerted on luteinizing hormone LH , resulting in the ovulatory phase. During the luteal phase, progesterone elevation halts proliferation of the endometrium and promotes its differentiation; progesterone production by the corpus luteum diminishes, causing endometrial shedding, or menstruation.
A menstrual cycle of fewer than 21 days or more than 35 days or a menstrual flow of fewer than two days or more than seven days is considered abnormal. Abruptio placentae. Ectopic pregnancy.
Placenta previa. Trophoblastic disease. Anticoagulants 7. Antipsychotics 7. Corticosteroids 7. Herbal and other supplements: ginseng, ginkgo, soy 7. Hormone replacement. Intrauterine devices. Oral contraceptive pills, including progestin-only pills. Selective serotonin reuptake inhibitors 7. Tamoxifen Nolvadex 7. Adrenal hyperplasia and Cushing's disease. Blood dyscrasias, including leukemia and thrombocytopenia.
Hepatic disease. Hypothalamic suppression from stress, weight loss, excessive exercise. Pituitary adenoma or hyperprolactinemia. Polycystic ovary syndrome. Renal disease. Thyroid disease. Infections: cervicitis, endometritis, myometritis, salpingitis. Neoplastic entities. Benign anatomic abnormalities: adenomyosis, leiomyomata, polyps of the cervix or endometrium.
Premalignant lesions: cervical dysplasia, endometrial hyperplasia. Malignant lesions: cervical squamous cell carcinoma, endometrial adenocarcinoma, estrogen-producing ovarian tumors, testosterone-producing ovarian tumors, leiomyosarcoma.
Trauma: foreign body, abrasions, lacerations, sexual abuse or assault. Information from references 7 and 8. Pregnancy is the first consideration in women of childbearing age who present with abnormal uterine bleeding Table 1. Patients should be questioned about cycle patterns, contraception, and sexual activity.
A bimanual pelvic examination seeking uterine enlargement , a beta-subunit human chorionic gonadotropin test, and pelvic ultrasonography are useful in establishing or ruling out pregnancy and pregnancy-related disorders.
Next, iatrogenic causes of abnormal uterine bleeding should be explored. Bleeding may be induced by medications, including anticoagulants, selective serotonin reuptake inhibitors, antipsychotics, corticosteroids, hormonal medications, and tamoxifen Nolvadex.
Herbal substances, including ginseng, ginkgo, and soy supplements, may cause menstrual irregularities by altering estrogen levels or clotting parameters. Nausea, weight gain, urinary frequency, fatigue.
Weight gain, cold intolerance, constipation, fatigue. Weight loss, sweating, palpitations. Easy bruising, tendency to bleed. Jaundice, history of hepatitis. Hirsutism, acne, acanthosis nigricans, obesity. Postcoital bleeding. Galactorrhea, headache, visual-field disturbance. Weight loss, excessive exercise, stress. Thyroid tenderness, tachycardia, weight loss, velvety skin. Bruising, jaundice, hepatomegaly. Enlarged uterus. Firm, fixed uterus. Adnexal mass. Uterine tenderness, cervical motion tenderness.
Complete blood count with platelet count and coagulation studies. Liver function tests, prothrombin time. Thyroid-stimulating hormone. Blood glucose. DHEA-S, free testosterone, hydroxyprogesterone if hyperandrogenic. Papanicolaou smear. Cervical testing for infection. Transvaginal ultrasonography. Saline-infusion sonohysterography. Once pregnancy and iatrogenic causes have been excluded, patients should be evaluated for systemic disorders, particularly thyroid, hematologic, hepatic, adrenal, pituitary, and hypothalamic conditions Table 2.
Menstrual irregularities are associated with both hypothyroidism Consistent cohort studies] Thyroid function tests may help the physician determine the etiology.
Inherited coagulopathy has been shown to be the underlying cause of abnormal uterine bleeding in 18 percent of white women and 7 percent of black women with menorrhagia. A complete blood count with platelet count should be obtained. If a coagulation defect is suspected, consultation with a hematologist may be the most cost-effective option in the absence of reasonable screening tests for specific abnormalities.
Obesity, acne, hirsutism, and acanthosis nigricans may be signs of polycystic ovary syndrome or diabetes mellitus. Polycystic ovary syndrome is associated with unopposed estrogen stimulation, elevated androgen lev els, and insulin resistance, and is a common cause of anovulation. The presence of galactorrhea, as determined by the history or physical examination, may indicate underlying hyperprolactinemia, which can cause oligoovulation or eventual amenorrhea.
A prolactin level confirms the diagnosis of hyperprolactinemia. Hypothalamic suppression secondary to eating disorders, stress, or excessive exercise may induce anovulation, which sometimes manifests as irregular and heavy menstrual bleeding or amenorrhea. Genital tract pathology may be associated with intermenstrual, postcoital, and heavy menstrual bleeding.
Uterine fibroids, endometrial polyps, adenomyosis, endometrial hyperplasia and atypia, and endometrial cancer should be excluded. The evaluation of postmenarchal women who present with abnormal uterine bleeding includes a pelvic examination, as well as a Pap smear if appropriate, to look for vulvar or vaginal lesions, signs of trauma, and cervical polyps or dysplasia. Cervical dysplasia seldom causes abnormal uterine bleeding, but it may be associated with postcoital bleeding.
A bimanual examination in the postmenarchal woman may reveal tenderness associated with infection, an adnexal mass consistent with an ovarian neoplasm or cyst, or uterine enlargement consistent with fibroids, pregnancy, or a tumor. Even if the pelvic examination is normal, further evaluation of the endometrium may be required to eliminate less obvious abnormalities.
Dysfunctional uterine bleeding, with both anovulatory and, less commonly, ovulatory 4 causes, occurs during the childbearing years. It is a diagnosis of exclusion and is made only after pregnancy, iatrogenic causes, systemic conditions, and obvious genital tract pathology have been ruled out Figure 1. Anovulatory dysfunctional uterine bleeding is a disturbance of the hypothalamic-pituitary-ovarian axis that results in irregular, prolonged, and sometimes heavy menstrual bleeding.
It may occur immediately after menarche but before maturation of the hypothalamic-pituitary-ovarian axis, or it may occur during perimenopause, when declining estrogen levels fail to regularly stimulate the LH surge and resulting ovulation.
Unopposed estrogen stimulation may lead to endometrial proliferation and hyperplasia. Without sufficient progesterone to stabilize and differentiate the endometrium, this mucous membrane becomes fragile and sloughs irregularly.
Request an Appointment at Mayo Clinic. Fibroid locations Open pop-up dialog box Close. Fibroid locations There are three major types of uterine fibroids. Uterine polyps Open pop-up dialog box Close.
Uterine polyps Uterine polyps attach to your uterus by a large base or a thin stalk and can grow to be several centimeters in size. Adenomyosis Open pop-up dialog box Close. Adenomyosis With adenomyosis, the same tissue that lines the uterus endometrial tissue is present within and grows into the muscular walls of your uterus.
Share on: Facebook Twitter. Show references Ferri FF. In: Ferri's Clinical Advisor Philadelphia, Pa. Accessed April 10, Heavy menstrual bleeding. Centers for Disease Control and Prevention. Accessed April 13, Frequently asked questions.
Gynecologic problems FAQ Abnormal uterine bleeding. American College of Obstetricians and Gynecologists. Accessed April. Cunningham FG, et al. In: Williams Obstetrics. New York, N. Abnormal uterine bleeding in adolescents. Mayo Clinic; Anemia is a condition in which your blood is lacking oxygen-carrying red blood cells.
Without oxygen-rich blood, you may feel weak and tired. Excessive menstrual bleeding can also be a symptom of some reproductive cancers and conditions that affect fertility.
Your doctor will test for disorders that can cause menometrorrhagia. For example, a blood test will be used to test for pregnancy. You can still test positive for pregnancy up to 35 days after a miscarriage. Your doctor will also take a Pap smear.
Pap smears can test for cervical cancer. Your doctor may also do a hysteroscopy. During this procedure, your doctor will use a thin, lighted, telescopic tube to see into the uterus. This test can help your doctor diagnose things like endometriosis.
Other tests may include ultrasound and MRI. Treatment for menometrorrhagia depends on the cause. For example, surgery to remove fibroids may be recommended. When there is no known cause of menometrorrhagia, the first line of treatment is usually pharmaceutical. Some common options include:. Heavy periods can be difficult to live with, but being prepared is the best way to protect against accidents. In many cases, the condition can be readily managed. Some of the underlying causes of the menometrorrhagia can affect fertility, but many women can go on to get pregnant and successfully deliver babies following treatment for this condition.
Heavy flows and cramps can be a common experience during your periods. You may see red, brown, and even black blood during your period. Here's what the different period blood colors mean and when to see your doctor.
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