Dysfunctional uterine bleeding

Background

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

Workup

• R/o pregnancy, CBC, TSH
• Coags if suspected liver disease or other coagulopathy
• Pelvic US

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

Treatment

• Heavy bleed
  • Fluid admin
  • Estrogen-progestin OCP until gyn f/u
• Severe
  • Maintain hemodynamics
  • Consider IV conjugated estrogen (Premarin) 25 mg IV q4-6 hrs until bleeding stops
  • Continued severe bleeding requires D&C

Sources

• UpToDate - Management of Abnormal Uterine Bleeding
• eMedicine - Dysfunctional Uterine Bleeding in Emergency Medicine Treatment & Management