Abnormal Uterine Bleeding

District 1 ACOG Medical Student

Education Module 2011
 Disorders of the Menstrual Cycle
• Amenorrhea
• Dysmenorrhea
• Premenstrual Syndrome
• Abnormal Uterine Bleeding
 Abnormal Uterine Bleeding:
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
 Abnormal Uterine Bleeding:
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)
– Thyroid disorders
– Hyperprolactinemia
• Malignancy
– Uterine or Cervical cancer
– Endometrial hyperplasia (potentially pre-malignant)
• Bleeding disorders
– von Willebrand’s Disease, Hemophilia/Factor deficiencies, platelet
disorders
 Abnormal Uterine Bleeding:
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, 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
Normal Menstrual Cycle
 Normal Ovulatory Cycle
• Follicular development  ovulation (d14)
 corpus luteal function  luteolysis
• Endometrium is exposed to:
– Ovarian production of estrogen 
(proliferation)
– Combination of estrogen and progesterone 
(secretory phase)
– Estrogen and progesterone withdrawal
(desquamation and repair)
 Anovulatory Bleeding
• Corpus luteum is not produced
– Ovary fails to secrete progesterone, although
estrogen production continues
– Result is continuous, unopposed E stimulation
of endometrium:
• Endometrial proliferation without P-induced
differentiation / stabilization
– Endometrium becomes excessively vascular
without stromal support  fragility and
irregular endometrial bleeding
 Anovulatory Bleeding:
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: Adolescents
(13-18 years)
• Anovulatory bleeding may be normal physiologic
process, with ovulatory cycles not established
until 1-2 yrs after menarche (immature HPG
axis)
• Screen for coagulation disorders (PT/PTT, plts)
• May be caused by leukemia, ITP, hypersplenism
• Consider endometrial bx in adolescents with 2-3
year history of untreated anovulatory bleeding,
especially if obese
Anovulatory Bleeding: Management
in Adolescents
• High dose estrogen therapy for acute bleeding
episodes (promotes rapid endometrial growth to
cover denuded endometrial surfaces):
conjugated equine estrogens PO up to 10 mg/d
in 4 divided doses or IV 25 mg q 4 hrs for 24 hrs
• Treat pts with blood dyscrasias for their specific
diseases, r/o leukemia
• Prevent recurrent anovulatory bleeding with:
• cyclic progestin (i.e. Provera)
or
• low dose (≤ 35 μg ethinyl estradiol) oral contraceptive
– suppresses ovarian and adrenal androgen production and
increases SHBG  decreasing bioavailable androgens
 Anovulatory Bleeding:
Reproductive Age (19-39 years)
• Anovulatory bleeding not considered physiologic,
evaluation required
• 6-10% of women have hyperandrogenic chronic
anovulation (i.e. PCOS), characterized by noncyclic
bleeding, hirsutism, obesity (BMI ≥ 25)
– Underlying biochemical abnormalities: noncyclic estrogen
production, elevated serum testosterone, hypersecretion of LH,
hyperinsulinemia.
– h/o rapidly progressing hirsutism with virilization suggests
tumor
• Lab testing: HCG, TSH, fasting serum prolactin
– If androgen-producing tumor is suspected, serum DHEAS and
testosterone levels
– If POF suspected, serum FSH
• Chronic anovulation resulting from hypothalamic
dysfunction (dx’d by low FSH level) may be due to
excessive psychologic stress, exercise, or weight loss
 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  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
 Anovulatory Bleeding:
Reproductive Age (19-39 yrs)
Medical therapies
• Can be treated safely with either cyclic progestin or
OCPs, similar to adolescents.
• Estrogen-containing OCPs
– relatively contraindicated in women with HTN or DM
– contraindicated for women > 35 who smoke or have h/o
thromboembolic dz
• If pregnancy is desired, ovulation induction with
clomid is initial tx of choice
– Can induce withdrawal bleed with progestin (i.e.
provera), followed by initiation of therapy with Clomid,
50 mg/d for 5 days, starting b/t days 3 and 5 of
menstrual cycle
 Anovulatory Bleeding:
Later Reproductive Age (40-Menopause)
• Incidence of anovulatory bleeding increases
toward end of reproductive years
• In perimenopausal women, onset of anovulatory
cycles is due to declining ovarian function.
• Can initiate hormone therapy for cycle control
When is endometrial evaluation indicated?
• Incidence of endometrial CA in women 40-49
years: 36.2/100,000
• All women > 40 yrs who present with suspected
anovulatory bleeding merit endometrial bx after
excluding pregnancy
 Anovulatory Bleeding:
Later Reproductive Age (40-Menopause)
Medical therapy
• Cyclic progestin, 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
progestin
 Anovulatory Bleeding:
Later Reproductive Age (40-Menopause)
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.