1. Menorrhagia (hypermenorrhea) is heavy or prolonged menstrual flow.
The presence of clots may not be abnormal but may signify excessive
bleeding. “Gushing” or “open-faucet” bleeding is always abnormal.
Submucous myomas, complications of pregnancy, adenomyosis, IUDs,
endometrial hyperplasias, malignant tumors, and dysfunctional bleeding are
causes of menorrhagia.
2. Hypomenorrhea (cryptomenorrhea) is unusually light menstrual flow,
sometimes only spotting. An obstruction such as hymenal or cervical
stenosis may be the cause. Uterine synechiae (Asherman's syndrome) can be
causative and are diagnosed by a hysterogram or hysteroscopy. Patients
receiving oral contraceptives occasionally complain of light flow and can be
reassured that this is not significant.
3. Metrorrhagia (intermenstrual bleeding) is bleeding that occurs at any
time between menstrual periods. Ovulatory bleeding occurs midcycle as
spotting and can be documented with basal body temperatures. Endometrial
polyps and endometrial and cervical carcinomas are pathologic causes. In
recent years, exogenous estrogen administration has become a common
cause of this type of bleeding.
4. Polymenorrhea describes periods that occur too frequently. This usually is
associated with anovulation and rarely with a shortened luteal phase in the
menstrual cycle.
5. Menometrorrhagia is bleeding that occurs at irregular intervals. The
amount and duration of bleeding also vary. Any condition that causes
intermenstrual bleeding can eventually lead to menometrorrhagia. Sudden
onset of irregular bleeding episodes may be an indication of malignant
tumors or complications of pregnancy.
6. Oligomenorrhea describes menstrual periods that occur more than 35 days
apart. Amenorrhea is diagnosed if no menstrual period occurs for more than
6 months. Bleeding usually is decreased in amount and associated with
anovulation, either from endocrine causes (eg, pregnancy, pituitary-
hypothalamic causes, menopause) or systemic causes (eg, excessive weight
loss). Estrogen-secreting tumors produce oligomenorrhea prior to other
patterns of abnormal bleeding.
7. Contact bleeding (postcoital bleeding) is self-explanatory but must be
considered a sign of cervical cancer until proved otherwise. Other causes of
,2
contact bleeding are much more common, including cervical eversion,
cervical polyps, cervical or vaginal infection (eg, Trichomonas), or atrophic
vaginitis. A negative cytologic smear does not rule out invasive cervical
cancer, and colposcopy, biopsy, or both may be necessary.
Evaluation of Abnormal Uterine Bleeding
Detailed history, physical examination, cytologic examination, pelvic ultrasound,
and blood tests are the first steps in the evaluation of abnormal uterine bleeding.
The main aim of the blood tests is to exclude a systemic disease, pregnancy, or a
trophoblastic disease. The blood tests usually include complete blood count, assay
of the β subunit of human chorionic gonadotropin (hCG), and thyroid-stimulating
hormone (TSH).
History
Many causes of bleeding are strongly suggested by the history alone. Note the
amount of menstrual flow, the length of the menstrual cycle and menstrual period,
the length and amount of episodes of intermenstrual bleeding, and any episodes of
contact bleeding. Note also the last menstrual period, the last normal menstrual
period, age at menarche and menopause, and any changes in general health. The
patient must keep a record of bleeding patterns to determine whether bleeding is
abnormal or only a variation of normal. However, most women have an occasional
menstrual cycle that is not in their usual pattern. Depending on the patient's age
and the pattern of the bleeding, observation may be all that is necessary.
Physical Examination
Abdominal masses and an enlarged, irregular uterus suggest myoma. A
symmetrically enlarged uterus is more typical of adenomyosis or endometrial
carcinoma. Atrophic and inflammatory vulvar and vaginal lesions can be
visualized, and cervical polyps and invasive lesions of cervical carcinoma can be
seen. Rectovaginal examination is especially important to identify lateral and
posterior spread or the presence of a barrel-shaped cervix. In pregnancy, a decidual
reaction of the cervix may be the source of bleeding. The appearance is a velvety,
friable erythematous lesion on the ectocervix.
Cytologic Examination
Although most useful in diagnosing asymptomatic intraepithelial lesions of the
cervix, cytologic smears can help screen for invasive cervical (particularly
endocervical) lesions. Although cytology is not reliable for the diagnosis of
endometrial abnormalities, the presence of endometrial cells in a postmenopausal
woman is abnormal unless she is receiving exogenous estrogens. Likewise, women
in the secretory phase of the menstrual cycle should not shed endometrial cells. Of
course, a cytologic examination that is positive or suspicious for endometrial
cancer demands further evaluation.
,3
Tubal or ovarian cancer can be suspected based on a cervical smear. The technique
of obtaining a smear is important, because a tumor may be present only in the
endocervical canal and may not shed cells to the ectocervix or vagina. Laboratories
should report the presence or absence of endocervical cells. The current use of a
spatula and endocervical brush has significantly increased the adequacy of
cytologic smears from the cervix. Any abnormal smear requires further evaluation
Pelvic Ultrasound Scan
Pelvic ultrasonography has become an integral part of the gynecologic pelvic
examination. The scan can be performed either transvaginally or transabdominally.
The transvaginal examination is performed with an empty bladder and enables a
closer look with greater details at the pelvic organs. The transabdominal
examination is performed with a full bladder and enables a wider, but less
discriminative, examination of the pelvis. The ultrasound scan can add many
details to the physical examination, such as a description of the uterine lining and
its width and and the presence of intramural or submucous fibroids intrauterine
polyps, and adnexal masses. Persistent thick and irregular endometrium is one of
the preoperative predictors of endometrial pathology and demands further
evaluation and tissue biopsy.
Sonohysterography is a modification of the pelvic ultrasound scan. The
ultrasound is performed following injection of saline by a thin catheter into the
uterus. This technique increases significantly the sensitivity of transvaginal
ultrasonography and has been used to evaluate the endometrial cavity for polyps,
fibroids, and other abnormalities.
Endometrial Biopsy
Methods of endometrial biopsy include use of the Novak suction curette, the
Duncan curette, the Kevorkian curette, or the Pipelle. Cervical dilatation is not
necessary with these instruments. Small areas of the endometrial lining are
sampled.
If bleeding persists and no cause of bleeding can be found or if the tissue obtained
is inadequate for diagnosis, hysteroscopy and, in some cases, formal dilatation and
curettage (D&C) must be performed.
Hysteroscopy
Placing an endoscopic camera through the cervix into the endometrial cavity
allows direct visualization of the cavity Because of its higher diagnostic accuracy
and suitability for outpatient investigation, hysteroscopy is increasingly replacing
D&C for the evaluation of abnormal uterine bleeding. Hysteroscopy currently is
regarded as the gold standard evaluation of pathology in the uterine cavity.
Resection attachments allow immediate capability to remove or biopsy lesions.
Dilatation & Curettage
, 4
For many years, D&C has been regarded as the gold standard for the diagnosis of
abnormal uterine bleeding. It can be performed with the patient under local or
general anesthesia, almost always in an outpatient or ambulatory setting. With
general anesthesia, relaxation of the abdominal musculature is greater, allowing for
a more thorough pelvic examination, more precise evaluation of pelvic masses, and
more complete curettage. Nevertheless, D&C is a blind procedure, and its
accuracy, particularly when the cause of the abnormal uterine bleeding is a focal
lesion such as a polyp, is debatable.
General Principles of Management
In making the diagnosis, it is important not to assume the obvious. A careful
history and pelvic examination are vital. The possibility of pregnancy must be
considered, as well as use of oral contraceptives, IUDs, and hormones.
Another important evaluation during the workup of abnormal uterine bleeding is to
decide whether the bleeding is associated with ovulatory or anovulatory cycles. In
ovulatory cycles, the bleeding might be due to a persistent corpus luteum cyst or
short luteal phase. In anovulatory cycles, the endometrium outgrows its blood
supply, partially breaks down, and is sloughed in an irregular manner. In these
cases, an organic cause of anovulation must be excluded (eg, thyroid or adrenal
abnormalities). Conversion from proliferative to secretory endometrium (by
combined oral contraceptive pills or progesterone in the luteal phase) corrects most
acute and chronic bleeding problems.
Improved diagnostic techniques and treatment have resulted in decreased use of
hysterectomy to treat abnormal bleeding patterns. If pathologic causes (eg,
submucous myomas, adenomyosis) can be excluded, if there is no significant risk
for cancer development (as from atypical endometrial hyperplasia), and if there is
no acute life-threatening hemorrhage, most patients can be treated with hormone
preparations or minimally invasive procedures, which are considered as
alternatives to hysterectomy. Myomectomy (hysteroscopic, laparoscopic, or
conservative) can be suggested for treatment of myoma if the patient wishes to
retain her childbearing potential. Endometrial ablation and endometrial resection
may offer successful outpatient and in-office alternatives.
For menorrhagia, antifibrinolytic therapy has been shown to significantly decrease
blood loss during menses, as have prostaglandin synthetase inhibitors. Long-acting
intramuscular progestin administration (Depo-Provera) can be given but may result
in erratic bleeding or even amenorrhea. Finally, levonorgestrel-releasing IUDs are
as effective as endometrial resection in decreasing blood loss.
Abnormal Bleeding Due to Nongynecologic Diseases & Disorders
In the differential diagnosis of abnormal bleeding, nongynecologic causes of
bleeding (eg, rectal or urologic disorders) must be ruled out, because patients may
have difficulty differentiating the source of bleeding. Gynecologic and
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