Abnormal Vaginal Bleeding
DR. ISAAC O. KORANTENG
Bsc. MB.,ChB.,FWACS
Normal Bleeding
• For most girls, menarche usually occurs within 2 to 3
years after the appearance of breast buds
• Many teens then experience "irregular" periods for 2
to 3 years following menarche because of anovulatory
cycles and an immature hypothalamic-pituitary-ovarian
axis.
• Once "regular" menses are established, normal
menstrual cycles are 21 to 35 days long, with bleeding
usually lasting 2 to 7days and an average blood loss of
20 to 80 mL
Definitions
• Menorrhagia is bleeding that lasts more than 7
consecutive days or is more than 80 mL of blood loss
but still occurs at regular intervals
• Metrorrhagia - Bleeding that occurs at irregular
intervals
• Menometrorrhagia is heavy irregular bleeding
• Oligomenorrhea - If menstrual cycles occur at
intervals from 35 days to 3 months apart
Dysfunctional uterine bleeding
• Dysfunctional uterine bleeding is defined as
abnormal shedding of the uterine lining in the
absence of a structural or medical abnormality
and is most often due to anovulation
• DUB is a diagnosis of exclusion, and other
causes must be ruled out
• DUB accounts for 90% of abnormal uterine
bleeding
Differential Diagnosis For Abnormal
Uterine Bleeding
• Pregnancy
• Haematologic
• Endocrine
• Infectious
• Pathology of the reproductive tract
• Medications
• Trauma
• Others
Pregnancy
• Implantation
• Ectopic pregnancy
• Threatened, spontaneous, or missed abortion
• Retained products of conception
Haematologic
• Thrombocytopenia
• Von willebrand disease
• Factor deficiency
• Coagulation defect
• Platelet dysfunction
Endocrine
• Thyroid disorders
• Hyperprolactinemia
• Polycystic ovarian syndrome
• Adrenal disorders
• Ovarian failure
Infectious
• Cervicitis (especially chlamydia)
• Pelvic inflammatory disease
Pathology of reproduction tract
• Polyp
• Fibroid
• Endometriosis
Medications
• Hormonal contraceptives
• Antipsychotic drugs
• Platelet inhibitors
• Anticoagulant
Trauma
• Sexual abuse
• Laceration
• Foreign body
• Related to abortion or other surgical
procedure
Other
• Stress
• Excessive exercise
• Eating disorders
• Intrauterine device
• Systemic disease
Diagnosis
• A good history
• A good physical examination
• Investigation
HISTORY DIFFERENTIAL DIAGNOSIS
Heavy periods since menarche Bleeding disorder
Easy bruising, gum bleeding, nose
bleeding Platelet dysfunction
Heat/cold intolerance, weight
changes, diarrhea or constipation Thyroid disorders
Nipple discharge Prolactinoma, antipsychotic
agents
Abnormal hair growth Polycystic Ovarian Syndrome
Dysuria, vaginal discharge Vaginitis, cervititis
Lower abdominal pain, dischage Pelvic inflammatory disease
Investigations
Initial work-up should include the following:
• Urine pregnancy test and/or quantitative
serum pregnancy test
• Complete blood cell count with differential
and platelet count
• A pelvic ultrasound also may aid in the
diagnosis
Suspected bleeding disorder
• Prothrombin time and partial thromboplastin
time
• Bleeding time and platelet aggregation
• von Willebrand panel (done prior to initiating
hormonal therapy)
• Factor levels and activity (depending on family
history and ethnicity)
Suspected endocrine disorder
• Thyroid-stimulating hormone to screen for thyroid
disorders
• Prolactin
• Total and free testosterone (usually elevated in
polycystic ovarian syndrome
• Dehydroepiandrosterone sulfate to assess for
adrenal tumors
• Luteinizing hormone and follicle-stimulating
hormone (may aid in the evaluation of pituitary or
ovarian function)
Suspected infectious etiologies
• Wet mount of discharge if bleeding not severe
• Urine nucleic amplification test for gonorrhea
and chlamydia
Management
• The management of abnormal vaginal
bleeding is determined by the underlying
etiology and by the severity of the bleeding
• The goals of controlling abnormal bleeding
include preventing complications, such as
anemia, as well as restoring regular cyclical
bleeding
Management of DUB
• Management of DUB will in part be directed
by the amount of flow, the degree of
associated anemia, and patient and family
comfort with different treatment modalities
Light Flow
• Reassurance
• Multivitamin with iron
• A nonsteroidal anti-inflammatory drug may
help to decrease flow
• Re-evaluate patient in 3 months; sooner if
bleeding persists or becomes more severe
Moderate Flow
• Oral contraceptive pills (OCPs) - One pill twice daily for 1
to 5 days, until the bleeding stops
• Once the bleeding stops, continue OCPs with a new pack,
one pill daily, for 3 to 6 months
• Iron supplementation (e.g., ferrous sulfate 325 mg twice
daily) for 6 months to replenish iron stores
• Non-steroidal anti-inflammatory drugs may be helpful
Heavy Flow; Hemoglobin <7 g/dL or if
Hemodynamically Unstable
• Admit to the hospital
• blood transfusion
• Begin OCP every 6 hours until bleeding slows - Taper
administration of pills to one pill a day over the next 7
days (e.g., one pill every 6
• hours for 2 days, then every 8 hours for 2 days, every 12
hours for 2 days, then once daily)
• If bleeding still persists, consider dilation and curettage
Contraindication to estrogen-containing
regimens
• Progesterone, 10 mg once daily for 5 - 10 days
• Patients also may be cycled monthly on a
progesterone-only regimen.
• Depot medroxyprogesterone acetate, 150 mg
intramuscularly every 3 months
• Levonorgestrel intrauterine device (5 years).
