Friday, October 21, 2011

Abnormal Menstrual Bleeding

An ideal menstrual cycle lasts for 28 days, with the first day calculated from the onset of menstrual bleeding and ovulation is at day-14 of the cycle. Normal menstrual cycle has a mean interval of 21-35 days, with a duration of 2-7 days and 30-80ml menstrual bleeding. 

Anything outside these range may be viewed as abnormal. These can be:
  • menorrhagia: excessive (>80ml/day) or prolonged (>7 days) bleeding
  • polymenorrhea: menstrual bleeding interval <21 days
  • oligomenorrhea: menstrual bleeding interval >35 days
  • metrorrhagia: irregular and more frequent menstrual bleeding
  • metromenorrhagia: irregular, more frequent and excessive bleeding
  • dysmenorrhea: excessive menses pain
  • amenorrhea: absent of menstrual bleeding for >6 months
  • intermenstrual bleeding: bleeding/spotting in between regular menstrual cycles
  • postmenopausal bleeding: bleeding after >6 months menopause

Important causes of abnormal menstrual bleeding that need to be ruled out:
  • Pregnancy and its related complication
  • Gynecological pathology
    • Benign lesion
      • uterine fibroid/polyp
      • cervical polyp
      • adenomyosis
      • polycystic ovary syndrome
    • Non-benign lesion
      • uterine cancer
      • ovarian cancer
      • cervical cancer
      • vaginal cancer
      • endometrial cancer
      • endometrial hyperplasia
    • Pelvic inflammatory disease
      • cervicitis
      • salpingitis
      • endometritis
    • Trauma
      • cervix
      • vagina
      • vulva
  • Endocrine disorders
    • Hyperthyroidism
    • Hypothyroidism
    • Hyperprolactin
  • Blood clotting disorders
    • Thrombocytopenia
    • Von-Willebrand's disease
    • Coagulopathy
  • Iatrogenic
    • Oral contraceptive pills
    • Intrauterine contraceptive devices
    • Medication
      • anti-coagulants
  • Dysfunctional uterine bleeding (diagnosis of exclusion in the absence of organic disease)
    • Stress / Excessive exercise etc.


Dysfunctional uterine bleeding is more common in the extremes of reproductive age, which are the first 2 years after the onset of menses (menarche) and a few years before the termination of menses (menopause). About 90% of the abnormal bleeding is anovulatory, in which there is no ovulation within the cycle because of certain disruption in the hypothalamus-pituitary-ovary axis.

Important investigations for abnormal uterine bleeding
  • pregnancy test
  • pelvis ultrasound scan
  • blood test: platelet, coagulation, thyroid function, prolactin
  • hysteroscopy
  • endometrial sampling/biopsy

     Endometrial biopsy

The treatment depends on the underlying cause of abnormal bleeding. If no organic disease can be found (dysfunctional uterine bleeding), treatment available includes:
  • Tranexemic acid
  • NSAIDs
  • Danazol (ethisterone)
  • GnRH agonists
  • Combined oral contraceptive pills
  • Progesterone only pills
  • Intrauterine devices with progesterone
  • Endometrial ablation (if future pregnancy not wanted)
  • Hysterectomy (if future pregnancy not wanted)

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