Abnormal Uterine Bleeding Peter J. Chen, M.D. Clinical Assistant Professor Department of Obstetrics and Gynecology Hospital of the University of Pennsylvania

What is normal uterine bleeding? Age of patient Frequency Duration Flow

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

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

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

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

Differential diagnosis Pregnancy related complications ectopic, inevitable

Differential diagnosis Disease of the cervix Polyp, ectropian, dysplasia, invasive cancer

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

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

Differential diagnosis Thyroid disease Prolactinomas Coagulation defects Renal, liver failure

Differential diagnosis Trauma Foreign bodies

Differential diagnosis Medications Hormonal contraceptives Hormone replacement therapy Phytoestrogens, ginseng SSRIs

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

Evaluation History and physical Labs Pregnancy test CBC TSH Prolactin (Liver function tests) (Coagulation panels) (Androgen profile) Testosterone, DHEAS, Hydroxyprogesterone

Evaluation (cont) Cytopathology Imaging studies Surgical Pap Endometrial biopsy Imaging studies Surgical D&C hysteroscopy

Treatments Medical therapy Surgical therapy Radiologic therapy Hormonal Progestin, estrogen (IV), combination OCPs GnRH agonist Surgical therapy D&C Endometrial ablation Myomectomy/hysterectomy Radiologic therapy Uterine artery embolization (UAE)