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Abnormal Uterine Bleeding Peter J. Chen, M.D. Clinical Assistant Professor Department of Obstetrics and Gynecology Hospital of the University of Pennsylvania What is normal uterine bleeding? Age of patient Frequency Duration Flow What is normal uterine bleeding? Frequency of menses

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abnormal uterine bleeding

Abnormal Uterine Bleeding

Peter J. Chen, M.D.

Clinical Assistant Professor

Department of Obstetrics and Gynecology

Hospital of the University of Pennsylvania

what is normal uterine bleeding
What is normal uterine bleeding?
  • Age of patient
  • Frequency
  • Duration
  • Flow
what is normal uterine bleeding3
What is normal uterine bleeding?
  • Frequency of menses
    • 21 days (0.5%) to 35 days (0.9%)
      • Age 25, 40% are between 25 and 28 days
      • Age 25-35, 60% are between 25 and 28 days
      • Teens and women over 40’s cycles may be longer apart

Munster K et al, Br J Obstet Gynaecology

what is normal uterine bleeding4
What is normal uterine bleeding?
  • Duration of menses
    • 2 days to 8 days
      • Usually 4-6 days

Hallberg L et al, Acta Obstet Gynecology Scandinavica

what is normal uterine bleeding5
What is normal uterine bleeding?
  • Flow/amount of menses
    • Normal volume of menstrual blood loss is 30 cc

Hallberg L et al, Acta Obstet Gynecology Scandinavica

traditional terminologies
Traditional terminologies
  • Menorrhagia
    • Regular intervals, excessive menstrual blood loss
      • amount >80mL
  • Metrorrhagia
    • Irregular intervals, excessive flow and duration
  • Oligomenorrhea
    • Interval longer than 35 days
  • Polymenorrhea
    • Interval less than 21 days

Cohen BJB et al, Obstetrical and Gynecologic Survey

differential diagnosis
Differential diagnosis
  • Pregnancy related complications
    • ectopic, inevitable
differential diagnosis8
Differential diagnosis
  • Disease of the cervix
    • Polyp, ectropian, dysplasia, invasive cancer
differential diagnosis9
Differential diagnosis
  • Disease of the uterus
    • Infection: endometritis
    • Endometrial polyp, adenomyosis, hyperplasia, adenocarcinoma
    • Fibroids
      • One third of patients with symptoms
        • Correlation between the severity of the bleeding and the area of endometrial surface
          • Sehgal N, et al American Journal of Surgery
        • Histologic abnormalities of the endometrium, ranging from atrophy to hyperplasia
          • Deligdish, et al Journal of Clinical Pathology
        • Endometrial venule ectasia
          • Faulkner RL American J of Obstetrics and Gynecology; Farrer-Brown G, et al Journal of Obstetrics and Gynaecology Br Common W
differential diagnosis10
Differential diagnosis
  • Disease of the ovary
    • Germ cell tumors
      • Choriocarcinomas
      • Embryonal carcinoma
    • Sex cord-stromal tumors
      • Granulosa cell tumors(1-2% of all ovarian tumors)
        • Peak incidence between 50 and 55 years of age
differential diagnosis11
Differential diagnosis
  • Thyroid disease
  • Prolactinomas
  • Coagulation defects
  • Renal, liver failure
differential diagnosis12
Differential diagnosis
  • Trauma
  • Foreign bodies
differential diagnosis13
Differential diagnosis
  • Medications
    • Hormonal contraceptives
    • Hormone replacement therapy
    • Phytoestrogens, ginseng
    • SSRIs
differential diagnosis14
Differential diagnosis
  • Dysfunctional uterine bleeding
    • Anovulatory cycles
      • Loss of normal regulatory mechanism
        • Immaturity
        • Dysfunction
          • Psychiatric medications, stress, anxiety, exercise, rapid weight loss, anorexia nervosa
      • Ovarian failure
      • Obesity
      • PCOS
evaluation
Evaluation
  • History and physical
  • Labs
    • Pregnancy test
    • CBC
    • TSH
    • Prolactin
    • (Liver function tests)
    • (Coagulation panels)
    • (Androgen profile)
      • Testosterone, DHEAS, Hydroxyprogesterone
evaluation cont
Evaluation (cont)
  • Cytopathology
    • Pap
    • Endometrial biopsy
  • Imaging studies
  • Surgical
    • D&C hysteroscopy
treatments
Treatments
  • Medical therapy
    • Hormonal
      • Progestin, estrogen (IV), combination OCPs
      • GnRH agonist
  • Surgical therapy
    • D&C
    • Endometrial ablation
    • Myomectomy/hysterectomy
  • Radiologic therapy
    • Uterine artery embolization (UAE)