Abnormal uterine bleeding

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Nima Nasiri, M.D.[2]Farman Khan, MD, MRCP [3]

Causes

Common Causes


Causes by Organ System

Cardiovascular No underlying causes
Chemical / poisoning No underlying causes
Dermatologic No underlying causes
Drug Side Effect Blood thinners, breakthrough bleeding in women using hormonal birth control, copper intrauterine device , depo-Provera

hormone replacement therapy, tamoxifen, corticosteroids, chemotherapy, clomiphene, dilantin, antipsychotic drugs , antibiotics ( due to toxic epidermal necrolysis or Stevens-Johnson syndrome )

Ear Nose Throat No underlying causes
Endocrine Diabetes, hyperthyroidism, hypothyroidism, Cushing's syndrome, Hormone secreting adrenal and ovarian tumors
Environmental No underlying causes
Gastroenterologic Liver disease
Genetic No underlying causes
Hematologic Clotting disorders, Von Willebrand disease, thrombocytopenia or platelet dysfunction,

acute leukemia ,Some factor deficiencies, Advanced liver disease

Iatrogenic Radiation therapy
Infectious Disease Chlamydia, gonorrhea, uterine infection, genitourinary tract infection, bacterial vaginosis

sexually transmitted diseases, atrophic vaginitis

Musculoskeletal / Ortho No underlying causes
Neurologic No underlying causes
Nutritional / Metabolic No underlying causes
Obstetric/Gynecologic Adenomyosis, atrophy of the tissue lining the vagina and uterus, cervicitis, ectopic pregnancy, endometrial hyperplasia, endometritis, uterine sarcoma, first few months after the first menstrual period, first few weeks after abortion, first few weeks after delivery, intrauterine device, miscarriage, ovarian cysts, placenta previa, polycystic ovarian syndrome, retained products of conception, uterine fibroids, uterine polyps, diseases involving the vulva for example Crohn's disease, Behcet's syndrome , pemphigoid , pemphigus , erosive lichen planus , lymphoma, skin tags, sebaceous cysts, condylomata, angiokerataoma
Oncologic Cancer or precancer of the cervix , cancer or precancer of the endometrium, ovarian cancer, uterine cancer, uterine sarcoma
Opthalmologic No underlying causes
Overdose / Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal / Electrolyte Chronic renal disease
Rheum / Immune / Allergy No underlying causes
Sexual Sexual abuse
Trauma Sexual intercourse , sexual abuse , foreign bodies (including IUD) , pelvic trauma, Straddle injuries
Urologic Genitourinary tract infection
Dental No underlying causes
Miscellaneous Foreign body, irritation of the genital area due to bubble baths, soaps, lotions or infection, smoking,

Excessive exercise

Causes in Alphabetical Order


Treatment

Contraindicated medications


Template:Abnormal uterine bleeding Editor-In-Chief: C. Michael Gibson, M.S., M.D. [4] Associate Editor(s)-in-Chief: Nima Nasiri, M.D.[5]

Overview

Abnormal uterine bleeding is defined as any alteration in the amount of menstrual blood flow or duration of menstruation. Women can experience heavy menstrual bleeding or irregular menstrual bleeding or combination of both. Normal menstruation occurs every 21 to 35 days and lasts 3 to 7 days.The diagnosis and evaluation of abnormal uterine bleeding is based on patient's assessment of her blood loss and its impact on her health status. There are structural and non-structural causes of abnormal uterine bleeding. Causes of abnormal uterine bleeding can be cervical cancer, cervical leiomyoma, polyps, coagulation disorders.

Abnormal uterine bleeding differential diagnosis

  • Abnormal uterine bleeding differential diagnosis include:[1][2]
  • Endometrial hyperplasia
  • Cervical polyp
  • Cervical leiomyoma
  • Cervical lymphoma
  • Cervical sarcoma
  • Metastases to the cervix
  • Cervical ectopic pregnancy
  • Cervicitis
  • Cervical erosion ( Ectropion )
  • IUD use
  • Pelvic inflammatory disease
  • Endometriosis
  • Adenomyosis
  • Postcoital bleeding
  • Clear cell adenocarcinoma
  • Hematologic causes:
    • Von willebrand disease
    • Thrombocytopenia
    • Clotting disorder
    • Platelet dysfunction
    • Factors deficiency
Abnormal Uterine bleeidng differential diagnosis
Ob-Gyn neoplasm and diseases Clinical manifestations Para-clinical findings Gold standard
Symptoms Physical exam Lab Findings Imaging Histopathology
Abnormal

vaginal bleeding

Other GU/GI symptoms Abdominal pain Pelvic

pain

Constitutional symptoms Gynecological examinations Abdominal

mass

HPV

Pap smear

STI panel

Other labs Ultrasound Other

imagings

Cervical cancer[3][4][5][6][7][8][9][10]

+

+ +
  • Cervical mass on exam
+ ± HPV T2-weighted MRI :
  • Ovoid, heterogeneous tumor distending the cervical canal with stromal involvement. PET/CT scan:
Cervical intraepithelial neoplasia:
Cervical polyp[11]
  • Mass on exam
  • RBC count
  • ↓ Hb, ↓ Hct
  • ↓ Serum Iron
  • Hyper/hypoechogenic masses with or without cysts
  • Filling the endocervical or vaginal canal
Cervical leiomyoma[12][13][14][15][16][17][18][19][20]
  • Heavy/prolonged menstrual bleeding
  • Intermenstrual bleeding
+ + ±
  • Well circumscribed hyperechoic mass
T2-weighted MRI:
  • Hypointense masses
  • Homogeneous

enhancement

  • Red degeneration
  • Clinical diagnosis/ and
Cervical lymphoma[21][22][23]
  • Difficulty urinating
  • Post-coital pain
+ + +
  • Irregularity
+ Pap smear:
  • Small round blue cells
  • High nuclear/cytoplasm ratio,
  • Scant cytoplasm
Immunohistochemistry markers:
  • Well-defined, solid, concentric, hypoechoic mass
MRI:
  • Intramyometrial infiltrative nodules
Cervical sarcoma[24][25][26][27] + + ± + Leiomyosarcoma markers: MRI:
  • Endometrial polypoid mass
  • Hypointense hypervascular solid components
Cervical erosion(Ectropion)[28][29][30][31][32]
  • Light bleeding after pelvic exam
  • Spotting
  • Post-coital pain
  • Painful cramps
+ + N/A N/A N/A
Cervicitis[33][34][35][36][37]
  • Intermenstrual bleeding
  • Postcoital
  • Bleeding after pelvic exam
  • Pain during urination
+ +
  • May have fever only
  • Red,inflammed swollen cervix
  • Inflammation/irritation of vulva/vagina
STI panel:
MRI:

May be detected as retention cysts in cervix.

Endometrial carcinoma[38][39][40][41][42]

bleeding

  • Pain during sex
  • Fulness in pelvic
  • Difficulty emptying bladder
+ + ±
  • Often normal
+
  • Myometrial invasion

T1-weighted MRI:

  • Hypo-to-isointense

T2-weighted MRI:

  • Intermediate signal intensity lower than the normal endometrium
Type I endometrioid endometrial carcinomas (EECs):
  • Moderately differentiated
  • Superficial invasion into the myometrium

Type II non-endometrioid endometrial carcinomas (NEECs):

Endometrial hyperplasia[43][44][45]
  • +
+
  • Normal or thickened endometrium
± N/A

T1-weighted MRI:

  • Hypo-to-isointense
  • Complex hyperplasia
  • Simple hyperplasia with atypia
Endometriosis[46][47][48][49][50][51][52]
  • Heavy mentrual bleeding
+ +

(limited value)

  • Ground glass echogenicity of the cyst fluid (Endometrioma)
  • Cysts are unilocular
Pelvic inflammatory diseases[53][54][55][56]
  • Bleeding after sex
  • Intermenstrual bleeding
  • Pelvic pain
+
  • Oral temperature >101F
  • Vaginal/vulvar tender lesion depending on microbial causes
STI panel:
  • WBC
  • Oral temperature >101F
Ultrasound:
  • Thickened, fluid-filled tubes with or without free pelvic or tubo-ovarian complex
MRI findings:
  • Inflammation in pelvic soft tissue
  • Clinical diagnosis is gold standard for diagnosing PID
Adenemyosis[57][58][59][60][61][62]
  • Abnormal uterine bleeding
  • Painful menstruation
+ +
  • Polypoid mass protruding into the endocervical canal.
  • Subendometrial striations
  • Myometrial cysts
  • Asymetrical thickness in myometrium walls
  • Heterogenous echotexture of myometrum
MRI:
  • Thickened junctional zone
  • Presence of ectopic endometrial glands into the myometrium.
Cervical ectopic pregnancy[63][64] +
  • Soft and disporportionally enlarged uterus.
± T2-weighted MRI:
  • Hypointense large mass

T1-weighted MRI:

  • Partially hyperintense mass
Vaginal cancer[65][66][67][68]
  • Postcoital bleeding
+ + ±
  • Ill-defined vaginal ulcer
Ultrasound: MRI:
  • Isointense on T1-weighted images
  • Soft-tissue mass with intermediate-to-high signal intensity on T2-weighted images
Biopsy findings:
Paget's disease of vulva to cervix[69][70][71][72][73]
  • Bleeding/oozing from lesion
  • Pain in vulva
  • Itching or burning sensation in vulva
  • Negative for S-100 and Melan-A
N/A MRI:
  • Hyperintense on diffusion weighted imaging
  • Thick vulvar skin
  • "Cake-icing effect", pathognomic for vulvar paget's disease
Nabothian cyst[74][75][76][77]
  • Postcoital bleeding
  • Majority of them are asymptomatic due to their small size (few milimeters)
N/A
  • Anechoic well defined cystic lesions
T1-weighted
  • Intermediate or slightly high signal intensity T2-weighted
  • High signal intensity on T2-weighted images
  • Benign cystic lesion
  • Multiple benign cystic masses, usually few milimieters in diameter.
IUD use[78][79][80]
  • Heavy bleeidng
+ +
  • Normal
  • May have decreased RBC count
  • Linear echogenic intrauterine structures
N/A N/A


Pregnancy and pregnancy related conditions Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Lab Findings Imaging Histopathology
Abnormal uterine bleeding Other symptoms
Miscarriage[81][82] +
  • Enlarged uterus
  • Blood clot in cervical os.
Ultrasound:
Abruptio placenta[83][84] +
  • Uterine tenderness
  • ↓ Fetal heart rate
  • ↓ Fetal movement

Ultrasound:

  • Uterine hypertonicity
  • Non-reassuring fetal heart
Placenta previa[85][86][87] +
  • Usually painless vaginal bleeding
  • Uterine contraction
  • Blood clot or spotting
Ultrasound:
  • Low lying placenta, less than 1cm from cervical os.
Ectopic pregnancy[88][89] + Ultrasound:
  • Absence of "Sliding sign" on gentle pressure of cervix
  • Tubal rupture
Associated conditions:
Molar pregnancy[90][91][92] +
  • Heavy vaginal bleeding
Ultrasound:
  • Complex and echogenic intrauterine mass
  • Containing many small cystic spaces
  • Classical "snow storm" appearance
  • Hydropic villi
  • Histological confirmation post-curettage
Associated conditions:
Hematologic conditions Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Lab findings Imaging Histopathology
Abnormal uterine

bleeding

Other symptoms
Von willebrand disease[93][94][95] +
  • Easy bruising
  • Gum/dental bleeding
  • Heavy menses
N/A N/A
  • Most common inherited bleeding disorder
  • History of bleeding disorder in family members.
Factors deficiencies[96][97] +
  • Easy bruising
  • Gum/dental bleeding
  • Heavy menses
  • Fatigue
  • Blood in stool
  • Blood in urine
N/A N/A
  • History of bleeding disorder in family members.
Platelet dysfunction[98][99][100][101][102] ± N/A N/A Gold standard diagnostic test:
  • Light transmission aggregometry (LTA)

Other useful diagnostic tests:

Associated conditions:
Metabolic conditions Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Lab findings Imaging Histopathology
Abnormal uterine bleeding Other symptoms
Hyperthyroidism[103][104] +
  • Wet skin/hair thinning
  • Low TSH
  • TSH receptor antibodies (TRAb)
Ultrasound:
  • Homogenous hypo-echogenicity
Microscopic histology:
  • Lymphocytic infiltration in follicles
  • Enlarged colloids

For Grave's disease:

  • TSH receptor antibody
Associated conditions:
Hypothyroidism[105][106][107][108][109] +
  • Dry skin
  • Hair loss
Ultrasound:
  • Homogenous hypo-echogenicity
Microscopic histology: Associated conditions with Hashimoto thyroiditis:
Adrenal hyperplasia[110][111][112][113][114] +
  • Irregular menses
Depending upon deficient enzyme:

Depending upon enzyme deficiencies may include the following:

CT-Scan:
  • Enlargement of glands
  • Cosyntropin stimulation test (250 μg cosyntropin intravenously):
Cushing's disease[115][116] +
  • Facial plethora
  • Abnormal fat distribution
  • Violacious striae
  • Emotional lability
T1-weighted MRI: Associated conditions:
Polycystic ovarian syndrome[117][118][119][120][121] + Ultrasound:
  • ↑ Number of follicles
  • ↑ Ovarian volume
  • Fluid filled ovaries
  • Multiple cysts in ovaries bilaterally.
Associated conditions:
  • Insulin resistance
Medication side effects/ Iatrogenic Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Lab Findings Imaging Histopathology
Abnormal uterine bleeding Other symptoms
Anticoagulants[122][123][124]
  • +
  • Heavy menstrual bleeding
  • Pallor
  • Heavy menstrual bleeding
N/A N/A
  • Complete medication history
Antipsychotics[125] +
  • Sexual dysfunction
N/A N/A
  • Complete medication history
  • Serum prolactin test
  • History of mood disorders
Oral contraceptive pills[126]
  • Break through bleeding
  • Heavy bleeding
N/A N/A
  • Ruling out organic cause, complete history of medication use
Herbal supplements[127][128][129] +
  • Heavy menstrual bleeding
  • Menstrual irregularity
Ultrasound:
  • Complete medication history

References

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