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Dysfunctional Uterine Bleeding in Emergency Medicine Clinical Presentation

  • Author: Amir Estephan, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: Nov 08, 2015
 

History

Patients often present with complaints of amenorrhea, menorrhagia, metrorrhagia, or menometrorrhagia. The amount and frequency of bleeding and the duration of symptoms, as well as the relationship to the menstrual cycle, should be established. Ask patients to compare the number of pads or tampons used per day in a normal menstrual cycle to the number used at the time of presentation. The average tampon or pad absorbs 20-30 mL or vaginal effluent. Personal habits vary greatly among women; therefore, the number of pads or tampons used is unreliable. The patient should be questioned about the possibility of pregnancy.[3]

A reproductive history should always be obtained, including the following:

  • Age of menarche and menstrual history and regularity
  • Last menstrual period (LMP), including flow, duration, and presence of dysmenorrhea
  • Postcoital bleeding
  • Gravida and para
  • Previous abortion or recent termination of pregnancy
  • Contraceptive use, use of barrier protection, and sexual activity (including vigorous sexual activity or trauma)
  • History of sexually transmitted diseases (STDs) or ectopic pregnancy

Questions about medical history should include the following:

  • Signs and symptoms of anemia or hypovolemia (including fatigue, dizziness, and syncope)
  • Diabetes mellitus
  • Thyroid disease
  • Endocrine problems or pituitary tumors
  • Liver disease
  • Recent illness, psychological stress, excessive exercise, or weight change
  • Medication usage, including exogenous hormones, anticoagulants, aspirin, anticonvulsants, and antibiotics
  • Alternative and complementary medicine modalities, such as herbs and supplements

An international expert panel including obstetrician/gynecologists and hematologists has issued guidelines to assist physicians to better recognize bleeding disorders, such as von Willebrand disease, as a cause of menorrhagia and postpartum hemorrhage and to provide disease-specific therapy for the bleeding disorder.[9] Historically, a lack of awareness of underlying bleeding disorders has led to underdiagnosis in women with abnormal reproductive tract bleeding. The panel provided expert consensus recommendations on how to identify, confirm, and manage a bleeding disorder. If a bleeding disorder is suspected, evaluation for a coagulation problem is required and consultation with a hematologist is suggested.

An underlying bleeding disorder should be considered when a patient has any of the following:

  • Menorrhagia since menarche
  • Family history of bleeding disorders
  • Personal history of one or several of the following: Notable bruising without known injury, bleeding of oral cavity or GI tract without obvious lesion, and/or epistaxis longer than 10 minutes' duration (possibly necessitating packing or cautery)
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Physical

Vital signs, including postural changes, should be assessed. Initial evaluation should be directed at assessing the patient's volume status and degree of anemia. Examine for pallor and absence of conjunctival vessels to gauge anemia.

An abdominal examination should be performed. Femoral and inguinal lymph nodes should be examined. Stool should be evaluated for the presence of blood.

Patients who are hemodynamically stable require a pelvic speculum, bimanual, and rectovaginal examination to define the etiology of vaginal bleeding. A careful physical examination will exclude vaginal or rectal sources of bleeding. The examination should look for the following:

  • The vagina should be inspected for signs of trauma, lesions, infection, and foreign bodies.
  • The cervix should be visualized and inspected for lesions, polyps, infection, or intrauterine device (IUD).
  • Bleeding from the cervical os
  • A rectovaginal examination should be performed to evaluate the cul-de-sac, posterior wall of the uterus, and uterosacral ligaments.

Uterine or ovarian structural abnormalities, including leiomyoma or fibroid uterus, may be noted on bimanual examination.

Patients with hematologic pathology may also have cutaneous evidence of bleeding diathesis. Physical findings include petechiae, purpura, and mucosal bleeding (eg, gums) in addition to vaginal bleeding.

Patients with liver disease that has resulted in a coagulopathy may manifest additional symptomatology because of abnormal hepatic function. Evaluate patients for spider angioma, palmar erythema, splenomegaly, ascites, jaundice, and asterixis.

Women with polycystic ovary disease present with signs of hyperandrogenism, including hirsutism, obesity, acne, palpable enlarged ovaries, and acanthosis nigricans (hyperpigmentation typically seen in the folds of the skin in the neck, groin, or axilla)

Hyperactive and hypoactive thyroid can cause menstrual irregularities. Patients may have varying degrees of characteristic vital sign abnormalities, eye findings, tremors, changes in skin texture, and weight change. Goiter may be present.

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Contributor Information and Disclosures
Author

Amir Estephan, MD Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, Brooklyn

Amir Estephan, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Mark Zwanger, MD, MBA Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

Steven A Conrad, MD, PhD Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center

Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Nedra R Dodds, MD, to the development and writing of this article.

References
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