Regular cyclic menstruation results from the choreographed relationship between the endometrium and its regulating factors (Chap. 15). Changes in either of these frequently result in abnormal bleeding. Causes of this bleeding include neoplastic growth, hormonal dysfunction, trauma, infection, coagulopathies, and complications of pregnancy (Table 8-1). As a result, abnormal uterine bleeding is a common gynecologic complaint that may affect females of all ages.
Table 8-1. Differential Diagnosis of Abnormal Bleeding |Favorite Table|Download (.pdf)
Table 8-1. Differential Diagnosis of Abnormal Bleeding
Dysfunctional uterine bleeding
Perimenarchal—immature hypothalamic-pituitary-ovarian axis
Perimenopausal—insensitive ovarian follicles
Endocrinopathies—see systemic causes
Drugs—hypothalamic depressants, sex steroids
Pregnancy-associated causes—implantation spotting, abortion, ectopic pregnancy, gestational trophoblastic disease, postabortal or postpartum infection
Anatomic uterine lesions
Neoplasm—leiomyoma, polyp, endometrial hyperplasia, cancer
Infection—sexually transmitted disease, tuberculosis, chronic endometritis
Mechanical causes—intrauterine device, perforation
Partial outflow obstruction—congenital müllerian defect, Asherman syndrome
Anatomic nonuterine lesions
Ovarian lesions—hormone-producing neoplasm
Fallopian tube lesions—salpingitis, cancer
Cervical and vaginal lesions—cancer, polyp, infection, atrophic vaginitis, foreign body, trauma
Exogenous hormone administration—sex steroids, corticosteroids
Chronic renal failure
Endocrinopathies—hypothyroidism, hyperthyroidism, adrenal disorders, diabetes mellitus, hypothalamic-pituitary disorders, polycystic ovarian syndrome, obesity
Abnormal bleeding may display several patterns. Menorrhagia is defined as prolonged or heavy cyclic menstruation. Objectively, menses lasting longer than 7 days or exceeding 80 mL of blood loss are determining values (Hallberg, 1966). Metrorrhagia describes intermenstrual bleeding. The term breakthrough bleeding is a more informal term for metrorrhagia that accompanies hormone administration. Frequently, women may complain of both patterns, menometrorrhagia. In some women, there is diminished flow or shortening of menses, hypomenorrhea. Normal menstruation typically occurs every 28 days ± 7 days. Cycles with intervals longer than 35 days describe a state of oligomenorrhea. Finally, the term withdrawal bleeding refers to the predictable bleeding that results from an abrupt decline in progesterone levels.
Assessing heavy bleeding in a clinical setting has its limitations. For example, several studies have documented the lack of correlation between patient perception of blood loss and objective measurement (Chimbira, 1980c; Fraser, 1984). As a result, methods to objectively assess blood loss have been investigated. Hallberg and associates (1966) describe a technique to extract hemoglobin from sanitary napkins using sodium hydroxide. Hemoglobin is converted to hematin and can be measured spectrophotometrically. The constraints to this approach in a clinical setting are obvious.
Other tools used to estimate menstrual blood loss include hemoglobin and hematocrit evaluation. Hemoglobin concentrations below <12 g/dL increase the chance of identifying women with menorrhagia. A normal level, however, does not exclude menorrhagia, as many women with clinically significant bleeding have normal values.
Another method involves estimating the number and type of pads or tampons used by a woman during menses. Warner and colleagues (2004) found positive correlations between objective menorrhagia and passing clots more than 1 inch in diameter and changing pads more frequently than every 3 hours. Attempts to standardize this type of evaluation have led ...