vaginal bleeding; abnormal uterine bleeding; anovulatory bleeding
Jump to navigation
Jump to search
Etiology
prepubertal
- vulvovaginitis
- vaginal trauma
- accidents from a fall on a sharp object
- foreign bodies
- sexual abuse
- urological abnormalities: urethral prolapse
- ovarian tumors (2/3 benign)
- follicular cysts
- juvenile granulosa cell tumor
- carcinomas (i.e. embryonal cell carcinoma) rare
- vaginal
- tumors, generally benign
- polyps
- hymenal tags
- hormonal stimulation
- menstruation secondary to precocious puberty
- exogenous estrogen exposure
- oral contraceptive ingestion
- bleeding disorder
reproductive age
- pregnancy
- early
- spontaneous abortion, ectopic pregnancy, gestational trophoblastic disease, lesions of the cervix or vagina
- late
- placenta previa (generally bright red, painless), abruptio placentae (generally dark red, painful)
- early
- hormonal abnormalities
- dysfunctional uterine bleeding
- endocrine diseases
- ovarian tumor or dysfunction
- hyperthyroidism
- hypothyroidism
- diabetes mellitus
- pituitary dysfunction
- adrenal tumor or dysfunction
- infections
- uterine pathology
- polyps (3% of women < 35, 23% of women > 35[2])
- fibroids (common) - intracavitary & intramural
- cervical polyps, lacerations or cervical carcinoma
- high risk of cervical cancer in patients with HIV1 infection, including those taking antiretroviral therapy[22]
- vaginal trauma, neoplasia, or atrophy
- vulvar atrophy or neoplasia
- systemic disease
- medications
- nutritional factors
perimenopausal
- endometrial cancer
- irregular menses for 9 months with period lasting 15 days is anovulatory bleeding warranting endometrial biopsy without transvaginal ultrasound[19][21]
- short-term (9 months) exposure to unopposed estrogen would place these women at sufficient risk for endometrial cancer to justify endometrial biopsy[19]
post-menopausal
- hormonal disturbances
- atrophic vaginitis/ genitourinary syndrome of menopause (most common)[7]
- estrogen withdrawal bleeding with cessation or interruption of HRT
- cervical lesions
- endometrial lesions (generally benign)
- polyps (23% of women > 35 have endometrial polyps[2])
- fibroids
- endometrial cancer (9% of postmenopausal vaginal bleeding)[16]
- endometrial atrophy, endometrial hyperplasia[7]
- ovarian neoplasm (functioning)[7]
- vaginal
- vaginitis
- vaginal neoplasm
- vaginal ulceration
- vulvar
- other
Epidemiology
History
- pattern of bleeding: onset, duration, intensity, clots, pads/day, last menstrual period, contraceptives, sexual history, sexual abuse, drug history, vasomotor flushing, pain, fever/chills, lightheadedness, coagulopathy, thyroid, renal or hepatic disease
Clinical manifestations
- hirsuitism or striae suggest adrenal disease
- petechiae or ecchymoses suggest bleeding disorder
- cervical abnormalities may be found
- enlarged uterus may suggest fibroids or pregnancy
Laboratory
- pregnancy test first line[3]
- complete blood count (CBC)
- other testing as indicated
Diagnostic procedures
- hysteroscopy if endometrial thickness cannot be visualized on ultrasound[10]
- endometrial biopsy (in office)
- premenopausal women > 45 years or obese (BMI >= 30) with anovulatory vaginal bleeding[3][19] or other risk factors for endometrial cancer*
- if < 35 years of age & no risk factors for endometrial cancer* hormonal therapy is appropriate[3]
- postmenopausal women with endometrial thickness > 5 mm[15][18]
- endometrial thickness determined by pelvic or transvaginal ultrasound
- endometrial biopsy may not be necessary in postmenopausal women without vaginal bleeding[15]
- postmenopausal women treated with tamoxifen*[17]
- failure of medical management[20]
- premenopausal women > 45 years or obese (BMI >= 30) with anovulatory vaginal bleeding[3][19] or other risk factors for endometrial cancer*
- dilatation & curettage
* risk factors for endometrial cancer
- prolonged unapposed estrogen stimulation of endometrium
- genetic syndromes: Lynch syndrome, Cowden syndrome
* irregular menstrual cycles suggests anovulatory vaginal bleeding[19]
Radiology
- pelvic or transvaginal ultrasound
- mean endometrial thickness correlates with endometrial cancer in postmenopausal women[3]
- sensitivity for endometrial cancer is 95% if thickness set for false-positive rate of 50%; 63% if thickness set for false-positive rate of 10%[3]
- not useful in premenopausal or perimenopausal women due to variation in endometrial thickness with hormonal levels[19]
- computed tomography
- magnetic resonance imaging
- hysterosalpingography
Management
- any vaginal bleeding in postmenopausal women is abnormal
- further evaluation indicated
- pelvic examination[7]
- endometrial biopsy to evaluate for endometrial cancer as indicated (see Diagnostic procedures/Special laboratory above)
- perineal hygiene
- antibiotics if indicated
- hormonal therapy
- combination oral contraceptives
- 4 pills daily for 4 days
- 3 pills daily for 3 days
- 1 pill daily for 1st 25 days of month for several months
- oral progestins
- 10 mg medroxyprogesterone for 1st 10-21 days of month[3]
- medroxyprogesterone for the 2nd 1/2 of the month will restore cyclic menses[3]
- levonorgestrel-releasing intrauterine system
- most effective hormonal treatment[5]
- approved in US only for contraception
- danazol (gonadotropin-releasing hormone agonist)
- intravenous estrogen 25 mg every 4-6 hours for 4-6 doses
- generally stops bleeding within 24 hours
- combination oral contraceptives
- transfusion if indicated
- non-steroidal anti-inflammatory agents
- Pap Smear & endometrial biopsy
- anovulatory bleeding in premenopausal women
- menstrual abnormalities taking oral contraceptives
- post-menopausal bleeding (beyond the initial months of beginning hormone replacement therapy)
- anovulatory bleeding in premenopausal women
- surgery
More general terms
More specific terms
- antepartum hemorrhage
- dysfunctional uterine bleeding (DUB)
- menometrorrhagia
- menorrhagia
- metrorrhagia
- polymenorrhagia
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 390-392
- ↑ 2.0 2.1 2.2 Journal Watch, Mass Med Soc 19(23):183 (Dec) 1999
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018,
- ↑ Journal Watch 22(10):78, 2002 Tabor A et al, Endometrial thickness as a test for endometrial cancer in women with postmenopausal vaginal bleeding. Obstet Gynecol 99:663, 2002 PMID: https://www.ncbi.nlm.nih.gov/pubmed/12039131
Runowicz CD, Can radiological procedures replace histologic examination in the evaluation of abnormal vaginal bleeding? Obstet Gynecol 99:529, 2002 PMID: https://www.ncbi.nlm.nih.gov/pubmed/12039104 - ↑ 5.0 5.1 Journal Watch 24(9):69, 2004
Kuppermann M, Varner RE, Summitt RL Jr, Learman LA, Ireland C, Vittinghoff E, Stewart AL, Lin F, Richter HE, Showstack J, Hulley SB, Washington AE; Ms Research Group. Effect of hysterectomy vs medical treatment on health-related quality of life and sexual functioning: the medicine or surgery (Ms) randomized trial. JAMA. 2004 Mar 24;291(12):1447-55. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15039411
Hurskainen R, Teperi J, Rissanen P, Aalto AM, Grenman S, Kivela A, Kujansuu E, Vuorma S, Yliskoski M, Paavonen J. Clinical outcomes and costs with the levonorgestrel-releasing intrauterine system or hysterectomy for treatment of menorrhagia: randomized trial 5-year follow-up. JAMA. 2004 Mar 24;291(12):1456-63. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15039412
Pitkin RM, Scott JR. Evaluating gynecological surgical procedures: trials and tribulations. JAMA. 2004 Mar 24;291(12):1503-4. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15039418 - ↑ Rahn DD et al Agency for Healthcare Research and Quality, Expert commentary Managing Numerous Outcomes: Experience from a Systematic Review of Abnormal Uterine Bleeding Trial http://guideline.gov/expert/expert-commentary.aspx?f=rss&id=24283
- ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - ↑ Fazio SB, Ship AN. Abnormal uterine bleeding. South Med J. 2007 Apr;100(4):376-82; quiz 383, 402. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17458397
- ↑ Burbos N, Musonda P, Giarenis I et al Age-related differential diagnosis of vaginal bleeding in postmenopausal women: a series of 3047 symptomatic postmenopausal women. Menopause Int. 2010 Mar;16(1):5-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20424279
- ↑ 10.0 10.1 Burbos N, Musonda P, Crocker SG Management of postmenopausal women with vaginal bleeding when the endometrium can not be visualized. Acta Obstet Gynecol Scand. 2012 Jun;91(6):686-91. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22443120
- ↑ Ronghe R, Gaudoin M. Women with recurrent postmenopausal bleeding should be re- investigated but are not more likely to have endometrial cancer. Menopause Int. 2010 Mar;16(1):9-11. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20424280
- ↑ 12.0 12.1 Timmermans A, Opmeer BC, Khan KS et al Endometrial thickness measurement for detecting endometrial cancer in women with postmenopausal bleeding: a systematic review and meta-analysis. Obstet Gynecol. 2010 Jul;116(1):160-7. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20567183
- ↑ 13.0 13.1 Paramsothy P et al. Bleeding patterns during the menopausal transition in the multi-ethnic Study of Women's Health Across the Nation (SWAN): A prospective cohort study. BJOG 2014 Apr 16 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24735184 <Internet> http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.12768/abstract
- ↑ Sweet MG, Schmidt-Dalton TA, Weiss PM, Madsen KP. Evaluation and management of abnormal uterine bleeding in premenopausal women. Am Fam Physician. 2012 Jan 1;85(1):35-43. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22230306 Free Article
- ↑ 15.0 15.1 15.2 15.3 American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 734: The role of transvaginal ultrasonography in evaluating the endometrium of women with postmenopausal bleeding. Obstet Gynecol 2018 May; 131:e124 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29683909
- ↑ 16.0 16.1 Clarke MA, Long BJ, Del Mar Morillo A et al Association of Endometrial Cancer Risk With Postmenopausal Bleeding in Women. A Systematic Review and Meta-analysis. JAMA Intern Med. Published online August 6, 2018. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30083701 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2695509
Matteson KA, Robison K, Jacoby VL Opportunities for Early Detection of Endometrial Cancer in Women With Postmenopausal Bleeding. JAMA Intern Med. Published online August 6, 2018. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30083765 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2695506 - ↑ 17.0 17.1 NEJM Knowledge+. Question of the Week. March 24, 2020 https://knowledgeplus.nejm.org/question-of-week/970/
- ↑ 18.0 18.1 Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
American College of Obstetricians and Gynecologists. ACOG Committee Opinion No 734. The role of transvaginal ultrasonography in evaluating the endometrium of women with postmenopausal bleeding. Obstet Gynecol. 2018 May;131(5):945-946. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29683904 https://journals.lww.com/greenjournal/Fulltext/2018/05000/ACOG_Committee_Opinion_No__734__The_Role_of.40.aspx
Clark MA, Long BJ, Del Mar Morillo A et al. Association of endometrial cancer risk with postmenopausal bleeding in women: a systematic review and meta-analysis. JAMA Intern Med. 2018;178(9):1210-1222 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30083701 PMCID: PMC6142981 Free PMC article https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2695509
Goldstein SR. Appropriate evaluation of postmenopausal bleeding. Menopause. 2018;25(12):1476 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30234731 - ↑ 19.0 19.1 19.2 19.3 19.4 19.5 Medical Knowledge Self Assessment Program (MKSAP) 19 American College of Physicians, Philadelphia 2022
- ↑ 20.0 20.1 American College of Obstetricians and Gynecologists. ACOG committee opinion no. 557: Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol. 2013;121:891-6. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23635706
- ↑ 21.0 21.1 Khafaga A, Goldstein SR. Abnormal uterine bleeding. Obstet Gynecol Clin North Am. 2019;46:595-605. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31677744
- ↑ 22.0 22.1 NEJM Knowledge+