ED visits for vaginal bleeding by women of reproductive age are common. Menorrhagia occurs
in 9% to 14% of healthy women, although most will
have a normal duration of menses. An estimated 5% of women
aged 30 to 49 years old will consult a physician for treatment alterations
in pattern or volume of flow of menses. The focus of this chapter
is on excessive or prolonged bleeding rather than oligomenorrhea
To understand abnormal uterine bleeding, it is necessary to define
normal menstrual flow. The mean interval between menses is 28 days
(±7 days). The mean duration of menstrual flow is 4 days, with most
blood loss occurring in the first 2 days. For practical purposes,
a change in the duration of flow is abnormal, even though by definition,
a woman may not have menorrhagia (Table 99-1).
Table 99-1 Definitions Related
to Vaginal Bleeding |Favorite Table|Download (.pdf)
Table 99-1 Definitions Related
to Vaginal Bleeding
|Vaginal bleeding||Defined temporally as midcycle (ovulatory), premenstrual,
menstrual, and postmenstrual|
|Abnormal vaginal bleeding||Vaginal bleeding occurring outside the regular cycle|
|Menorrhagia||Menses >7 d, or menstruation >60 mL, or <21-day recurrence,
from any cause|
|Metrorrhagia||Irregular vaginal bleeding outside the normal cycle|
|Menometrorrhagia||Excessive irregular vaginal bleeding|
|Dysfunctional uterine bleeding||Abnormal vaginal bleeding due to anovulation|
|Postcoital bleeding||Vaginal bleeding after intercourse, suggesting cervical pathology|
|Postmenopausal bleeding||Any bleeding that occurs more than 6 mo after cessation of
The lower age limit for menarche tends to be 10 years old, and the
mean age in North America is 12.5 years. Most girls develop secondary
breast changes 2 years before the onset of menarche. At the time
of ovarian stimulation, a white or yellow vaginal discharge, which
is both nonodorous and nonirritating, may appear. Early cycles are
anovulatory and irregular, but unlike adult anovulatory cycles,
bleeding is generally not excessive. The hypothalamic pituitary
axis takes 1 to 5 years to reach full maturity, and the average
time to establish ovulatory cycles is 2 years after menarche.
The normal menstrual cycle is 28 days and is divided into four phases:
menses, follicular, ovulation, and luteal or secretory. The first
day of the cycle corresponds to the first day of menses, which generally
lasts 4 days and involves the sloughing of the functionalis layer
of the endometrium. The interval from day 5 through day 14 is the
follicular (proliferation) phase, during which the ovary matures
an oocyte for ovulation, and the granulosa cells, lining the follicle,
produce estrogen. This stimulates the endometrium to proliferate
and thicken (Figure 99-1).
The hormonal, ovarian, endometrial, and basal body temperature
changes and relationships throughout the normal menstrual cycle.
E2 = prostaglandin E2; FSH = follicle-stimulating
hormone; LH ...
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