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Chapter 96: Abnormal Uterine Bleeding

Bophal Sarha Hang

INTRODUCTION

Abnormal uterine bleeding is an overarching term that is defined as bleeding from the uterine corpus that is irregular in volume, frequency, or duration in absence of pregnancy (Table 96-1).1,2 Vaginal bleeding is a common complaint in the ED, and differential diagnoses include pregnancy, structural abnormalities (e.g., polyps, fibroids), endometritis, coagulopathies, trauma, and various other causes. This chapter will focus on the ED evaluation and management of abnormal uterine bleeding.

TABLE 96-1FIGO Terminology for Bleeding2*
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TABLE 96-1 FIGO Terminology for Bleeding2*
Type Definition
Abnormal uterine bleeding Bleeding that is abnormal in regularity, volume, frequency, or duration. Bleeding may be acute or chronic and is present for at least 6 months.
Heavy menstrual bleeding (heavy uterine bleeding [HUB] replaces menorrhagia) Excessive menstrual bleeding that interferes with a woman’s physical, emotional, social, and quality of life. Note that the definition is menstrual bleeding deemed excessive by the patient regardless of duration, frequency, or timing.
Amenorrhea Bleeding that is absent for >6 months.
Prolonged menstrual bleeding Menstrual periods that exceed 8 days’ duration on a regular basis.
Intermenstrual bleeding (replaces metrorrhagia) Bleeding episodes between normally timed menstrual periods.
Irregular menstrual bleeding Unpredictable onset of menses, with cycle variations >20 days over a period of 1 year.
Postmenopausal bleeding Any bleeding that occurs >12 months after cessation of menstruation.

Abbreviation: FIGO = International Federation of Gynecology and Obstetrics.

Source: https://www.figo.org/news/ground-breaking-figo-classification-published-ijgo-0014139.

*Discarded terms include dysfunctional uterine bleeding, menorrhagia, functional uterine bleeding, hypermenorrhea, hypomenorrhea, menometrorrhagia, metrorrhagia, oligomenorrhea, polymenorrhea, and uterine hemorrhage.2

MENSTRUAL CYCLE

A normal menstrual cycle has an average duration of 4.5 to 8 days and an interval of 24 to 38 days between the onset of menses. The average blood loss is ≤30 mL, and menstrual blood loss >80 mL is considered abnormal. Menstrual cycle variation during early menarche and the perimenopausal period is due to high prevalence of anovulation. Figure 96-1 depicts hormonal and endometrial changes associated with a normal menstrual cycle.

FIGURE 96-1.

The hormonal, ovarian, endometrial, and basal body temperature changes and relationships throughout the normal menstrual cycle. E2 = prostaglandin E2; FSH = follicle-stimulating hormone; LH = luteinizing hormone; P = progesterone. [Reproduced with permission from Patel DR, Greydanus DE, Baker RJ: Pediatric Practice Sports Medicine. © 2009, McGraw-Hill, Inc., New York, NY.]

The image shows a graphical representation of the hormonal, ovarian, endometrial, and basal body temperature changes and relationships throughout the normal menstrual cycle.
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In response to the rising estrogen levels, the pituitary gland secretes follicle-stimulating hormone and luteinizing hormone, stimulating the release of a mature oocyte. The residual follicular capsule forms the corpus luteum. During the luteal phase, the corpus luteum secretes estrogen and progesterone, which maintains the integrity of the endometrium for implantation. In the absence of human chorionic gonadotropin released by a pregnancy, the corpus luteum involutes, and ...

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