abnormal uterine bleeding - university of pennsylvania · pdf file ·...
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Abnormal Uterine Bleeding
Rochelle Lindenbaum, M.D. Assistant Professor
Department of Obstetrics and Gynecology Hospital of the University of Pennsylvania
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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.
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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.
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What is normal uterine bleeding?
• Age of patient • Frequency • Duration • Flow
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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
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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
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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
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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
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Etiology • Organic vs Dysfunctional
• Organic: reproductive and systemic • Dysfunctional: usually anovulatory
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Reproductive: • Pregnancy • Anatomic • Malignancy • Infectious • Trauma • Drugs
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Differential diagnosis • Pregnancy related complications
– Ectopic – Abortion: threatened, inevitable,
complete/incomplete – GTD
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Differential diagnosis • Disease of the cervix
– Polyp, ectropian, dysplasia, invasive cancer
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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
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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
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Differential diagnosis • Thyroid disease • Prolactinomas • Coagulation defects • Renal, liver failure
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Differential diagnosis • Trauma • Foreign bodies
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Differential diagnosis • Medications
– Hormonal contraceptives – Hormone replacement therapy – Phytoestrogens, ginseng – SSRIs – Anti-psychotic drugs
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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.
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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
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Evaluation • History and physical • Labs
– Pregnancy test – CBC – TSH – Prolactin – (Liver function tests) – (Coagulation panels) – (Androgen profile)
• Testosterone, DHEAS, Hydroxyprogesterone
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Evaluation (cont) • Cytopathology
– Pap – Endometrial biopsy
• Imaging studies • Surgical
– D&C hysteroscopy
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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)