MENSTRUAL ABNORMALITIES AND COMPLICATIONS pot

707

ABNORMAL UTERINE BLEEDING

Abnormal uterine bleeding may be caused by: hormonal factors,

complications of pregnancy, systemic diseases, endometrial abnor￾malities (polyps), uterine or cervical problems (leiomyomas), or

cancer. The pattern of abnormal bleeding is often very helpful in

determining the etiology; thus, a number of terms differentiate the

various types of abnormal uterine bleeding.

Menorrhagia (hypermenorrhea) is prolonged or heavy men￾strual flow that may be further complicated by clots. Menorrhagia

may be caused by leiomyomas (often submucous), pregnancy com￾plications, endometrial hyperplasia, adenomyosis, malignancy, or

coagulopathies.

Metrorrhagia (intermenstrual bleeding) is defined as bleeding

at any time between menstrual periods. The causes of metrorrhagia

include midcycle (ovulatory) bleeding, endometrial polyps, en￾dometrial or cervical cancer, endogenous estrogen production, and

exogenous estrogen administration.

Menometrorrhagia is bleeding occurring at irregular intervals.

Generally, the amount and duration of bleeding vary. The causes of

menometrorrhagia are the same as those of metrorrhagia.

Polymenorrhea is menstrual-like bleeding that occurs too fre￾quently. The usual cause of polymenorrhea is anovulation, but oc￾casionally a shortened luteal phase may be the fault.

Postcoital bleeding must be investigated to rule out cervical can￾cer, although the most common causes are benign and include cer￾vical eversion, cervical polyps, and cervical or vaginal infections.

Hypomenorrhea (cryptomenorrhea or spotting) is unusually

light menstrual bleeding. Possible causes are obstructions (e.g., hy￾menal or cervical), uterine synechiae (Asherman’s syndrome), and

inappropriate oral contraceptive dosage (correctable).

25

MENSTRUAL ABNORMALITIES

AND COMPLICATIONS

CHAPTER

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BENSON & PERNOLL’S

708 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

Oligomenorrhea is defined as menstruation occurring at an in￾terval
35 days.

The differential diagnosis of abnormal uterine bleeding must in￾clude the possibility of gynecologic but nonuterine bleeding. The

most common causes of vulvar and vaginal bleeding are: atrophic

vulvovaginitis, infectious vulvovaginitis, local trauma, and genital

cancer. Cervical causes of bleeding include eversion, erosion, cer￾vical polyps, pedunculated leiomyomas, and cancer. With the ex￾ception of tubal ectopic gestation, other causes of bleeding from

the uterine tube are unusual (e.g., fallopian tube cancer). The ovar￾ian causes of vaginal bleeding include functional ovarian cysts,

estrogen-producing tumors, polycystic ovaries (PCO), and ovarian

neoplasms.

Uterine causes of abnormal bleeding are endometritis, en￾dometrial hyperplasia, endometrial cancer, endometrial polyps, ade￾nomyosis, submucous leiomyomas, IUD abnormalities, or reaction

to oral contraceptives or exogenous steroids. Systemic conditions

that may cause abnormal uterine bleeding include hypothyroidism,

hepatic dysfunction (abnormal estrogen metabolism), coagu￾lopathies, blood dyscrasias, and extreme weight loss (e.g., eating

disorders or excessive exercise leading to anovulation). The use of

anticoagulants or adrenal steroids may also lead to abnormal uter￾ine bleeding.

Nongynecologic causes of bleeding that may be confused with

abnormal uterine bleeding include anorectal or urological problems.

The history of abnormal uterine bleeding must detail the inter￾vals between bleeding, the duration and amount of the bleeding, the

character of the blood loss (e.g., color, consistency, and clots), and

when the abnormal pattern began. Additional information useful to

evaluate the bleeding, includes: obstetric history, contraceptive his￾tory, postcoital bleeding, LMP, LNMP, menarche (or menopause),

and alteration(s) in general health. A patient-generated contempo￾raneous menstrual record is useful.

Evaluation of abnormal uterine bleeding requires a general

physical examination, noting systemic health. In addition to the

pelvic examination, a cytologic smear assists to screen for cervical

(and in some cases uterine) malignancy. An enlarged or irregular

uterus suggests leiomyomas, and a symmetrically enlarged uterus

is more commonly noted with endometrial cancer or adenomyosis.

Pelvic examination should reveal vulvar, vaginal, and cervical le￾sions (e.g., atrophic, inflammatory, neoplastic), and bimanual ex￾amination should reveal uterine, tubal, or ovarian masses.

If pregnancy is not a factor (a pregnancy test may be required),

and the patient is in satisfactory hemodynamic status, the en￾dometrium may be sampled by endometrial aspiration, endometrial