Dysfunctional uterine bleeding

This diagnosis should be used only when all organic causes are ruled-out, which generally does not occur in the ED. See nonpregnant vaginal bleeding for the general approach.

Background

Normal female anatomy with uterus highlighted.

Diagram of uterine blood supply.

Vaginal bleeding definitions

• Menorrhagia: >7 day (prolonged) or >80 mL/day (excessive) uterine bleeding at regular intervals
• Metrorrhagia: irregular vaginal bleeding outside the normal cycle
• Menometrorrhagia: excessive irregular vaginal bleeding
• Intermenstrual bleeding: variable amounts between regular menstrual periods
• Midcycle spotting: spotting just before ovulation (due to decline in estrogen)
• Polymenorrhea: frequent and light bleeding
• Postcoital bleeding: vaginal bleeding after intercourse, suggesting cervical pathology
• Postmenopausal bleeding: recurrence of bleeding >6 mo after menopause
• Amenorrhea: bleeding that is absent for > 6 months

Clinical Features

• The patient will not report bleeding amounts in mL/day so knowing the capacities of products is useful:
  • One Light tampon holds ~3mL
  • One Super tampon holds ~10-12mL
  • One Maxi pad holds up to 20-25mL

• Other symptoms related to anemia and hypovolemia should be noted.
• The patient may report cramping lower abdominal pain and back pain.

Differential Diagnosis

Nonpregnant Vaginal Bleeding

Systemic Causes

• Cirrhosis
• Coagulopathy (Von Willebrand disease, ITP)
• Group A strep vaginitis (prepubertal girls)
• Hormone replacement therapy
• Anticoagulants
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Hypothyroidism
• Polycystic Ovary Syndrome
• Secondary anovulation

Reproductive Tract Causes

• Adenomyosis
• Atrophic endometrium
• Dysfunctional uterine bleeding
• Endometriosis
• Leiomyoma (Fibroid)
• Foreign Body
• Infection (vaginitis, PID)
• IUD
• Neoplasia (especially in women >45 years old or in younger women with other risk factors)
• Vaginal Trauma

Evaluation

• See nonpregnant vaginal bleeding for general approach
• This diagnosis generally requires a endocervical curettage/endometrial biopsy to have been performed

Management

Heavy bleeding

• Fluid administration
• Estrogen-progestin OCP until gyn follow up - Preferred approach for most patients
• Contraindications to Estrogen-progestin OCP:
  • Age greater than 35 years
  • Heavy tobacco use;Hypertension
  • History of CVA or ischemic heart disease
  • SLE
  • Migraines with Aura
• TXA (Tranexamic acid) FDA approved for heavy menstrual bleeding. 1300mg (two 650mg tabs) PO TID

Severe Bleeding

• Maintain hemodynamics
• Consider IV conjugated estrogen (Premarin) 25mg IV q4-6 hrs until bleeding stops
• Continued severe bleeding requires D&C

See Also

• Nonpregnant vaginal bleeding