Dysfunctional Uterine Bleeding Clinical Presentation

  • Author: Amir Estephan, MD; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: Feb 1, 2010
 

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.[5] 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 1 or several of the following:
      • Notable bruising without known injury
      • Bleeding of oral cavity or GI tract without obvious lesion
      • Epistaxis >10 min 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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Causes

  • Systemic disease, including thrombocytopenia, hypothyroidism, hyperthyroidism, Cushing disease, liver disease, diabetes mellitus, and adrenal and other endocrine disorders, can present as abnormal uterine bleeding.
  • Pregnancy and pregnancy-related conditions may be associated with vaginal bleeding.
  • Trauma to the cervix, vulva, or vagina may cause abnormal bleeding.
  • Carcinomas of the vagina, cervix, uterus, and ovaries must always be considered in patients with the appropriate history and physical examination findings. Endometrial cancer is associated with obesity, diabetes mellitus, anovulatory cycles, nulliparity, and age older than 35 years.
  • Other causes of abnormal uterine bleeding include structural disorders, such as functional ovarian cysts, cervicitis, endometritis, salpingitis, leiomyomas, and adenomyosis. Cervical dysplasia or other genital tract pathology may present as postcoital or irregular bleeding.
  • Polycystic ovary disease results in excess estrogen production and commonly presents as abnormal uterine bleeding.
  • Primary coagulation disorders, such as von Willebrand disease, myeloproliferative disorders, and immune thrombocytopenia, can present with menorrhagia.
  • Excessive exercise, stress, and weight loss cause hypothalamic suppression leading to abnormal uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian pathway.
  • Bleeding disturbances are common with combination oral contraceptive pills as well as progestin-only methods of birth control. However, the incidence of bleeding decreases significantly with time. Therefore, only counseling and reassurance are required during the early months of use.
  • Contraceptive intrauterine devices (IUDs) can cause variable vaginal bleeding for the first few cycles after placement and intermittent spotting subsequently. The progesterone impregnated IUD (Mirena) is associated with less menometrorrhagia and usually results in secondary amenorrhea.[2]
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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, and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Coauthor(s)

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

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Pfizer Salary Employment

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. Frick KD, Clark MA, Steinwachs DM, et al. Financial and quality-of-life burden of dysfunctional uterine bleeding among women agreeing to obtain surgical treatment. Womens Health Issues. Jan-Feb 2009;19(1):70-8. [Medline].

  2. Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG. Abnormal uterine bleeding. In: Williams Gynecology. McGraw-Hill; 2008:Chap 8.

  3. Tibbles CD. Selected gynecologic disorders. In: Marx JA, Hockberger RS, Walls RM, Adams JG. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 1. 7th ed. Mosby (Elsevier); 2009:Chap 98.

  4. Pitkin J. Dysfunctional uterine bleeding. BMJ. May 26 2007;334(7603):1110-1. [Medline].

  5. [Guideline] James AH, Kouides PA, Abdul-Kadir R, et al. Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel. Am J Obstet Gynecol. Jul 2009;201(1):12.e1-8. [Medline].

  6. Casablanca Y. Management of dysfunctional uterine bleeding. Obstet Gynecol Clin North Am. Jun 2008;35(2):219-34, viii. [Medline].

  7. [Best Evidence] Hickey M, Higham J, Fraser IS. Progestogens versus oestrogens and progestogens for irregular uterine bleeding associated with anovulation. Cochrane Database Syst Rev. Oct 17 2007;CD001895. [Medline].

  8. Dickersin K, Munro MG, Clark M, et al. Hysterectomy compared with endometrial ablation for dysfunctional uterine bleeding: a randomized controlled trial. Obstet Gynecol. Dec 2007;110(6):1279-89. [Medline].

 
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