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

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

3. 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

4. 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

5. 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

6. 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

7. Differential diagnosis
Pregnancy related complications
ectopic, inevitable

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

9. 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

10. 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

11. Differential diagnosis
Thyroid disease
Prolactinomas
Coagulation defects
Renal, liver failure

12. Differential diagnosis
Trauma
Foreign bodies

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

14. 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

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

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

17. 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)