Dysfunctional Uterine Bleeding in Emergency Medicine Clinical Presentation
- Author: Amir Estephan, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD more...
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.
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
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)
Endocrine problems or pituitary tumors
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. 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)
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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