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Abnormal Vaginal Bleeding

Study guide:

Definitions:

  • Menorrhagia: regular cycles with excessive flow (>80 ml), duration (>7days), or both.

  • Metrorrhagia:  bleeding occurring at frequent, irregular intervals.

  • Menometrorrhagia: utrine bleeding that is prolonged and excessive, frequent and irregular.

  • Polymenorrhea: regular bleeding at intervals of less than 21 days.

  • Oligomenorrhea: regular bleeding at intervals of more than 35 days.

  • Intermenstrual bleeding: uterine bleeding between regular cycles.

Ovulatory cycle : Regular cycle length

Anovulatory cycle : Unpredictable

Etiology (in general):

  • Ovulatory cycle

  • Anovulatory cycle

  • Regular cycle length

  • Unpredictable

  • Generally, Imbalance between estrogen and progesterone. 

  • Sructural abnormalities like fibroids, polyps, or endometrial hyperplasia.

  • Cancer.

  • Systemic illness: coagulation disorders, platelet abnormalities, and renal or hepatic problems.

  • Obesity increases peripheral estrogen production witch interfere with HP axis.

  • Endocrine problems: thyroid diseases, adrenal diseases, and prolactin disorders. 

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Pathogenesis:

  • Low level of estrogen for a long time is associated with thin endometrium and intermittent spotting with light bleeding.

  • High Levels of estrogen →proliferation of endometrium (without sufficient progesterone) → abnormal thickness (outgrows vascular support) → endometrium sloughs off.

    • Resulting in estrogen break through bleeding (Anovulatory cycle) e.g. PCO.

  • Sudden estrogen withdrawal after ovulation → self-limited vaginal bleeding (mid-cycle spotting), (ovulatory cycle).

  • High Progesterone to estrogen ratio → endometrium becomes atrophic and ulcerated causing progesterone breakthrough bleeding (Metrorrhagia).

  • 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:

  • History and physical examination.

  • Initial tests:

    1. CBC & coagulation profile.

    2. Pregnancy test: urine and serum beta- hCG.

    3. Progesterone levels.

    4. Endocrine function tests: TSH, FSH, LH, prolactin, androgen, estrogen, and ovulatory function.

    5. Imaging:

       

 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.

  • If the patient in shock resuscitation should be initiated.

  • Anemia should be treated with oral iron.

  • Oral contraceptives are used to treat DUB​​

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References:

  • Lipsky, Martin S, and Mitchell S King. Blueprints Family Medicine. Baltimore, MD: Lippincott Williams & Wilkins, 2011. Print.Essentials of family medicine, Sloan 6th edition.

  • Sloane, Philip D. Essentials Of Family Medicine. Philadelphia: Wolters Kluwer/Lippincott, Williams & Wilkins, 2008. Print.

  • First Aid for obstetric & gynecology clerkship 3rd edition.

  • Merck Manuals Professional Edition,. "Vaginal Bleeding - Gynecology And Obstetrics". N.p., 2016. Web. 10 Jan. 2016.

  • Uptodate.com,. "Approach To Abnormal Uterine Bleeding In Nonpregnant Reproductive-Age Women". N.p., 2016. Web. 10 Jan. 2016.

  • Kaufman, Matthew S. First Aid For The Obstetrics & Gynecology Clerkship. New York: McGraw-Hill Medical, 2011. Print.

  • Lipsky, Martin S, and Mitchell S King. Blueprints Family Medicine. Baltimore, MD: Lippincott Williams & Wilkins, 2011. Print. (Figure1). 

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First author:          Roaa Amer

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Second authors :  Abdullah AlAsaad

                            Lama AlLuhaidan

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Reviewers:            Abdulrahman Al Nasser

                            Bayan AlZomaili

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Format Editor :    Adel Yasky 

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