Abnormal Vaginal Bleeding
Study guide:
Definitions:
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Menorrhagia: regular cycles with excessive flow (>80 ml), duration (>7days), or both.
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Metrorrhagia: bleeding occurring at frequent, irregular intervals.
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Menometrorrhagia: utrine bleeding that is prolonged and excessive, frequent and irregular.
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Polymenorrhea: regular bleeding at intervals of less than 21 days.
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Oligomenorrhea: regular bleeding at intervals of more than 35 days.
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Intermenstrual bleeding: uterine bleeding between regular cycles.
Ovulatory cycle : Regular cycle length
Anovulatory cycle : Unpredictable
Etiology (in general):
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Ovulatory cycle
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Anovulatory cycle
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Regular cycle length
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Unpredictable
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Generally, Imbalance between estrogen and progesterone.
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Sructural abnormalities like fibroids, polyps, or endometrial hyperplasia.
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Cancer.
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Systemic illness: coagulation disorders, platelet abnormalities, and renal or hepatic problems.
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Obesity increases peripheral estrogen production witch interfere with HP axis.
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Endocrine problems: thyroid diseases, adrenal diseases, and prolactin disorders.
Pathogenesis:
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Low level of estrogen for a long time is associated with thin endometrium and intermittent spotting with light bleeding.
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High Levels of estrogen →proliferation of endometrium (without sufficient progesterone) → abnormal thickness (outgrows vascular support) → endometrium sloughs off.
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Resulting in estrogen break through bleeding (Anovulatory cycle) e.g. PCO.
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Sudden estrogen withdrawal after ovulation → self-limited vaginal bleeding (mid-cycle spotting), (ovulatory cycle).
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High Progesterone to estrogen ratio → endometrium becomes atrophic and ulcerated causing progesterone breakthrough bleeding (Metrorrhagia).
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Abnormal hypothalamic – pituitary – ovarian axis → abnormal follicle development → corpus luteum does not develop → deficiency in progesterone causing Dysfunctional Uterine Bleeding (DUB).
Approach to Vaginal Bleeding:
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History and physical examination.
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Initial tests:
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CBC & coagulation profile.
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Pregnancy test: urine and serum beta- hCG.
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Progesterone levels.
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Endocrine function tests: TSH, FSH, LH, prolactin, androgen, estrogen, and ovulatory function.
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Imaging:
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A. Ultrasound is considered the diagnostic modality of choice ->Transvaginal ultrasound is more sensitive than transabdominal.
B. CT is used if complications are suspected.
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Laparoscopy: can be diagnostic or operative in cases of ectopic pregnancy.

Figure 1: Approach to vaginal bleeding.
Management:
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Definitive treatment of vaginal bleeding is directed at the cause.
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If the patient in shock resuscitation should be initiated.
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Anemia should be treated with oral iron.
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Oral contraceptives are used to treat DUB
References:
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Lipsky, Martin S, and Mitchell S King. Blueprints Family Medicine. Baltimore, MD: Lippincott Williams & Wilkins, 2011. Print.Essentials of family medicine, Sloan 6th edition.
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Sloane, Philip D. Essentials Of Family Medicine. Philadelphia: Wolters Kluwer/Lippincott, Williams & Wilkins, 2008. Print.
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First Aid for obstetric & gynecology clerkship 3rd edition.
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Merck Manuals Professional Edition,. "Vaginal Bleeding - Gynecology And Obstetrics". N.p., 2016. Web. 10 Jan. 2016.
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Uptodate.com,. "Approach To Abnormal Uterine Bleeding In Nonpregnant Reproductive-Age Women". N.p., 2016. Web. 10 Jan. 2016.
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Kaufman, Matthew S. First Aid For The Obstetrics & Gynecology Clerkship. New York: McGraw-Hill Medical, 2011. Print.
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Lipsky, Martin S, and Mitchell S King. Blueprints Family Medicine. Baltimore, MD: Lippincott Williams & Wilkins, 2011. Print. (Figure1).
First author: Roaa Amer
Second authors : Abdullah AlAsaad
Lama AlLuhaidan
Reviewers: Abdulrahman Al Nasser
Bayan AlZomaili
Format Editor : Adel Yasky