Abnormal Vaginal Bleeding

Last updated On August 29th, 2021

Basic Terms

• Menorrhagia –

Prolonged (>7 days) and/or heavy (>80 mL) uterine bleeding occurring at regular intervals.

• Metrorrhagia –

Variable amounts of intermenstrual bleeding occurring at irregular but frequent intervals.

• Polymenorrhea  –

An abnormally short interval (<21 days) between regular menses.

• Oligomenorrhea –

An abnormally long interval (>35 days) between regular menses.

Causes of Abnormal Vaginal Bleeding

Organic Causes –

1 Reproductive tract disease

  •  Pregnancy-related conditions are the most common causes of abnormal vaginal bleeding in women of reproductive age (threatened, incomplete, and missed abortion; ectopic pregnancy ; and gestational trophoblastic disease. Implantation bleeding is also quite common at about the time of the first missed menstrual period.
  • Uterine lesions commonly produce menorrhagia or metrorrhagia by increasing endometrial surface area, distorting the endometrial vasculature, or having a friable/inflamed surface.
  • Cervical lesions usually result in metrorrhagia (especially postcoital bleeding) due to erosion or direct trauma.
  • Iatrogenic causes include the intrauterine device (IUD), oral/ injectable steroids for contraception or hormone replacement, and tranquilizers or other psychotropic drugs. Oral contraceptives are often associated with irregular bleeding during the first 3 months of use, if doses are missed or the patient is a smoker. Long-acting progesteroneonly contraceptives (Depo-Provera, Nexplanon) frequently cause irregular bleeding. Some patients may be unknowingly taking herbal medications that have an impact on the endometrium.

2 Systemic Disease

  • Blood dyscrasias such as von Willebrand disease and prothrombin deficiency may present with profuse vaginal bleeding during adolescence. Other disorders that produce platelet deficiency (leukemia, severe sepsis) may also present as irregular bleeding.
  • Hypothyroidism is frequently associated with menorrhagia and/or metrorrhagia. Hyperthyroidism is usually not associated with menstrual abnormalities, but oligomenorrhea and amenorrhea are possible.
  • Cirrhosis is associated with excessive bleeding secondary to the reduced capacity of the liver to metabolize estrogens.

Dysfunctional (endocrinologic) Causes –

The diagnosis of dysfunctional uterine bleeding (DUB) can be made after organic, systemic, and iatrogenic causes for abnormal vaginal bleeding have been ruled out (diagnosis of exclusion).

1 Anovulatory DUB

  • The predominant type in the postmenarchal and premenopausal years due to alterations in neuroendocrinological function.
  • Characterized by continuous production of estradiol-17β without corpus luteum formation and progesterone release.
  • Unopposed estrogen leads to continuous proliferation of the endometrium which eventually outgrows its blood supply and is sloughed in an irregular, unpredictable pattern.

2 Ovulatory DUB

  •  Incidence: up to 10% of ovulatory women.
  •  Mid-cycle spotting following the LH surge is usually physiologic. Polymenorrhea is most often due to the shortening of the follicular phase of menstruation. Alternatively, the luteal phase may be prolonged by a persistent corpus luteum.

Diagnosis –

  • Patient age is the most important factor in the evaluation.
  • Ruling out pregnancy-related complications should be the first priority in all women of reproductive age.
  • A complete list of medications is essential to rule out their interference with normal menstruation.
  •  Non-gynecologic physical findings (thyromegaly, hepatomegaly) may suggest the presence of an underlying systemic disorder. Genitourinary (urinary infection) or gastrointestinal (hemorrhoids) bleeding may also be mistakenly interpreted by the patient as vaginal bleeding.
  • Pelvic examination may reveal an obvious structural abnormality (cervical polyp), but frequently additional evaluation is necessary.
  •  Measurement of serum hemoglobin concentration, iron levels, and ferritin levels is an objective measure of the quantity and duration of menstrual blood loss. Additional laboratory tests (thyroid-stimulating hormone, coagulation profile) may be indicated.
  • A menstrual calendar may be helpful in accurately determining the amount, frequency, and duration of the bleeding.
  • Ovulation can be assessed by careful history taking and, if necessary, ovulation prediction kits .
  • Further evaluation of the uterus can be achieved in non-pregnant women by performing an endometrial biopsy or hysteroscopy. Pelvic ultrasound may also be indicated if the cause of bleeding cannot be confirmed.

Medical Management

The majority of women with abnormal vaginal bleeding can be treated medically, particularly in the absence of a structural lesion.

  • Oral contraceptives effectively correct the vast majority of common menstrual irregularities (anovulatory and ovulatory DUB). However, DUB can occasionally present as an acute hemorrhage requiring shortterm, high-dose oral or intravenous estrogen therapy to transiently support the endometrium.
  • Non-steroidal anti-inflammatory drugs (mefenamic acid) have been shown to reduce menstrual blood loss, particularly in ovulatory patients. Surgical management Structural abnormalities frequently require surgical intervention to alleviate symptoms.
  • Dilation and curettage (D&C) can be both diagnostic and therapeutic, especially in women with acute vaginal bleeding due to endometrial overgrowth.
  • Hysteroscopy is an office or day-surgery procedure that can be used to diagnose and treat abnormal uterine lesions. The uterine cavity is distended with fluid, allowing direct visualization of the abnormality and use of hysteroscopic instruments.
  •  Endometrial ablation (such as NovaSure) can dramatically reduce the amount of cyclic blood loss.
  • Hysterectomy is usually reserved for women with structural lesions not amenable to more conservative surgery (multiple large leiomyomas, uterine prolapse). It may also be indicated in women with persistent DUB, but only if medical therapy has failed.