History

Suspect abnormal uterine bleeding (AUB) when a patient presents with unpredictable or episodic heavy or light bleeding despite a normal pelvic examination.

Note the following:

Typically, the usual moliminal symptoms that accompany ovulatory cycles will not precede bleeding episodes.
Exclude the diagnosis of pregnancy first.
Address the presence of local and systemic disease. Rule out the presence of signs or symptoms indicative of bleeding disorders. Screening for personal and family history of easy bruising, bleeding gums, epistaxis, and excessive bleeding episodes during childbirth, surgery, or dental procedures may be useful.
Rule out iatrogenic causes of bleeding, including bleeding secondary to steroid hormone contraception, hormone replacement therapy, or other hormone treatments, which are common causes.
Many patients are adolescents or are older than 40 years.

Patients who report irregular menses since menarche may have polycystic ovarian syndrome (PCOS).^[43]PCOS is characterized by anovulation or oligo-ovulation and hyperandrogenism. These patients often present with unpredictable cycles and/or infertility, hirsutism with or without hyperinsulinemia, and obesity. A retrospective study by Maslyanskaya et al identified 125 female patients, 8-20 years of age, who were admitted for treatment of abnormal uterine bleeding and reported that PCOS accounted for 33% of admissions and was the most common underlying etiology. Other underlying causes were hypothalamic pituitary ovarian axis immaturity (31%); endometritis (13%); and bleeding disorders (10%).^[44]

Patients with adrenal enzyme defects, hyperprolactinemia, thyroid disease, or other metabolic disorders also might present with anovulatory bleeding.

Physical Examination

The physical examination can elicit several findings that suggest an etiology for AUB (see the Table below).

Table. Physical Findings in AUB (Open Table in a new window)

Examination	Finding	Differential
Vital signs	Tachycardia	Anemia Hypovolemia
Weight	Obesity	PCOS, weight-related anovulation
Eyes	Exophthalmos Periorbital edema	Graves disease Hypothyroidism
Neck	Thyromegaly	Hypothyroidism
Breasts	Galactorrhea	Hyperprolactinemia
Skin	Increased skin tags Acanthosis nigricans Hirsutism Ecchymosis, purpura	PCOS Insulin resistance PCOS, CAH, Cushing syndrome, androgen-secreting tumor Bleeding disorder
Pelvic examination	Cervical polyp/cervicitis/cervical ectropion Globally enlarged uterus Irregular uterus Adnexal mass	Adenomyosis Fibroids Ovarian cyst or mass
AUB = abnormal uterine bleeding; CAH = congenital adrenal hyperplasia; PCOS = polycystic ovary syndrome.

Differential Diagnoses

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Table. Physical Findings in AUB

Table. Physical Findings in AUB

Examination	Finding	Differential
Vital signs	Tachycardia	Anemia Hypovolemia
Weight	Obesity	PCOS, weight-related anovulation
Eyes	Exophthalmos Periorbital edema	Graves disease Hypothyroidism
Neck	Thyromegaly	Hypothyroidism
Breasts	Galactorrhea	Hyperprolactinemia
Skin	Increased skin tags Acanthosis nigricans Hirsutism Ecchymosis, purpura	PCOS Insulin resistance PCOS, CAH, Cushing syndrome, androgen-secreting tumor Bleeding disorder
Pelvic examination	Cervical polyp/cervicitis/cervical ectropion Globally enlarged uterus Irregular uterus Adnexal mass	Adenomyosis Fibroids Ovarian cyst or mass
AUB = abnormal uterine bleeding; CAH = congenital adrenal hyperplasia; PCOS = polycystic ovary syndrome.

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Author

Thomas Michael Price, MD Professor Emeritus, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Former Director of Reproductive Endocrinology and Infertility Fellowship Program, Duke University Medical Center

Thomas Michael Price, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Phi Beta Kappa, Society for Reproductive Endocrinology and Infertility, Society for Reproductive Investigation

Disclosure: Received research grant from: Insigtec Inc<br/>Received consulting fee from Clinical Advisors Group for consulting; Received consulting fee from MEDA Corp Consulting for consulting; Received consulting fee from Gerson Lehrman Group Advisor for consulting; Received honoraria from ABOG for board membership.

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.

Frances E Casey, MD, MPH Associate Professor, Director of Family Planning Services, Department of Obstetrics and Gynecology, VCU Medical Center

Frances E Casey, MD, MPH is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Reproductive Health Professionals, National Abortion Federation, Physicians for Reproductive Health, Society of Family Planning

Disclosure: Nothing to disclose.

Chief Editor

Richard Scott Lucidi, MD, FACOG Associate Professor of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine

Richard Scott Lucidi, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Anthony Charles Sciscione, DO Professor, Department of Obstetrics and Gynecology, Drexel University College of Medicine; Director, Maternal and Fetal Medicine, Christiana Care Health System; Director, Delaware Center for Maternal and Fetal Medicine

Anthony Charles Sciscione, DO is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association

Disclosure: Nothing to disclose.

Millie A Behera, MD Assistant Professor (Adjunct), Division of Reproductive Endocrinology and Fertility, Department of Obstetrics and Gynecology, Duke University Medical Center; Medical Director, Bloom Reproductive Institute

Millie A Behera, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, AAGL

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author John T Queenan, Jr, MD, to the development and writing of this article.

Sections Abnormal (Dysfunctional) Uterine Bleeding
Overview
Presentation
DDx
Workup
Treatment
Medication
Questions & Answers
Tables
References

Abnormal (Dysfunctional) Uterine Bleeding Clinical Presentation

History

Physical Examination

References

Tables

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