Abnormal Uterine Bleeding

Anisa Ssengoba-Ubogu, M.D.

BCM Kelsey- Seybold Clinic
Family Medicine Residency Program

Goals
Review

causes of Abnormal uterine

bleeding

Management

 Menstrual

disorders accounted for

19.1% of 20.1 million visits to physician
offices for gynecologic conditions over a
two-year period

25%

of gynecologic surgeries involve

abnormal uterine bleeding

 NORMAL MENSTRUAL CYCLES

DAY INTERVALS

21-35

OCCUR AT 28

DAY RANGE IS NORMAL

400-500

CYCLES OCCUR BETWEEN THE FIRST

AND LAST PERIODS

70%

OF THE BLOOD LOSS FROM A MENSTRUAL

CYCLE OCCURS IN THE FIRST TWO DAYS

 Menorrhagia-

Bleeding occurs at normal

intervals (21 to 35 days) but with heavy flow
(>=80 mL) or duration (>=7 days

Metrorrhagia-Irregular,

frequent uterine
bleeding of varying amounts but not
excessive

Menometrorrhagia-Bleeding

occurs at
irregular, noncyclic intervals and with heavy
flow (>=80 mL) or duration (>=7 days).

 Polymenorrhea-Regular

of less than 21 days

bleeding at intervals

Oligomenorrhea-Bleeding

than every 35 days

Amenorrhea-No

months

Acute

at intervals greater

uterine bleeding for at least 6

emergent abnormal uterine bleeding-

significant blood loss that results in hypovolemia

(hypotension or tachycardia) or shock.

Differential Diagnosis
Medications
Systemic

Disease

Infection
Trauma
Complications

of Pregnancy
Benign Pelvic Pathology
Neoplasm

Medications/iatrogenic
Anticoagulants

OCPs, including

Antipsychotics

progestin-only pill
SSRIs
Tamoxifen (Nolvadex)
Thyroid hormone
replacement

Corticosteroids
Herbal and other

supplements:
ginseng, ginkgo, soy
Hormone
replacement
Intrauterine devices

Systemic disease
Blood dyscrasias, including leukemia and

thrombocytopenia
Coagulopathies
Hepatic disease
Polycystic ovary syndrome
Renal disease
Adrenal hyperplasia and Cushing's disease
Hypothalamic suppression (from stress, weight loss,
excessive exercise)
Pituitary adenoma or hyperprolactinemia
Thyroid disease

Infection
Cervicitis
Endometritis
Myometritis
Salpingitis

Trauma
Laceration
Abrasion
Foreign

body
Sexual Abuse/ Assault

Complications of Pregnancy
Intrauterine

pregnancy
Ectopic pregnancy
Spontaneous abortion
Gestational trophoblastic disease
Placenta previa

Benign pelvic pathology

Cervical

polyp
Endometrial polyp
Leiomyoma
Adenomyosis

Endocervical polyp

Endometrial Polyp

Leiomyoma

Malignant neoplasm
cervical squamous cell carcinoma
endometrial adenocarcinoma
estrogen-producing ovarian tumors
testosterone-producing ovarian tumors
leiomyosarcoma
1 IN 5 WOMEN OLDER THAN 45 WILL HAVE A

MALIGNANT OR PREMALIGNANT CAUSE OF

BLEEDING

Endometrial Cancer

Risk Factors for

Endometrial Cancer
Chronic

anovulatory cycles

Obesity
Nulliparity
Age

> 35 years
Diabetes
Tamoxifen therapy
H/o unopposed estrogen use

Labs
Pregnancy
Cbc-

test!

access anemia/ platelet dysfunction

STD check (GC/CT/trich)
PAP
LFTS/INR
TSH
Prolactin
Blood glucose
DHEA-S, free testosterone, 17alphahydroxyprogesterone

Imaging/ tissue sampling

EMB
TVUS
Saline-infusion
Hysteroscopy

sonohysterography

Bleeding pattern
Severe

acute
Ovulatory
Anovulatory
Related to contraception

Severe Acute Bleeding

Premarin

2.5mg qid plus promethazine

25mg
D &C if no response after 2-4doses of
Premarin
Switch to OCP (LoOval qid x 4d, tid x 3d,
bid x 2d, qd x3wks, 1wk off then cycle for
3mo

Dysfunctional Uterine
Bleeding
Abnormal

uterine bleeding not caused

by pelvic pathology, medications,
systemic disease or pregnancy.

Can

be ovulatory or anovulatory.

Causes of DUB
Estrogen

breakthrough bleeding

Estrogen

withdrawal bleeding

Progesterone

breakthrough bleeding

Medical Management
Anovulatory-

OCPs/patch/ring or cyclic
progestins if contraindication to OCPs

NSAIDS, levonorgestrelreleasing intrauterine system (Mirena)

OCPs, Depo, patch, ring, Implanon

Ovulatory-

Ortho Evra

Mirena

Nuva Ring

Implanon

Abnormal bleeding w/ OCPs

Low

dose OCPs increase estrogen Necon

1/35, Demulen 1/35, Demulen 1/50, LoOvral

-check
-

STDs

imaging

Abnormal Bleeding with Depo

1st

4-6mo? Observe, add OCP, inc injection

freq q2mo

Premarin

recurs

1.25mg qd x 7d, repeat if bleeding

OTHER OPTIONS:
-Ethinyl estradiol (Estinyl)- 20
mcg per day for 1 to 2 weeks
Estradiol (Estrase)- 0.5 to 1

mg per day for 1 to 2 weeks

Abnormal Bleeding with IUD

Observe

if mild for 4-6mo

OCP for one cycle if Mirena
Provera 10mg for 7days if Paraguard

Surgical Management
Hysterectomy
Uterine

artery embolization
Endometrial ablation
Myomectomy
Operative hysteroscopy

Case #1
18

year old female h/o Depo x 4years,

complains of heavy bleeding and cramping

(give

estradiol 1mg daily x 2wks, Motrin,

check cbc,calcium+D, consider other birth
ctl options)

Case #2
25

year old female with complaint of heavy

menses lasting 10 days+ dysmennorhea,
hct-30.

(regulate

with birth ctl, tx anemia,

NSAIDS)

Case #3
59

year old widowed female with 2

episodes of spotting.

(check

cultures, refer to Gyn)

Case #4
30

year old female complains of lack of

menses for 3months

(trial

of Provera 10mg daily x 10days for

withdrawal bleeding)

Case #5
19

y/o female with severe bleeding, 1

tampon/hr. BP stable.

(Premarin

OCP)

2.5 qid with antiemetic, then