Abnormal Uterine Bleeding

Rochelle Lindenbaum, M.D. Assistant Professor

Department of Obstetrics and Gynecology Hospital of the University of Pennsylvania

The Normal Cycle: • Results from a complex feedback

system involving the hypothalamus, pituitary, ovary, and uterus.

• The endometrium proliferates from estrogen stimulation, then undergoes secretory changes when exposed to progesterone, and ultimately desquamates upon withdrawal of ovarian steroid support.

The Normal Cycle • Cessation of bleeding depends on clot

formation and uterine factors, such as vasoconstriction and uterine contraction, which is regulated by local prostaglandins.

What is normal uterine bleeding?

• 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

Etiology • Organic vs Dysfunctional

• Organic: reproductive and systemic • Dysfunctional: usually anovulatory

Reproductive: • Pregnancy • Anatomic • Malignancy • Infectious • Trauma • Drugs

Differential diagnosis • Pregnancy related complications

– Ectopic – Abortion: threatened, inevitable,

complete/incomplete – GTD

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 • Thyroid disease • Prolactinomas • Coagulation defects • Renal, liver failure

Differential diagnosis • Trauma • Foreign bodies

Differential diagnosis • Medications

– Hormonal contraceptives – Hormone replacement therapy – Phytoestrogens, ginseng – SSRIs – Anti-psychotic drugs

DUB Defined • Excessive noncyclic endometrial

bleeding unrelated to anatomical lesions of the uterus or to systemic disease

• It is a diagnosis of exclusion. • It is anovulatory bleeding that may

be related to a systemic medical disease or factors which affect the hypothalamic pituitary axis.

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

– 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)