Approach to abnormal uterine bleeding in nonpregnant reproductive age women

10/2/2016 Approach to abnormal uterine bleeding in nonpregnant reproductiveage women
http://www.uptodate.com/contents/approachtoabnormaluterinebleedinginnonpregnantreproductiveagewomen?topicKey=OBGYN%2F3263&elapse… 1/42
Official reprint from UpToDate
www.uptodate.com ©2016 UpToDate
Author
Andrew M Kaunitz, MD
Section Editors
Robert L Barbieri, MD
Deborah Levine, MD
Deputy Editor
Sandy J Falk, MD, FACOG
Approach to abnormal uterine bleeding in nonpregnant reproductiveage women
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2016. | This topic last updated: Aug 15, 2014.
INTRODUCTION — Abnormal uterine bleeding (AUB) (a term which refers to menstrual bleeding of abnormal
quantity, duration, or schedule) is a common gynecologic complaint, accounting for onethird of outpatient visits
to gynecologists [1]. AUB can be caused by a wide variety of local and systemic diseases or related to
medications (figure 1) [2]. The most common etiologies in nonpregnant women are structural uterine pathology
(eg, fibroids, endometrial polyps, adenomyosis), anovulation, disorders of hemostasis, or neoplasia.
The initial approach to the evaluation of nonpregnant reproductiveage women with AUB will be reviewed here.
An overview of genital tract bleeding in women, terminology regarding AUB, bleeding during pregnancy, and
postmenopausal bleeding are discussed separately. (See "Differential diagnosis of genital tract bleeding in
women" and "Postmenopausal uterine bleeding" and "Overview of the etiology and evaluation of vaginal
bleeding in pregnant women".)
TERMINOLOGY — A revised terminology system for abnormal uterine bleeding (AUB) in nongravid
reproductiveage women was introduced in 2011 by the International Federation of Gynecology and Obstetrics
(FIGO) [3]. This was the result of an international consensus process with the goal of avoiding poorly defined
or confusing terms used previously (eg, menorrhagia, menometrorrhagia, oligomenorrhea). The classification
system is referred to by the acronym PALMCOEIN (polyp, adenomyosis, leiomyoma, malignancy and
hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) (figure 1).
In this topic, the term premenopausal women refers to women of reproductiveage and those in the menopausal
transition (figure 2).
PREVALENCE AND ETIOLOGY — Abnormal uterine bleeding (AUB) is common. A United States population
based survey of women ages 18 to 50 years reported an annual prevalence rate of 53 per 1000 women [4]. The
importance of AUB relates to its major impact on women’s quality of life, productivity, and utilization of
healthcare services [5].
The differential diagnosis of AUB in a nonpregnant reproductiveage woman is listed here (table 1 and table 2)
and discussed in more detail separately (see "Differential diagnosis of genital tract bleeding in women"):
®
®
Structural abnormalities – These abnormalities are common and a large proportion of them may be
asymptomatic. Even when a lesion is noted, the clinician must determine whether it is the cause of the
patient’s symptoms:
●
Uterine leiomyomas (See "Epidemiology, clinical manifestations, diagnosis, and natural history of
uterine leiomyomas (fibroids)".)
•
Endometrial polyps (See "Endometrial polyps".)
•
Adenomyosis (See "Uterine adenomyosis".)
•
Other lesions – Cesarean scar defect, arteriovenous malformation
•
Ovulatory dysfunction (AUBO) (See 'Irregular bleeding (ovulatory dysfunction)' below and "Differential
diagnosis of genital tract bleeding in women", section on 'Ovulatory dysfunction'.)
●
Bleeding disorders (See "Approach to the adult patient with a bleeding diathesis", section on
'Menorrhagia'.)
●
Iatrogenic (eg, anticoagulants, hormonal contraceptives, intrauterine device [IUD]) – AUB is common in
●

INITIAL EVALUATION — In a patient with a complaint of possible uterine bleeding, several questions must
be answered initially to confirm pregnancy status, reproductive status, and the source of the bleeding. This
guides the further evaluation, differential diagnosis, and disposition of the patient (ie, whether immediate
evaluation and intervention are needed). The algorithm includes the basic components of the evaluation
(algorithm 1).
Is the uterus the source of the bleeding? — Women with abnormal uterine bleeding (AUB) typically present
with a complaint of vaginal bleeding. There are many potential sources of genital tract bleeding, and the actual
site must be determined (table 1). Sites that are commonly mistaken for uterine bleeding include the lower
genital tract (vulva, vagina, or cervix), urinary tract, and gastrointestinal tract. The following elements of the
history and physical examination help to exclude extrauterine sources of bleeding:
women on progestinonly contraceptives, particularly initially and users may eventually develop
amenorrhea. (See "Management of unscheduled bleeding in women using contraception".)
Neoplastic (endometrial hyperplasia or carcinoma, or uterine sarcoma) (See "Endometrial carcinoma:
Epidemiology and risk factors" and "Classification and diagnosis of endometrial hyperplasia" and "Uterine
sarcoma: Classification, clinical manifestations, and diagnosis".)
●
Infection and inflammation – Endometritis, pelvic inflammatory disease (See "Endometritis unrelated to
pregnancy" and "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)
●
Disorders of local endometrial hemostasis (See "Differential diagnosis of genital tract bleeding in women",
section on 'Local endometrial hemostasis disorders'.)
●
Bleeding from the vulva, vagina, or cervix
●
Most genital tract bleeding is from the uterus or the lower genital tract (vulva, vagina, cervix).
Extrauterine upper genital tract bleeding is less common. The most common etiology of upper
genital tract bleeding is ectopic pregnancy, which can be excluded with negative pregnancy testing
(see 'Pregnancy test' below). Uncommon extrauterine etiologies of upper tract bleeding are ovarian
or fallopian tubal cancer.
•
The volume of bleeding gives some suggestion of the source for genital tract bleeding. Heavy
bleeding typically derives from the uterus, while staining, spotting, or light bleeding may be from any
genital tract site.
•
The color of the blood provides a limited amount of information regarding the source. Brown staining
may represent old blood as a result of light bleeding or spotting from the upper vagina, cervix, or
uterus. Red blood may derive from any genital tract site.
•
If the bleeding is consistently postcoital, this suggests cervical pathology, including cervical
neoplasia. However, postcoital bleeding may occur with contact during intercourse of any site along
the lower genital tract that is friable (eg, due to cervicitis or vulvovaginal atrophy) or has a lesion
(eg, cervical polyp or vulvar ulcer). (See "Postcoital bleeding in women".)
•
Pelvic examination should include evaluation of all lower genital tract sites to assess for areas of
friability or lesions. In addition, a finding on bimanual examination of pelvic tenderness or a pelvic
mass warrants further evaluation for pelvic inflammatory disease (PID) or uterine or adnexal
pathology.
•
Urinary or gastrointestinal tract bleeding
●
The following medical history questions help to determine whether the bleeding is from a nongenital
source: (1) Is the patient certain that the bleeding is from the vagina? (2) Does the patient see the
blood in the toilet only during or after either urination or defecation? (3) Does the patient see the
bleeding only when she wipes with toilet tissue? If so, has tried to separately dab the urethra,
vagina, and anus with toilet tissue to check the source of the bleeding? (4) Does she still see the
bleeding while she has a tampon in the vagina?
•

Is the patient premenarchal or postmenopausal? — The differential diagnosis of AUB for reproductiveage
women differs from that of premenarchal or postmenopausal patients. Thus, it is important to establish the
reproductive status of the patient.
The average age of menarche is 12 years [6]. For premenarchal girls, there is a range of causes of vaginal
bleeding, for example, hormonal issues, infection, foreign body, trauma, or malignancy. (See "Evaluation of
vaginal bleeding in children and adolescents", section on 'Vaginal bleeding before normal menarche'.)
The average age of menopause is 51 years [7]. Menopause is defined as 12 months of amenorrhea in the
absence of other biological or physiological causes. This is typically preceded by several years of irregular
uterine bleeding and menopausal symptoms (eg, hot flushes). In healthy women age 45 years and older,
laboratory testing of serum follicle stimulating hormone is not required to make the diagnosis. (See "Clinical
manifestations and diagnosis of menopause".)
Women with AUB who have not had amenorrhea for 12 months should be considered premenopausal for the
purpose of evaluation, but should have endometrial sampling if risk factors for endometrial cancer are present
(table 3 and table 4). All postmenopausal bleeding is abnormal, and requires evaluation for endometrial cancer.
(See "Postmenopausal uterine bleeding" and 'Endometrial sampling' below.)
Is the patient pregnant? — All patients with AUB should have pregnancy testing. The history of the last
several menstrual periods should be elicited to get some sense of whether menses are delayed. However,
pregnancy testing should be performed even in women with recent vaginal bleeding, since this may represent
bleeding during pregnancy rather than menses. It should also be performed in women who report no sexual
activity and in those who report use of contraception.
Women who are pregnant are evaluated primarily for pregnancyrelated causes of bleeding, but the evaluation
should include assessment for etiologies not related to pregnancy if appropriate. (See "Overview of the etiology
and evaluation of vaginal bleeding in pregnant women".)
FURTHER EVALUATION — In nonpregnant reproductiveage women with abnormal uterine bleeding (AUB),
the goals of the evaluation are to determine the pattern, severity, and etiology of the bleeding, and thereby to
guide management. Key questions that help to guide the clinician include:
As the evaluation proceeds, the possibility of concurrent factors should be considered. As an example, a
woman with a fibroid uterus may also have a defect of hemostasis that is the primary reason for her heavy
bleeding or she may be bleeding from an endometrial or endocervical malignancy unrelated to the fibroid uterus.
Therefore, several potential etiologies often need to be investigated and, if a cause of AUB is determined but
bleeding persists despite treatment, the patient should be evaluated for additional etiologies.
The basic components of the evaluation are shown in the algorithm (algorithm 1). The table provides
Physical examination helps to identify some, but not all, urinary or gastrointestinal tract bleeding
sources. Inspection of the urethra may reveal a urethral caruncle (see "Urethral caruncle"). A finding
on anorectal examination of a lesion (eg, hemorrhoid or rectal mass) or positive fecal occult blood
testing provides evidence of a nongenital source.
•
In general, if the bleeding occurs solely with urination or defecation and the pattern of bleeding or
findings on physical examination are consistent with a urinary or gastrointestinal tract source, this
should be the focus of further evaluation. If these etiologies are excluded, evaluation of the genital
tract should continue. Evaluation of hematuria and rectal bleeding is discussed in detail separately.
(See "Etiology and evaluation of hematuria in adults" and "Approach to minimal bright red bleeding
per rectum in adults".)
•
What is the bleeding pattern?
●
Should endometrial sampling be performed?
●
Should a coagulation evaluation be performed?
●
Is bleeding related to a contraceptive method?
●

information about how to choose additional testing and use the information from the evaluation to make a
diagnosis (table 5).
HISTORY — The relevant medical history in nonpregnant reproductiveage women with abnormal uterine
bleeding (AUB) includes the following:
General history
Additional questions that may help to suggest an etiology include:
Menstrual history — AUB varies from normal menses in terms of frequency, regularity, volume, or duration.
The characteristics of normal menstrual bleeding are (table 7) [9,10]:
Gynecologic and obstetric history, including:
●
Menstrual history. (See 'Menstrual history' below.)
•
Sexual history – This information may help determine the patient’s risk for pregnancy or sexually
transmitted infections.
•
History of obstetric or gynecologic surgery – A prior cesarean delivery, particularly multiple prior
abdominal deliveries, raises the possibility that a cesarean scar defect may be responsible for AUB
[8]. A prior myomectomy raises the possibility that uterine fibroids are responsible for AUB.
•
Contraceptive history – Women using estrogenprogestin contraceptives may develop unscheduled
bleeding, while use of progestinonly contraceptives often results in irregular uterine bleeding or
amenorrhea. Use of the copper intrauterine device (IUD) increases menstrual flow. Levonorgestrel
IUDs typically cause an initial period of irregular spotting or bleeding, followed by a gradual
decrease in menstrual flow and possible amenorrhea. (See "Management of unscheduled bleeding in
women using contraception".)
•
Risk factors for endometrial cancer. The indications for endometrial sampling are discussed below.
(See 'Endometrial sampling' below.)
•
Other medical history; issues that help to determine the etiology of AUB include:
●
Symptoms, risk factors (anticoagulant therapy, liver or renal disease), or a family history of a
bleeding disorder. The indications for coagulation testing are discussed below. (See 'Coagulation
tests' below.)
•
Symptoms or family history of thyroid disease. (See 'Endocrine tests' below and "Pathogenesis,
epidemiology, and clinical manifestations of celiac disease in adults", section on
'Nongastrointestinal manifestations'.)
•
Celiac disease. (See "Pathogenesis, epidemiology, and clinical manifestations of celiac disease in
adults", section on 'Menstrual and reproductive issues'.)
•
Medications – Medications can cause AUB in a variety of ways: (1) anticoagulants may result in heavy or
prolonged uterine bleeding; (2) a variety of medications can cause hyperprolactinemia (table 6), resulting
in oligomenorrhea or amenorrhea.
●
Were there precipitating factors, such as trauma? Bleeding related to trauma suggests a vaginal or
cervical, rather than uterine, source of bleeding.
●
Are there any associated symptoms? Lower abdominal pain, fever, and/or vaginal discharge could
indicate infection (pelvic inflammatory disease [PID], endometritis). Dysmenorrhea, dyspareunia or
infertility suggest endometriosis and possible adenomyosis. Changes in bladder or bowel function
suggest extrauterine uterine bleeding or a mass effect from a neoplasm. Galactorrhea, heat or cold
intolerance, hirsutism, or hot flashes suggest an endocrinologic issue.
●
Has there been a recent illness, stress, excessive exercise, or possible eating disorder? This suggests
hypothalamic dysfunction.
●

The clinician should determine the bleeding pattern by asking the patient the following questions:
A woman may have strong concerns over changes in menstrual blood loss, however, patient selfreports are
inaccurate indicators of the quantity of blood lost at menses and pathologic examination of the uterus often
shows no abnormality [1216]. This was illustrated by a populationbased study in which onequarter of women
with normal periods considered their blood loss excessive, whereas 40 percent of those with excessive
bleeding (>80 mL) described their periods as light or moderate [11]. In another study, only onethird of women
who considered their periods heavy had blood loss >80 mL [17].
There are several typical bleeding patterns that correlate with particular etiologies of AUB, including:
Heavy menstrual bleeding — Based upon current terminology, regular bleeding that is heavy or prolonged
(referred to as heavy menstrual bleeding) refers only to cyclic (ovulatory) menses. The term heavy menstrual
bleeding (HMB) was introduced as part of the PALMCOEIN (polyp, adenomyosis, leiomyoma, malignancy and
hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) classification
system for AUB [3]. This replaces the term menorrhagia, which was previously used to describe heavy or
prolonged uterine bleeding. Menorrhagia is a less precise word because it does not differentiate between
volume and duration of bleeding or between cyclic and anovulatory bleeding. (See 'Terminology' above.)
The most common etiologies of HMB are:
Other etiologies associated with HMB include:
Frequency every 21 to 35 days
●
Occurs at fairly regular intervals
●
Volume of blood ≤80 mL
●
Duration is 5 days
●
What was the first day of the last menstrual period and several previous menstrual periods?
●
For how many days does bleeding continue? How many days of full bleeding and how many days of light
bleeding or brown staining does this include?
●
Does bleeding occur between menstrual periods?
●
How heavy is the bleeding? The definition of normal menses is <80 mL of blood. Populationbased
studies that employed precise assessment of menstrual blood loss found that women with a loss per
cycle of >80 mL were more likely to become anemic [11]. However, volume of blood is difficult to
measure. In clinical practice, heavy menses are generally defined as soaking a pad or tampon more than
every two hours or as a volume of bleeding that interferes with daily activities (eg, wakes patient from
sleep, stains clothing or sheets). Questions that help to characterize the volume of uterine bleeding are
shown in the table (table 8).
●
If bleeding is irregular, how many bleeding episodes have there been in the past 6 to 12 months? What is
the average time from the first day of one bleeding episode to the next?
●
Uterine leiomyomas – HMB associated with uterine leiomyomas is most likely to occur with submucosal
leiomyomas, but leiomyomas at other sites may also cause AUB. (See "Epidemiology, clinical
manifestations, diagnosis, and natural history of uterine leiomyomas (fibroids)".)
●
Adenomyosis – This is often accompanied by dysmenorrhea or chronic pelvic pain. (See "Uterine
adenomyosis".)
●
Cesarean scar defect – Some twothirds of women who have had one or (in particular) multiple cesarean
births may have a cesarean scar defect, and approximately onethird of women with this condition
experience cyclical, postmenstrual bleeding [18].
●
Bleeding disorder. (See 'Coagulation tests' below.)
●
Endometrial hyperplasia or carcinoma or, rarely, uterine sarcoma may be associated with HMB, but the
typical bleeding pattern for these conditions is irregular or postmenopausal bleeding. (See "Endometrial
●

Thyroid disease has traditionally been thought to be a common cause of HMB. However, the available data
suggest that it is an uncommon etiology of this bleeding pattern. As an example, one study reported that the
prevalence of menstrual disturbances was similar among 586 women with hyperthyroidism and 111 women
with hypothyroidism compared with 105 healthy controls [22]. Rates of hypermenorrhea were comparable in
women with thyroid disease compared with controls, but there were few women with this bleeding pattern
(hyperthyroidism: 2 of 586 women; hypothyroidism: 0 of 111; and 1 of 105 controls). Another study found that
menorrhagia was more common in 171 women with hypothyroidism than in 214 healthy controls (7 versus 1
percent), but the proportion of women with this symptom was low [23]. (See "Clinical manifestations of
hypothyroidism", section on 'Reproductive abnormalities' and 'Endocrine tests' below.).
Additional causes of HMB are listed in the table (table 9).
Intermenstrual bleeding — Intermenstrual uterine bleeding may be related to a variety of etiologies (table
10), including:
carcinoma: Clinical features and diagnosis" and "Classification and diagnosis of endometrial hyperplasia"
and "Uterine sarcoma: Classification, clinical manifestations, and diagnosis".)
IUD – The Tcu380A (Paraguard) IUD is associated with iatrogenic heavy or prolonged menses; in
contrast, the levonorgestrel IUDs decrease menstrual blood loss. (See "Intrauterine contraception:
Devices, candidates, and selection".)
●
Endometrial polyps, endometritis, or PID – These entities may present with heavy or prolonged menses,
but intermenstrual bleeding is the more common clinical manifestation. (See "Endometrial polyps" and
"Postpartum endometritis" and "Endometritis unrelated to pregnancy".)
●
Congenital or acquired uterine arteriovenous malformation – This is a rare cause of HMB [1921]. This
lesion should be suspected when an invasive procedure for unexplained bleeding seems to aggravate the
problem. Acquired uterine arteriovenous malformations typically occur after an intrauterine procedure.
(See "Differential diagnosis of genital tract bleeding in women", section on 'Arteriovenous malformation'.)
●
Disorders of local endometrial hemostasis – Alterations in prostaglandins may result in HMB. (See
"Differential diagnosis of genital tract bleeding in women", section on 'Local endometrial hemostasis
disorders'.)
●
Endometrial polyps. (See "Endometrial polyps".)
●
Unscheduled bleeding due to a contraceptive method. (See "Management of unscheduled bleeding in
women using contraception".)
●
Endometrial hyperplasia or carcinoma or, rarely, uterine sarcoma. (See "Endometrial carcinoma: Clinical
features and diagnosis" and "Classification and diagnosis of endometrial hyperplasia" and "Uterine
sarcoma: Classification, clinical manifestations, and diagnosis".)
●
Endometritis or PID – AUB in women with symptomatic chronic endometritis may present as
intermenstrual bleeding or spotting, postcoital bleeding, or heavy menstrual bleeding (HMB). In women
with AUB, the presence of pelvic pain, cervicitis, or vaginal leukorrhea should alert the clinician to the
possibility of endometritis. Endometritis is most likely to occur in women with a recent history of childbirth
or an intrauterine procedure (eg, pregnancy termination, IUD insertion). Regarding PID, for example, in
one series, 15 percent of women with possible upper genital tract infection presented with AUB [24]. (See
"Endometritis unrelated to pregnancy" and "Postpartum endometritis" and "Pelvic inflammatory disease:
Clinical manifestations and diagnosis".)
●
Endometrial abnormalities related to previous endometrial trauma (eg, a hysterotomy scar or “niche”
following cesarean delivery) (See "Differential diagnosis of genital tract bleeding in women", section on
'Cesarean scar defect'.) Among women with regular menses, intermenstrual spotting occurs in less than
3 percent of cycles and may represent physiologic intermenstrual bleeding associated with ovulation [25].

●

Intermenstrual bleeding is often due to conditions of the cervix, including cervical cancer, cervical polyps,
cervicitis, or ectropion. These conditions are discussed separately. (See "Invasive cervical cancer:
Epidemiology, risk factors, clinical manifestations, and diagnosis", section on 'Clinical manifestations' and
"Congenital cervical anomalies and benign cervical lesions", section on 'Polyps' and "Congenital cervical
anomalies and benign cervical lesions", section on 'Cervicitis' and "Congenital cervical anomalies and benign
cervical lesions", section on 'Ectropion'.)
Irregular bleeding (ovulatory dysfunction) — Irregular uterine bleeding is most commonly associated
with ovulatory dysfunction (AUBO). Women may either have anovulation, which refers to the absence of
ovulatory cycles, or oligoovulation, in which they shift between ovulatory cycles and anovulation. (See
"Differential diagnosis of genital tract bleeding in women", section on 'Ovulatory dysfunction'.)
Irregular bleeding associated with AUBO is typically characterized by phases of no bleeding that may last for
two or more months and other phases with either spotting or episodes of heavy bleeding. Molimina are typically
absent.
AUBO should be suspected in women with an irregular bleeding pattern, particularly those at the extremes of
reproductive age (postmenarchal and in the menopausal transition). In addition, polycystic ovarian syndrome
and other endocrine disorders can cause AUBO (thyroid disease, hyperprolactinemia). Causes of ovulatory
dysfunction are shown in the table (table 11).
The diagnosis of anovulatory bleeding is made primarily by the bleeding pattern, provided that etiologies of
intermenstrual bleeding have been excluded (see 'Intermenstrual bleeding' above). Laboratory evaluation is not
generally required to confirm anovulation, but is helpful in excluding thyroid disease or hyperprolactinemia. (See
'Endocrine tests' below and "Evaluation of female infertility", section on 'Assessment of ovulatory function'.)
If a patient has a bleeding pattern consistent with AUBO, subsequent evaluation is directed toward identifying
the cause. In addition, women with prolonged amenorrhea due to anovulation are exposed to unopposed
estrogen and are at risk of endometrial hyperplasia or cancer, and endometrial sampling may be required (table
4). Ideally, the cause of anovulation can be identified and treated so that normal cyclic menses can be re
established. (See 'Endometrial sampling' below.)
Other bleeding patterns — Other types of bleeding patterns include:
PHYSICAL EXAMINATION — Vital signs should be assessed and a complete pelvic examination should be
performed, with a particular focus on:
Amenorrhea – Amenorrhea refers to absence of bleeding for at least three usual cycle lengths.
Amenorrhea may be primary (ie, menarche is absent) or secondary (menses cease after menarche). The
evaluation of amenorrhea is discussed separately. (See "Evaluation and management of primary
amenorrhea" and "Evaluation and management of secondary amenorrhea".)
●
Decreased volume – Women sometimes report that periods that are regular, but have become unusually
light or of short duration. This may occur with use of hormonal contraception. Other causes include partial
cervical stenosis or Asherman syndrome. However, the bleeding pattern should be reviewed to determine
whether the light bleeding represents irregular bleeding or intermenstrual bleeding. (See "Congenital
cervical anomalies and benign cervical lesions", section on 'Cervical stenosis' and "Intrauterine
adhesions".)
●
Regular menses with increased frequency – During the menopausal transition (figure 2), women may
experience a decrease in the interval between menses (figure 3). Cycle length that has shortened, but not
to less than every 21 days, may be normal during this phase. If the bleeding is also irregular or occurs
less often than every 21 days, other etiologies should be investigated. (See 'Irregular bleeding (ovulatory
dysfunction)' above and 'Intermenstrual bleeding' above.)
●
Potential sites of bleeding on the vulva, vagina, cervix, urethra, anus, or perineum
●
Any abnormal findings along the genital tract (eg, mass, laceration, ulceration, friable area, vaginal or
cervical discharge, foreign body)
●

A general examination should be performed to look for signs of systemic illness, such as fever, ecchymoses,
an enlarged thyroid gland, or evidence of hyperandrogenism (hirsutism, acne, clitoromegaly, or male pattern
balding). Acanthosis nigricans may be seen in women with polycystic ovarian syndrome (PCOS). Galactorrhea
(bilateral milky nipple discharge) suggests the presence of hyperprolactinemia.
LABORATORY EVALUATION
Initial tests — Most reproductiveage women with abnormal uterine bleeding (AUB) should be evaluated
initially with the following tests:
Pregnancy test — Pregnancy should be excluded in all reproductiveage women with AUB.
A urine hCG test may be performed as an initial test in a clinic or urgent care setting, since these results are
available quickly. Regardless of the result, a quantitative serum hCG should also be performed:
Diagnosis of pregnancy is discussed in detail separately. (See "Clinical manifestations and diagnosis of early
pregnancy".)
Gestational trophoblastic disease, which in some cases presents weeks to years after a pregnancy, is also
associated with uterine bleeding and a positive pregnancy test. (See "Hydatidiform mole: Epidemiology, clinical
features, and diagnosis".)
Complete blood count — Women with heavy or prolonged bleeding should be evaluated with a
hemoglobin and/or hematocrit for anemia. (See "Approach to the adult patient with anemia".)
Size and contour of the uterus – An enlarged uterus may be due to pregnancy, uterine leiomyomas,
adenomyosis, or uterine malignancy. Limited uterine mobility should be noted, if present; this finding
suggests that pelvic adhesions or a pelvic mass is present. Pelvic adhesions may be due to prior
infection, surgery, or endometriosis, and also may impact surgical planning if surgical treatment is
indicated. A boggy, globular, tender uterus is typical of adenomyosis. Uterine tenderness is present in
women with pelvic inflammatory disease (PID), but is not consistently found in those with chronic
endometritis.
●
Current uterine bleeding – The presence and volume of bleeding from the cervical os should be noted.
Blood or blood clots in the vaginal vault should be noted. Patients who present with a complaint of heavy
vaginal bleeding should be assessed for acute bleeding. Patients who are hemodynamically unstable or
who have copious, ongoing blood flow from the uterus or other genital tract site should be evaluated and
managed in an urgent care facility. (See "Managing an episode of severe or prolonged uterine bleeding",
section on 'Hemodynamically unstable women' and "Approach to vaginal bleeding in the emergency
department".)
●
Presence of an adnexal mass or tenderness
●
Human chorionic gonadotropin (hCG) to exclude pregnancy
●
Complete blood count, hemoglobin and/or hematocrit to assess for anemia; the exception to this are
patients who do not have heavy or frequent bleeding
●
If the urine test is negative, but the clinician continues to suspect early pregnancy may be present, serum
hCG should be measured. A serum hCG assay can detect a pregnancy by one week after conception,
while a urine hCG test is able to detect most pregnancies within two weeks after conception (table 12)
[26,27].
●
If the urine test is positive, serial quantitative serum hCG testing is appropriate if ectopic pregnancy or
spontaneous abortion is suspected. (See "Spontaneous abortion: Risk factors, etiology, clinical
manifestations, and diagnostic evaluation" and "Ectopic pregnancy: Clinical manifestations and
diagnosis".)
●
If the serum hCG is negative, the test should be repeated in one week if an early pregnancy is
suspected.
●

In addition, a platelet count is helpful if a bleeding disorder is suspected. A white blood cell count is helpful if
an infection is suspected. Pelvic inflammatory disease (PID) with endometritis is a potential etiology of AUB.
Acute endometritis following childbirth or an intrauterine procedure may be associated with leukocytosis, but
the white blood cell count is typically normal in chronic endometritis. (See "Endometritis unrelated to
pregnancy" and "Pelvic inflammatory disease: Clinical manifestations and diagnosis", section on 'Pointofcare
and laboratory tests'.)
Additional tests — Additional testing is selective and depends upon information obtained on history and
physical examination.
Endocrine tests — Tests of endocrine function are performed based upon the history and physical
examination findings:
Coagulation tests — Bleeding disorders are common in reproductiveage women. Up to 15 to 24 percent of
women presenting with menorrhagia may have some type of bleeding diathesis (eg, von Willebrand disease,
immune thrombocytopenia, or platelet function defect) [2931]. In addition, excessive bleeding may be caused
by leukemia, liver or renal disease, anticoagulants, prescription and nonprescription drugs that impact
coagulation or platelet function, and chemotherapeutic agents. (See "Approach to the adult patient with a
bleeding diathesis", section on 'Menorrhagia' and "Differential diagnosis of genital tract bleeding in women",
section on 'Bleeding disorders'.)
Thyroid function tests — It is not necessary to assess for thyroid disease in all women with AUB.
Thyroid disease appears to be associated mainly with oligomenorrhea or amenorrhea. If the menstrual
history suggests ovulatory dysfunction, checking a thyroidstimulating hormone (TSH) is appropriate.
Some data suggest that heavy menstrual bleeding (HMB) is associated with hypothyroidism in a small
proportion of women. For women with HMB, a TSH should be performed if no other etiology has been
identified. (See 'Irregular bleeding (ovulatory dysfunction)' above and 'Heavy menstrual bleeding' above.)
●
Prolactin level – A prolactin level should be measured in women who complain of anovulatory bleeding,
amenorrhea, or galactorrhea, or are taking medications that can cause hyperprolactinemia (table 6). (See
"Clinical manifestations and evaluation of hyperprolactinemia".)
●
Androgen levels – Serum androgens should be measured in women with AUB and signs of androgen
excess. Hirsutism (excessive malepattern facial and body hair) is far more common than virilization
(deepening of the voice, temporal balding, breast atrophy, changes toward a male body habitus, and/or
clitoromegaly) [28]. Polycystic ovarian syndrome (PCOS) is the most common cause of hirsutism and
amenorrhea or anovulatory bleeding. However, clinical manifestations of hyperandrogenism may also be
seen in women with congenital adrenal hyperplasia. If virilization is present, a more severe androgen
excess should be suspected and the patient should be evaluated for an androgensecreting tumor of the
adrenal gland or ovary (table 13). (See "Diagnosis of polycystic ovary syndrome in adults", section on
'Serum androgens' and "Pathogenesis and causes of hirsutism".)
●
Follicle stimulating hormone or luteinizing hormone – Follicle stimulating hormone (FSH) and
luteinizing hormone (LH) are released by the pituitary gland. If premature ovarian insufficiency is
suspected, a serum FSH should be performed. For women with suspected hypothalamic dysfunction (due
to poor nutrition or intense exercise), a FSH and LH should be performed, as well as an
estrogen/progestin withdrawal test. (See "Clinical manifestations and evaluation of spontaneous primary
ovarian insufficiency (premature ovarian failure)", section on 'Diagnosis' and "Evaluation and management
of secondary amenorrhea", section on 'Followup testing based upon initial results'.)
●
Estrogen levels – Estrogen excess due to an estrogensecreting ovarian tumor is a rare etiology of AUB,
but should be considered if an adnexal mass is present and if other etiologies have been excluded (table
13). (See "Sex cordstromal tumors of the ovary: Granulosastromal cell tumors".)
●
Assessment of ovulatory function – Anovulation is typically diagnosed based upon the characteristic
bleeding pattern; laboratory evaluation is not typically required. Laboratory confirmation of anovulation
may be useful in women with infertility. (See "Evaluation of female infertility", section on 'Assessment of
ovulatory function'.)
●

http://www.uptodate.com/contents/approachtoabnormaluterinebleedinginnonpregnantreproductiveagewomen?topicKey=OBGYN%2F3263&elaps… 10/42
Coagulation disorders typically present as heavy bleeding at menarche or in women in their later reproductive
years. For von Willebrand disease, decreasing estrogen levels during the menopausal transition impact von
Willebrand factor synthesis. Excessive bleeding related to medications or systemic illness may present at any
age. (See "Clinical presentation and diagnosis of von Willebrand disease", section on 'Variations in VWF levels
in health and disease'.)
A bleeding disorder should be suspected if heavy or prolonged menses began at menarche, is associated with
a family history of coagulopathy, the patient has signs of a bleeding diathesis (eg, easy bruising or prolonged
bleeding from mucosal surfaces), or is taking medications associated with an increased bleeding tendency
(table 14) [3234].
Women who are taking warfarin should have coagulation parameters assessed to see if the effect is within the
therapeutic window. In addition, patients should be asked about other prescription or nonprescription
medications that may impact coagulation or platelet function. (See "Approach to the adult patient with a
bleeding diathesis", section on 'Medication use'.)
The evaluation for patients with a suspected bleeding disorder is discussed separately. (See "Approach to the
adult patient with a bleeding diathesis", section on 'Laboratory testing'.)
Tests to exclude cervical bleeding — It is often difficult to differentiate cervical and uterine bleeding
based upon history and physical examination. If there is uncertainty about the source of the bleeding, a basic
evaluation for etiologies of cervical bleeding should be performed. (See 'Is the uterus the source of the
bleeding?' above.)
ENDOMETRIAL SAMPLING — After pregnancy has been excluded, endometrial sampling should be
performed in women with AUB and an increased risk of endometrial hyperplasia or cancer (table 3 and table 4).
Indications for endometrial sampling in women of reproductiveage with AUB vary by age group (table 3):
Use of 45 yearsold as the threshold for increased concern regarding endometrial neoplasia is supported by
evidence that the risk of endometrial hyperplasia and carcinoma is fairly low prior to age 45 years and
increases with advancing age; 19 percent of cases occur in women aged 45 to 54 years compared with 6
percent in those aged 35 to 44 years [3638]. This age threshold is also consistent with American College of
Obstetricians and Gynecologists (ACOG) guidelines [9,35]. (See "Classification and diagnosis of endometrial
hyperplasia", section on 'Epidemiology' and "Endometrial carcinoma: Epidemiology and risk factors", section
Cervical cancer screening – Cervical neoplasia can cause cervical bleeding, which is often mistaken for
uterine bleeding. All women with AUB should be appropriately screened for cervical cancer, according to
current guidelines. (See "Screening for cervical cancer".)
●
Tests for cervicitis – Genital tract infection with Neisseria gonorrhoeae or Chlamydia trachomatis may
cause cervicitis and present with cervical bleeding. In addition, these are common pathogens in PID,
which is an etiology of AUB. Although less common than N. gonorrhoeae and C. trachomatis as a cause
of cervicitis, trichomonas and herpes simplex virus infections can cause cervicitis and result in cervical
bleeding. Testing for these infections should be performed in women at high risk and in those with a
finding on examination of a friable cervix, purulent vaginal or cervical discharge, or pelvic tenderness [2].
(See "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents"
and "Acute cervicitis" and "Clinical manifestations and diagnosis of Chlamydia trachomatis infections".)
●
Age 45 years to menopause – In women who are ovulatory, any AUB, including intermenstrual bleeding.
In any woman, bleeding that is frequent (interval between the onset of bleeding episodes is <21 days),
heavy, or prolonged (>5 days) (table 7).
●
Younger than 45 years – In reproductiveage women, the majority of cases of endometrial neoplasia
occur in the setting of ovulatory dysfunction due to estrogenic proliferation with absent or inadequate
progestational protection [35]. Endometrial sampling is indicated if AUB is persistent, occurs in the
setting of a history of unopposed estrogen exposure (obesity, chronic anovulation) or failed medical
management of the bleeding, or in women at high risk of endometrial cancer (eg, tamoxifen therapy,
Lynch or Cowden syndrome).
●

on 'Epidemiology'.)
Among women <45 yearsold, there is no standard definition of persistent AUB. For women with ovulatory
dysfunction, given that six months of unopposed estrogen therapy substantially increases the risk of
endometrial hyperplasia in menopausal women, it is reasonable to consider six months or more of AUBO as
“persistent” [39]. For other types of AUB, the clinician must use their judgement regarding when abnormal
bleeding is persistent.
Endometrial neoplasia is rare in adolescents ages 13 to 18 years (0.05 percent of cases of endometrial cancer
occur in patients ages 15 to 19 years [40]), but it may develop in the setting of obesity with anovulation
(polycystic ovarian syndrome [PCOS]) [41]. In this age group, as with other reproductiveage women, the level
of suspicion is higher in patients who are obese or who fail medical therapy.
Transvaginal ultrasound measurement of endometrial thickness to evaluate for endometrial neoplasia is an
alternative to endometrial sampling in women with postmenopausal bleeding, but NOT in premenopausal
women. In premenopausal women, measurement of endometrial thickness is not a useful test, since major
variation of the thickness occurs during the normal menstrual cycle. In this patient population, transvaginal
ultrasound does provide useful information regarding structural causes of AUB and can identify a heterogenous
endometrium due to hyperplasia or cancer. (See "Evaluation of the endometrium for malignant or premalignant
disease", section on 'Premenopausal women'.)
Suspicion of endometritis is another indication for endometrial sampling. For women with AUB during the
postpartum or postabortal period, endometrial sampling may reveal retained products of conception. (See
"Postpartum endometritis" and "Endometritis unrelated to pregnancy" and "Retained products of conception".)
Endometrial sampling is typically performed as an office biopsy, but dilation and curettage or hysteroscopically
directed biopsy may be performed if bleeding persists after a normal endometrial biopsy or if there are other
indications for an operative procedure. (See "Endometrial sampling procedures" and "Evaluation of the
endometrium for malignant or premalignant disease".)
IMAGING AND HYSTEROSCOPY — The decision to proceed with pelvic imaging should be based upon the
clinician’s judgement, depending on patient age, history and symptoms.
The choice to do imaging is guided by several factors:
Choice of modality — Pelvic ultrasound is the firstline imaging study in women with AUB. Transvaginal
examination should be performed, unless there is a reason to not perform the vaginal study (eg, virginal
patient). Transabdominal sonography should also be performed if transvaginal imaging does not allow adequate
assessment of the uterus or adnexa or if a large pelvic mass is present.
Ultrasound is effective at characterizing uterine and adnexal lesions. As noted above, assessment of
endometrial thickness is not a useful test in premenopausal women. Ultrasound is less expensive than
magnetic resonance imaging (MRI), which should be used for pelvic assessment only as a followup imaging
test and only when it will give information that is not available on ultrasound. Computed tomography is used to
evaluate the pelvis for metastatic disease in some malignancies, but has no role in routine pelvic assessment.
(See "Evaluation of the endometrium for malignant or premalignant disease", section on 'Premenopausal
women'.)
If intracavitary pathology (lesions that protrude into the uterine cavity, ie, endometrial polyps, submucosal
myomas, intramural myomas with an intracavitary component) is suspected based upon the initial ultrasound,
the patient may be evaluated with either saline infusion sonohysterography or hysteroscopy.
If the abdominal and/or bimanual pelvic examination findings include an enlarged or globular uterus or
adnexal mass, imaging is appropriate to evaluate for leiomyomas, adenomyosis, and adnexal pathology.
●
Imaging may be omitted, at least in the initial evaluation, if the bleeding is thought to be due to a lesion
observed on physical examination (endocervical polyp), anovulation, or infection [42].
●
If the pelvic examination is normal, imaging is also appropriate if symptoms persist despite treatment.
●

We suggest SIS for most women for intracavitary evaluation. Both SIS and hysteroscopy are effective tests
for diagnosing endometrial polyps and submucosal leiomyoma [46], while ultrasound alone has limited
sensitivity and specificity for the characterization of these lesions [47,48]. Compared with hysteroscopy, the
major advantage of SIS is that it can assess the depth of extension of leiomyomas into the myometrium or
serosal surface (image 2). Some fibroids appear to be submucosal at hysteroscopy, but are actually intramural
with a component that protrudes into the uterine cavity. This information and the ability to identify fibroids at
other sites (figure 4) can help surgical planning. Some data also suggest that SIS is less painful than office
hysteroscopy [47,49]. SIS also is able to identify asymmetric or focal endometrial thickening, a potentially
important marker of endometrial neoplasia (image 3) [46].
Advantages of hysteroscopy are that office hysteroscopy may offer patients greater convenience, particularly if
it can be performed at the same visit as the initial evaluation. Operative hysteroscopy is not typically available
in an office setting and therefore is not part of the initial evaluation of AUB.
Factors such as convenience, availability of equipment and trained personnel, and cost of SIS and
hysteroscopy vary in different clinical settings, and these factors often influence the choice of study.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics”
and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5 to 6
grade reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer short, easytoread
materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed.
These articles are written at the 10 to 12 grade reading level and are best for patients who want indepth
information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
“patient info” and the keyword(s) of interest.)
SUMMARY AND RECOMMENDATIONS
Saline infusion sonography (SIS) – Saline infusion sonography (also called sonohysterography) is a
technique in which sterile saline is instilled into the endometrial cavity and a transvaginal ultrasound
examination is performed [43]. This procedure allows for an architectural evaluation of the uterine cavity
to detect lesions (eg, polyps or small submucous fibroids) that may be missed or poorly defined by
transvaginal sonography alone (image 1). SIS is also useful in evaluating AUB associated with cesarean
scar defects [8]. (See "Saline infusion sonohysterography".)
●
Hysteroscopy – Hysteroscopy provides direct visualization of the endometrial cavity. Diagnostic
hysteroscopy can be performed in an office setting. In an operative setting, hysteroscopy allows targeted
biopsy or excision of lesions identified during the procedure [44,45]. (See "Overview of hysteroscopy".)
●
th th
th th
Basics topics (see "Patient information: Heavy periods (The Basics)")
●
Beyond the Basics topics (See "Patient information: Abnormal uterine bleeding (Beyond the Basics)" and
"Patient information: Heavy or prolonged menstrual bleeding (menorrhagia) (Beyond the Basics)" and
"Patient information: Absent or irregular periods (Beyond the Basics)".)
●
Abnormal uterine bleeding (AUB) is a common gynecologic complaint. AUB can be caused by a wide
variety of local and systemic diseases or related to medications (table 1) [2]. The most common
etiologies are conditions associated with pregnancy, structural uterine pathology (eg, fibroids, endometrial
polyps, adenomyosis), anovulation, bleeding disorders, or neoplasia. (See 'Introduction' above and
'Prevalence and etiology' above.)
●
The initial approach to evaluation of nonpregnant reproductiveage women with AUB is to confirm that the
source of bleeding is the uterus, exclude pregnancy, and confirm that the patient is premenopausal. In
addition, women with acute bleeding should be evaluated in an urgent care facility. (See 'Initial evaluation'
above.)
●

ACKNOWLEDGMENT — The author and UpToDate would like to acknowledge Dr. Annekathryn Goodman,
who contributed to earlier versions of this topic review.
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Spencer CP, Whitehead MI. Endometrial assessment revisited. Br J Obstet Gynaecol 1999; 106:623.
2. Committee on Practice Bulletins—Gynecology. Practice bulletin no. 128: diagnosis of abnormal uterine
bleeding in reproductiveaged women. Obstet Gynecol 2012; 120:197.
3. Munro MG, Critchley HO, Broder MS, et al. FIGO classification system (PALMCOEIN) for causes of
abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011; 113:3.
4. Kjerulff KH, Erickson BA, Langenberg PW. Chronic gynecological conditions reported by US women:
findings from the National Health Interview Survey, 1984 to 1992. Am J Public Health 1996; 86:195.
5. Matteson KA, Boardman LA, Munro MG, Clark MA. Abnormal uterine bleeding: a review of patientbased
outcome measures. Fertil Steril 2009; 92:205.
6. Anderson SE, Must A. Interpreting the continued decline in the average age at menarche: results from
two nationally representative surveys of U.S. girls studied 10 years apart. J Pediatr 2005; 147:753.
7. McKinlay SM. The normal menopause transition: an overview. Maturitas 1996; 23:137.
8. Tower AM, Frishman GN. Cesarean scar defects: an underrecognized cause of abnormal uterine
bleeding and other gynecologic complications. J Minim Invasive Gynecol 2013; 20:562.
The goals of further evaluation are to determine the pattern, severity, and etiology of the bleeding to guide
management. A primary focus is to identify women who require evaluation for endometrial carcinoma or
other uterine malignancies. (See 'Further evaluation' above.)
●
AUB varies from normal menses in terms of frequency, regularity, volume, or duration (table 7). Typical
abnormal bleeding patterns include: regular menses that are heavy or prolonged, intermenstrual bleeding,
irregular bleeding (typically associated with ovulatory dysfunction), and amenorrhea. (See 'Menstrual
history' above.)
●
Endometrial sampling should be performed in nonpregnant women with AUB and an increased risk of
endometrial hyperplasia or cancer. Indications for endometrial sampling vary by age group (table 3 and
table 4). (See 'Endometrial sampling' above.)
●
Bleeding disorders, particularly von Willebrand disease (VWD), are common in reproductiveage women.
A disorder should be suspected if heavy or prolonged menses began at menarche or is associated with a
family history of coagulopathy or other signs of a bleeding diathesis (eg, easy bruising or prolonged
bleeding from mucosal surfaces). In addition, anticoagulants may cause heavy or prolonged uterine
bleeding. (See 'Coagulation tests' above.)
●
Hormonal contraception or an intrauterine device (IUD) may cause AUB. (See 'General history' above.)
●
All women with AUB should have a complete history and physical examination. Information should be
obtained on the frequency, duration, and volume of AUB, as well as the presence of associated
symptoms and precipitating factors. (See 'History' above and 'Physical examination' above.)
●
Most reproductiveage women with AUB should be evaluated initially with the following tests: human
chorionic gonadotropin (hCG), complete blood count, hemoglobin and/or hematocrit. Additional tests may
be performed to assess for particular etiologies. (See 'Initial tests' above and 'Additional tests' above.)
●
Pelvic imaging is useful if a structural lesion (endometrial polyps, leiomyomas, adenomyosis, or an
adnexal mass) is suspected based upon the history and physical examination; it is not required in every
woman with AUB. Pelvic ultrasound is the firstline study and is often used alone, or may be combined
with either saline infusion sonography or hysteroscopy to provide information about lesions that protrude
into the endometrial cavity (submucosal leiomyomas, myometrial leiomyomas that protrude into the
cavity, and endometrial polyps). (See 'Imaging and hysteroscopy' above.)
●

9. Committee on Practice Bulletins—Gynecology. Practice bulletin no. 128: diagnosis of abnormal uterine
bleeding in reproductiveaged women. Obstet Gynecol 2012; 120:197.
10. Treloar AE, Boynton RE, Behn BG, Brown BW. Variation of the human menstrual cycle through
reproductive life. Int J Fertil 1967; 12:77.
11. Hallberg L, Högdahl AM, Nilsson L, Rybo G. Menstrual blood lossa population study. Variation at
different ages and attempts to define normality. Acta Obstet Gynecol Scand 1966; 45:320.
12. Greenberg M. The meaning of menorrhagia: an investigation into the association between the complaint
of menorrhagia and depression. J Psychosom Res 1983; 27:209.
13. Hurskainen R, Aalto AM, Teperi J, et al. Psychosocial and other characteristics of women complaining
of menorrhagia, with and without actual increased menstrual blood loss. BJOG 2001; 108:281.
14. Wright B, Gannon MJ, Greenberg M, et al. Psychiatric morbidity following endometrial ablation and its
association with genuine menorrhagia. BJOG 2003; 110:358.
15. Grant C, Gallier L, Fahey T, et al. Management of menorrhagia in primary careimpact on referral and
hysterectomy: data from the Somerset Morbidity Project. J Epidemiol Community Health 2000; 54:709.
16. Clarke A, Black N, Rowe P, et al. Indications for and outcome of total abdominal hysterectomy for
benign disease: a prospective cohort study. Br J Obstet Gynaecol 1995; 102:611.
17. Warner PE, Critchley HO, Lumsden MA, et al. Menorrhagia I: measured blood loss, clinical features, and
outcome in women with heavy periods: a survey with followup data. Am J Obstet Gynecol 2004;
190:1216.
18. van der Voet LF, Bij de Vaate AM, Veersema S, et al. Longterm complications of caesarean section.
The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine
bleeding. BJOG 2014; 121:236.
19. Hoffman MK, Meilstrup JW, Shackelford DP, Kaminski PF. Arteriovenous malformations of the uterus:
an uncommon cause of vaginal bleeding. Obstet Gynecol Surv 1997; 52:736.
20. Halperin R, Schneider D, Maymon R, et al. Arteriovenous malformation after uterine curettage: a report
of 3 cases. J Reprod Med 2007; 52:445.
21. Nicholson AA, Turnbull LW, Coady AM, Guthrie K. Diagnosis and management of uterine arteriovenous
malformations. Clin Radiol 1999; 54:265.
22. Kakuno Y, Amino N, Kanoh M, et al. Menstrual disturbances in various thyroid diseases. Endocr J 2010;
57:1017.
23. Krassas GE, Pontikides N, Kaltsas T, et al. Disturbances of menstruation in hypothyroidism. Clin
Endocrinol (Oxf) 1999; 50:655.
24. Peipert JF, Boardman LA, Sung CJ. Performance of clinical and laparoscopic criteria for the diagnosis of
upper genital tract infection. Infect Dis Obstet Gynecol 1997; 5:291.
25. Dasharathy SS, Mumford SL, Pollack AZ, et al. Menstrual bleeding patterns among regularly
menstruating women. Am J Epidemiol 2012; 175:536.
26. O'Connor RE, Bibro CM, Pegg PJ, Bouzoukis JK. The comparative sensitivity and specificity of serum
and urine HCG determinations in the ED. Am J Emerg Med 1993; 11:434.
27. Norman RJ, Menabawey M, Lowings C, et al. Relationship between blood and urine concentrations of
intact human chorionic gonadotropin and its free subunits in early pregnancy. Obstet Gynecol 1987;
69:590.
28. Fritz MA, Speroff L. Hirsutism. In: Clinical Gynecologic Endocrinology and Infertility, 8th ed., Lippincott
Williams & Wilkins, Philadelphia 2011. p.533.
29. Kadir RA, Economides DL, Sabin CA, et al. Frequency of inherited bleeding disorders in women with
menorrhagia. Lancet 1998; 351:485.
30. Kouides PA, Byams VR, Philipp CS, et al. Multisite management study of menorrhagia with abnormal
laboratory haemostasis: a prospective crossover study of intranasal desmopressin and oral tranexamic
acid. Br J Haematol 2009; 145:212.
31. Committee on Adolescent Health Care, Committee on Gynecologic Practice. Committee Opinion
No.580: von Willebrand disease in women. Obstet Gynecol 2013; 122:1368.
32. Dilley A, Drews C, Miller C, et al. von Willebrand disease and other inherited bleeding disorders in
women with diagnosed menorrhagia. Obstet Gynecol 2001; 97:630.
33. Philipp CS, Faiz A, Dowling N, et al. Age and the prevalence of bleeding disorders in women with
menorrhagia. Obstet Gynecol 2005; 105:61.
34. Lukes AS, Kadir RA, Peyvandi F, Kouides PA. Disorders of hemostasis and excessive menstrual

bleeding: prevalence and clinical impact. Fertil Steril 2005; 84:1338.
35. Committee on Practice Bulletins—Gynecology. Practice bulletin no. 136: management of abnormal
uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol 2013; 122:176.
36. http://seer.cancer.gov/statfacts/html/corp.html (Accessed on August 13, 2012).
37. Reed SD, Newton KM, Clinton WL, et al. Incidence of endometrial hyperplasia. Am J Obstet Gynecol
2009; 200:678.e1.
38. http://seer.cancer.gov/statfacts/html/corp.html (Accessed on December 20, 2011).
39. Lethaby A, Suckling J, Barlow D, et al. Hormone replacement therapy in postmenopausal women:
endometrial hyperplasia and irregular bleeding. Cochrane Database Syst Rev 2004; :CD000402.
40. http://seer.cancer.gov/statfacts/html/corp.html (Accessed on September 11, 2013).
41. Brown AJ, Westin SN, Broaddus RR, Schmeler K. Progestin intrauterine device in an adolescent with
grade 2 endometrial cancer. Obstet Gynecol 2012; 119:423.
42. Doubilet PM. Diagnosis of abnormal uterine bleeding with imaging. Menopause 2011; 18:421.
43. Khan F, Jamaat S, AlJaroudi D. Saline infusion sonohysterography versus hysteroscopy for uterine
cavity evaluation. Ann Saudi Med 2011; 31:387.
44. APGO educational series on women's health issues. Clinical management of abnormal uterine bleeding.
Association of Professors of Gynecology and Obstetrics, 2006.
45. Bradley LD. Diagnosis of abnormal uterine bleeding with biopsy or hysteroscopy. Menopause 2011;
18:425.
46. La Sala GB, Blasi I, Gallinelli A, et al. Diagnostic accuracy of sonohysterography and transvaginal
sonography as compared with hysteroscopy and endometrial biopsy: a prospective study. Minerva
Ginecol 2011; 63:421.
47. Kelekci S, Kaya E, Alan M, et al. Comparison of transvaginal sonography, saline infusion sonography,
and office hysteroscopy in reproductiveaged women with or without abnormal uterine bleeding. Fertil
Steril 2005; 84:682.
48. Farquhar C, Ekeroma A, Furness S, Arroll B. A systematic review of transvaginal ultrasonography,
sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal
women. Acta Obstet Gynecol Scand 2003; 82:493.
49. Van den Bosch T, Verguts J, Daemen A, et al. Pain experienced during transvaginal ultrasound, saline
contrast sonohysterography, hysteroscopy and office sampling: a comparative study. Ultrasound Obstet
Gynecol 2008; 31:346.
Topic 3263 Version 15.0

GRAPHICS
PALMCOEIN classification system for abnormal uterine
bleeding in nongravid reproductiveage women
Basic classification system. The basic system comprises four categories that
are defined by visually objective structural criteria (PALM: polyp;
adenomyosis; leiomyoma; and malignancy and hyperplasia), four that are
unrelated to structural anomalies (COEI: coagulopathy; ovulatory
dysfunction; endometrial; iatrogenic), and one reserved for entities that are
not yet classified (N). The leiomyoma category (L) is subdivided into patients
with at least one submucosal myoma (LSM) and those with myomas that do
not impact the endometrial cavity (LO).
Reproduced from: Munro MG, Critchley HO, Broder MS, Fraser IS, FIGO Working Group
on Menstrual Disorders. FIGO classification system (PALMCOEIN) for causes of
abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol
Obstet 2011; 113:3. Illustration used with the permission of Elsevier Inc. All rights
reserved.
Graphic 90483 Version 1.0

The Stages of Reproductive Aging Workshop +10 staging system for
reproductive aging in women
Arrow: elevated; FMP: final menstrual period; FSH: folliclestimulating hormone; AMH: antimüllerian
hormone.
* Blood draw on cycle days 2 to 5.
• Approximate expected level based on assays using current international pituitary standard.
Reproduced with permission from: Harlow SD, Gass M, Hall JE, et al. Executive Summary of the Stages of
Reproductive Aging Workshop + 10: Addressing the Unfinished Agenda of Staging Reproductive Aging. J Clin
Endocrinol Metab 2012. Copyright © 2012 The Endocrine Society.

Causes of abnormal genital tract bleeding in women
Genital tract disorders
Uterus
Benign growths:
Endometrial polyps
Endometrial hyperplasia
Adenomyosis
Leiomyomas (fibroids)
Cancer:
Endometrial adenocarcinoma
Sarcoma
Infection:
Pelvic inflammatory disease
Endometritis
Ovulatory dysfunction
Cervix
Benign growths:
Cervical polyps
Ectropion
Endometriosis
Cancer:
Invasive carcinoma
Metastatic (uterus, choriocarcinoma)
Infection:
Cervicitis
Vulva
Benign growths:
Skin tags
Sebaceous cysts
Condylomata
Angiokerataoma
Cancer
Vagina
Benign growths:
Gartner duct cysts
Polyps
Adenosis (aberrant glandular tissue)
Cancer
Vaginitis/infection:
Trauma
Sexual intercourse
Sexual abuse
Foreign bodies (including intrauterine
device)
Pelvic trauma (eg, motor vehicle accident)
Straddle injuries
Drugs
Contraception:
Hormonal contraceptives
Intrauterine devices
Postmenopausal hormone therapy
Anticoagulants
Tamoxifen
Corticosteroids
Chemotherapy
Phenytoin
Antipsychotic drugs
Antibiotics (eg, due to toxic epidermal
necrolysis or StevensJohnson syndrome)
Systemic disease
Diseases involving the vulva:
Crohn's disease
Behcet's syndrome
Pemphigoid
Pemphigus
Erosive lichen planus
Lymphoma
Bleeding disorders:
von Willebrand disease
Thrombocytopenia or platelet dysfunction
Acute leukemia
Some coagulation factor deficiencies
Advanced liver disease
Thyroid disease
Polycystic ovary syndrome
Chronic liver disease
Cushing's syndrome

Bacterial vaginosis
Sexually transmitted diseases
Atrophic vaginitis
Upper genital tract disease
Fallopian tube cancer
Ovarian cancer
Pelvic inflammatory disease
Pregnancy complications
Hormonesecreting adrenal and ovarian
tumors
Renal disease
Emotional or physical stress
Smoking
Excessive exercise
Diseases not affecting the
genital tract
Urethritis
Bladder cancer
Urinary tract infection
Inflammatory bowel disease
Hemorrhoids
Other
Endometriosis
Vascular tumors and anomalies in the
genital tract

Usual causes of abnormal genital bleeding in women by age group
Neonates
Estrogen withdrawal
Premenarchal
Foreign body
Trauma, including sexual abuse
Infection
Urethral prolapse
Sarcoma botryoides
Ovarian tumor
Precocious puberty
Early postmenarche
Ovulatory dysfunction (hypothalamic
immaturity)
Bleeding diathesis
Stress (psychogenic, exercise induced)
Pregnancy
Infection
Reproductiveage
Ovulatory dysfunction
Pregnancy
Cancer
Polyps, leiomyomas, adenomyosis
Infection
Endocrine dysfunction (polycystic ovary
syndrome, thyroid, hyperprolactinemia)
Bleeding diathesis
Medication related (eg, hormonal
contraception)
Menopausal transition
Anovulation
Polyps, fibroids, adenomyosis
Cancer
Menopause
Endometrial atrophy
Cancer
Postmenopausal hormone therapy
Adapted from: APGO educational series on women's health issues. Clinical management of abnormal
uterine bleeding. Association of Professors of Gynecology and Obstetrics, May 2002.

Evaluation of abnormal uterine bleeding in nonpregnant
reproductiveage women

Risk factors for endometrial cancer
Risk factor
Relative risk (RR)
(other statistics are noted when
used)
Increasing age Women 50 to 70yearsold have a 1.4
percent risk of endometrial cancer
Unopposed estrogen therapy 2 to 10
Tamoxifen therapy 2
Early menarche NA
Late menopause (after age 55) 2
Nulliparity 2
Polycystic ovary syndrome (chronic
anovulation)
3
Obesity 2 to 4
Diabetes mellitus 2
Estrogensecreting tumor NA

Lynch syndrome (hereditary nonpolyposis
colorectal cancer)
22 to 50 percent lifetime risk
Cowden syndrome 13 to 19 percent lifetime risk
Family history of endometrial, ovarian, breast,
or colon cancer
NA
NA: RR not available.
Adapted from data in Smith RA, von Eschenbach AC, Wender R, et al. American Cancer Society
Guidelines for Early Endometrial Cancer Detection: Update 2001.

Women who should undergo evaluation for endometrial
hyperplasia or endometrial cancer
Abnormal uterine bleeding
Postmenopausal women – Any uterine bleeding, regardless of volume (including spotting
or staining). Further evaluation of a sonographic finding of an endometrial thickness >4
mm (even if the patient has no uterine bleeding).
Age 45 years to menopause – Any abnormal uterine bleeding, including intermenstrual
bleeding in women who are ovulatory. Abnormal uterine bleeding in any woman that is
frequent (interval between the onset of bleeding episodes is less than 21 days), heavy
(total volume of >80 mL), or prolonged (longer than seven days).
Younger than 45 years – Abnormal uterine bleeding that is persistent, occurs in the
setting of a history of unopposed estrogen exposure (obesity, chronic anovulation) or
failed medical management of the bleeding, or in women at high risk of endometrial
cancer (eg, tamoxifen therapy, Lynch syndrome, Cowden syndrome).
In addition, endometrial neoplasia should be suspected in premenopausal women who are
anovulatory and have prolonged periods of amenorrhea (six or more months).
Cervical cytology results
Presence of atypical glandular cells (AGC)endometrial.
Presence of AGCall subcategories other than endometrial – If ≥35 years old OR at risk for
endometrial cancer (risk factors or symptoms).
Presence of benignappearing endometrial cells in women ≥40 years of age who also have
abnormal uterine bleeding or risk factors for endometrial cancer.
Other indications
Monitoring of women with endometrial pathology (eg, endometrial hyperplasia).
Screening in women at high risk of endometrial cancer (eg, Lynch syndrome).

Evaluation and differential diagnosis of abnormal uterine bleeding
(AUB) in nonpregnant reproductiveage women
Bleeding
pattern
Other
associated
clinical
features
Differential diagnosis
Evaluation
Common
etiologies
Less
common
etiologies
Regular menses
that are heavy
or prolonged
Enlarged uterus
on examination,
discrete masses
may be noted
Uterine leiomyoma Pelvic ultrasound
Saline infusion
sonography or
hysteroscopy (if
intracavitary
pathology is
suspected)
Dysmenorrhea
Enlarged,
boggy uterus on
examination
Adenomyosis Pelvic ultrasound
Family history
of bleeding
disorder
Symptoms of
bleeding
diathesis
Anticoagulant
therapy
Bleeding disorder Testing for
bleeding disorder
Risk factors for
uterine
malignancy
Endometrial
carcinoma or
uterine
sarcoma
Endometrial
sampling
Regular menses
with
intermenstrual
bleeding
Endometrial polyp Pelvic ultrasound
Saline infusion
sonography or
hysteroscopy (if
available)
Risk factors for
uterine
malignancy
Endometrial
carcinoma or
uterine
sarcoma
See endometrial
carcinoma above
Recent history
of uterine or
cervical
procedure or
childbirth,
particularly if
infection was
present
Chronic
endometritis
Endometrial
sampling

Irregular
bleeding, may
be more or less
frequent than
normal menses
and volume and
duration may
vary
Ovulatory
dysfunction:

Hirsutism, acne,
and/or obesity
PCOS Total testosterone
and/or other
androgens (may
not be increased in
all women with
PCOS)
Galactorrhea Hyperprolactinemia Prolactin
Recent weight
gain or loss
Heat or cold
intolerance
Family history
of thyroid
dysfunction
Thyroid disease Thyroid function
tests
Risk factors for
uterine
malignancy
Endometrial
carcinoma or
uterine
sarcoma

Secondary
amenorrhea
Poor nutrition or
intense exercise
Hypothalamic
amenorrhea
Follicle
stimulating
hormone
Luteinizing
hormone

Estrogen/progestin
withdrawal test
Hot flushes Premature ovarian
insufficiency
Follicle stimulating
hormone
Recent history
of uterine or
cervical
procedure or
childbirth,
particularly if
infection was
present
(menses may
present, but
abnormally light
or brief)
Cervical
stenosis
On pelvic
examination,
instrument cannot
be passed through
internal cervical os
Intrauterine
adhesions
(Asherman
syndrome)
Hysteroscopy
Irregular or
heavy bleeding
in a patient on
hormonal
contraceptives
or with an
intrauterine
Iatrogenic AUB

device
Other uncommon etiologies of AUB include a uterine arteriovenous malformation or
endometriosis.
PCOS: polycystic ovarian syndrome.

Medications that cause hyperprolactinemia
Medication class
Frequency of
prolactin elevation*
Mechanism
Antipsychotics, first generation
Chlorpromazine Moderate Dopamine D receptor
blockade within hypothalamic
tuberoinfundibular system
Fluphenazine High
Haloperidol High
Loxapine Moderate
Perphenazine Moderate
Pimozide Moderate
Thiothixene Moderate
Trifluoperazine Moderate
Antipsychotics, second generation
Aripiprazole None or low Dopamine D receptor
blockade
Asenapine Moderate
Clozapine None or low
Iloperidone None or low
Lurasidone None or low
Olanzapine Low
Paliperidone High
Quetiapine None or low
Risperidone High
Ziprasidone Low
Antidepressants, cyclic
Amitriptyline Low Not well understood. Possibly
by GABA stimulation and
indirect modulation of
prolactin release by serotonin.
Desipramine Low
Clomipramine High
Nortriptyline None
Antidepressants, SSRI
Citalopram, fluoxetine,
fluvoxamine, paroxetine,
sertraline
None or low (rare reports) Same as for cyclic
antidepressants
Antidepressants, other
Bupropion, venlafaxine,
mirtazapine, nefazodone,
trazodone
None Not applicable
Antiemetic and gastrointestinal
Metoclopramide High Dopamine D receptor
blockade
Domperidone (not available High
2
2
2

in United States)
Prochlorperazine Low
Antihypertensives
Verapamil Low Not well understood. Specific
to verapamil. May involve
calcium influx inhibition
within tuberoinfundibular
dopaminergic neurons.
Methyldopa Moderate Decreased conversion of L
dopa to dopamine;
suppression of dopamine
synthesis
Most other
antihypertensives
(including other calcium
channel blockers)
None Not applicable
Opioid analgesics
Methadone, morphine,
others
Transient increase for several
hours following dose
Potentially an indirect effect of
mu opiate receptor activation
Medication induced hyperprolactinemia can cause decreased libido and erectile dysfunction
in men and galactorrhea and amenorrhea in women.
GABA: gammaaminobutyric acid; SSRI: selective serotonin reuptake inhibitor.
* Frequency of increase to abnormal prolactin levels with chronic use: high >50 percent; moderate:
25 to 50 percent; low: <25 percent; none or low: case reports. Effect may be dosedependent.
Data from:
1. Molitch ME. Drugs and prolactin. Pituitary 2008; 11:209.
2. Molitch ME. Medication induced hyperprolactinemia. Mayo Clin Proc 2005; 80:1050.
3. Coker F, Taylor D. Antidepressant induced hyperprolactinemia. CNS Drugs 2010; 24:563.
4. Drugs for psychiatric disorders. Treat Guidel Med Lett 2013; 11:53.

Characteristics of normal menses versus abnormal uterine
bleeding
Characteristic
Normal
menses
Abnormal uterine bleeding
Frequency Every 21 to 35
days
<21 days or >35 days
Regularity Cycles occur
with a fairly
consistent
frequency
Variation from one cycle to the next of more than 20
days is considered irregular
Volume 5 to 80 mL
of blood
Volume of blood is difficult to measure. In clinical
practice, heavy menses are generally defined as
soaking a pad or tampon more than every two hours
or as a volume of bleeding that interferes with daily
activities (eg, wakes patient from sleep, stains clothing
or sheets).
Duration Bleeding for 5
days
Bleeding for >5 days
Reference:
1. Fraser IS, Critchley HO, Munro MG, Broder M. Can we achieve international agreement on
terminologies and definitions used to describe abnormalities of menstrual bleeding? Hum
Reprod 2007; 22:635.
Data from: Committee on Practice Bulletins—Gynecology. Diagnosis of abnormal uterine bleeding in
reproductiveaged women. Practice Bulletin No. 128. Obstet Gynecol 2012; 120:197.
[1]

Questions to ask to help quantify blood loss during menses
How often do you change your sanitary pad/tampon during peak flow days?
How many pads/tampons do you use over a single menstrual period?
Do you need to change the pad/tampon during the night?
How large are any clots that are passed?
Has a medical provider told you that you are anemic?
Women with a normal volume of menstrual blood loss tend to:
change pads/tampons at ≥3 hour intervals,
use fewer than 21 pads/tampons per cycle,
seldom need to change the pad/tampon during the night,
have clots less than 1 inch in diameter,
not be anemic
Adapted from: Warner PE, Critchley HD, Lumsden MA, et al. Menorrhagia I: measured blood loss,
clinical features, and outcome in women with heavy periods: a survey with followup data. Am J
Obstet Gynecol 2004; 190:1216.

Causes of heavy or prolonged menses
Coagulopathy
von Willebrand disease
Thrombocytopenia (due to idiopathic
thrombocytopenic purpura, hypersplenism,
chronic renal failure)
Acute leukemia
Anticoagulants
Advanced liver disease
Neoplasm
Endometrial hyperplasia or carcinoma
Uterine sarcoma
Structural lesion
Uterine leiomyomas (fibroids)
Adenomyosis
Endometrial polyps
Other
Endometritis
Hypothyroidism
Intrauterine device
Hyperestrogenism
Endometriosis

Causes of intermenstrual bleeding
Drugs
Oral contraceptives
Infection
Cervicitis*
Endometritis
Sexually transmitted ulcerations*
Vaginitis
Benign growths
Cervical polyps*
Endometrial polyps
Ectropion*
Uterine fibroids
Vulvar skin tags, sebaceous cysts, condylomata
Vaginal Gartner's duct cysts, polyps, adenosis
Cancer
Uterine
Cervical*
Vaginal
Vulvar
Rarely ovarian or fallopian tube
Trauma
Previous cesarean delivery incision
* Often cause postcoital bleeding.

Causes of ovulatory dysfunction
Primary hypothalamicpituitary dysfunction
Kallman's syndrome
Idiopathic hypogonadotropic hypogonadism
Tumors, trauma, or radiation of the hypothalamic or pituitary area
Sheehan's syndrome
Empty sella syndrome
Pituitary adenoma or other pituitary tumors
Lymphocytic hypophysitis (autoimmune diseases)
Lactational amenorrhea
Stress
Eating disorders
Intense exercise
Immaturity at onset of menarche or perimenopausal decline
Other disorders
Polycystic ovary syndrome
Hyperthyroidism or hypothyroidism
Hormone producing tumors (adrenal, ovarian)
Chronic liver or renal disease
Cushing's disease
Congenital adrenal hyperplasia
Premature ovarian failure, which may be autoimmune, genetic, surgical idiopathic, or related
to drugs or radiation
Turner syndrome
Androgen insensitivity syndrome
Medications
Estrogenprogestin contraceptives
Progestins
Antidepressant and antipsychotic drugs
Corticosteroids
Chemotherapeutic agents

Agerelated interval between menses
Selected percentiles for the distribution of menstrual interval by age
based on data from over 200,000 cycles. Longer intermenstrual
intervals occur in women just after menarche and in the years
preceding menopause.
Data from: Treloar AE, Boynton RE, Behn BG, Brown BW. Variation of the
human menstrual cycle through reproductive life. Int J Fertil 1967; 12:77.

Pregnancy testing
Urine pregnancy test Serum pregnancy test
Minimum hCG
level for a
positive test
Qualitative test: 20 to 50 int.
units/L, depending on test
Qualitative test: 5 to 10 int. units/L,
depending on test
Quantitative test: 1 to 2 int. units/L
for an ultrasensitive test
Causes of a
false negative
test
1. Performed too soon after conception; hCG concentration is below
threshold for a positive test
2. The hCG isoform measured is different from the hCG isoform in the
sample (pertains mostly to urine tests)
3. Hook effect due to extremely high hCG concentration (>500,000 int.
units/L, these levels are most commonly seen in gestational
trophoblastic neoplasia)
Causes of a
false positive
test
1. Pregnancy loss very soon after implantation ("biochemical
pregnancy")
2. hCG secretion from a tumor
3. Pituitary hCG secretion
4. Interference from human antibodies against animal antibodies or
heterophilic antibodies (serum test positive but urine hCG will be
negative)
5. Patient has received a medication containing hCG or certain antibodies
hCG: human chorionic gonadotropin.

Markers secreted by germ cell and sex cordstromal tumors of the
ovary
AFP hCG LDH E2 Inhibin Testost Andro DHEA AMH
Germ cell tumors
Dysgerminoma –* ± + ± – – – –
Embryonal ± + ± ± – – – –
Immature
teratoma
± – ± ± – – – ±
Choriocarcinoma – + ± – – – – –
Endodermal sinus + – + – – – – –
Gonadoblastoma – – – ± ± ± ± ±
Polyembryona ± + – – – – – –
Mixed germ cell ± ± ± – – – – –
Sex cordstromal tumors
Thecomafibroma – – – – – – – –
Granulosa cell – – – ± + ± – –
SertoliLeydig ± – – ± ± ± ± ±
AFP: alphafetoprotein; hCG: human chorionic gonadotrophin; LDH: lactate dehydrogenase; E2:
estradiol; testost: testosterone; andro: androstenedione; DHEA: dihydroepiandrostenedione; AMH:
antiMullerian hormone.
* Borderline elevations in case reports (<16 ng/ml).
¶ Low level seen in dysgerminomas with either nondysgerminomatous elements of
syncytiotrophobalstic cells.
Δ Type of germ cellsex cord stromal tumor consisting of neoplastic germ cells and sex cordstromal
derivatives.
¶
Δ

Screening for bleeding disorders in women with heavy menstrual
bleeding
Initial screening for an underlying disorder of hemostasis in patients
with excessive menstrual bleeding should be structured by medical
history (positive screen comprises any of the following):*
Heavy menstrual bleeding since menarche
One of the following:
Postpartum hemorrhage
Surgeryrelated bleeding
Bleeding associated with dental work
Two or more of the following symptoms:
Bruising one to two times per month
Epistaxis one to two times per month
Frequent gum bleeding
Family history of bleeding symptoms
* Patients with a positive screen should be considered for further evaluation, including consultation
with a hematologist and testing of von Willebrand factor and ristocetin cofactor.
Original figure modified for this publication. Kouides PA, Conard J, Peyvandi F, et al. Hemostasis and
menstruation: appropriate investigation for underlying disorders of hemostasis in women with
excessive menstrual bleeding. Fertil Steril 2005; 84:1345. Table used with the permission of Elsevier
Inc. All rights reserved.

Approach to abnormal uterine bleeding in nonpregnant reproductive age women

Approach to abnormal uterine bleeding in nonpregnant reproductive age women

Recommended

Recommended

More Related Content

What's hot

What's hot (19)

More from Antolino Rosales

More from Antolino Rosales (8)

Approach to abnormal uterine bleeding in nonpregnant reproductive age women