ABNORMAL UTERINE BLEEDING













  • Refernces [1,2,3]
Heavy Cyclical Bleeding
Cause Comments
Adenomyosis
  • Adenomyosis is a condition where the glandular tissue of the endometrium grows into the underlying uterine muscle
  • On exam, the uterus may be enlarged or lobular
Anticoagulant use
Coagulation disorders
  • Coagulopathy (particularly Von Willebrand disease) may cause heavy bleeding
  • Signs of coagulopathy include heavy bleeding since menarche, easy bruising, and prolonged mucosal surface bleeding
  • See coagulopathy screening for recommendations on who to screen
Copper IUD
  • The copper IUD may cause heavier and longer menstrual bleeding
  • See copper IUD for more
Leiomyoma (fibroids)
  • Fibroids are noncancerous growths of the uterus
  • On exam, the uterus may be enlarged or lobular
  • May be treated with uterine artery embolization

  • Refernces [1,2,3]
Noncyclical Bleeding
Cause Comments
Cervical polyp
  • May cause postcoital bleeding
Cervicitis
Endometrial hyperplasia
  • More common in perimenopausal and early postmenopausal women
  • Obesity, PCOS, and chronic anovulation are also risk factors
Endometrial polyp
  • May cause intermenstrual bleeding
  • Larger polyps may be seen on uterine ultrasound
  • May be removed with hysteroscopy
Endometritis
Hormonal contraceptives
Hyperprolactinemia
  • Hyperprolactinemia may present as amenorrhea or oligomenorrhea. Galactorrhea may also be present.
  • Hyperprolactinemia may occur from a pituitary adenoma, or it may be drug-induced (see antipsychotics for more)
Kidney disease
  • Kidney disease may cause irregular menses. In end-stage renal disease, amenorrhea is common.
Malignancy (endometrial, cervical, vaginal)
  • May cause postcoital bleeding
Menarche
  • Menarche is the onset of menstruation. It typically occurs between 12 and 13 years of age (median 12.43 years).
  • During the first 2 - 3 years after menarche, irregular menstrual cycles are common
Perimenopause
  • Perimenopause is the beginning of menopause, and it occurs at a median age of 47 years
  • Menstrual cycles often become irregular during perimenopause (see menopause for more)
Polycystic ovary syndrome
  • PCOS is a common cause of noncyclical menses
  • Hirsutism may be present
  • Measure serum testosterone level. See treatment recommendations for more.
Thyroid disease
  • Both hyper- and hypothyroidism can affect menstrual patterns
  • Amenorrhea and oligomenorrhea are seen in hyperthyroidism, and increased bleeding is common in hypothyroidism



  • References [1]
ACOG recommendations for working up menorrhagia
All patients
  • CBC
  • Blood type cross and match (if bleeding is severe)
  • Pregnancy test
Most patients
  • Pelvic ultrasound
  • Pelvic exam with PAP smear
Patients at risk for coagulopathy (see coagulopathy screening below)
  • activated Partial Thromboplastin Time (aPTT)
  • Prothrombin time (PT-INR)
  • Testing for von Willebrand disease
  • Fibrinogen
Women ≥ 45 years old
  • Endometrial biopsy
Other considerations in appropriate patients
  • Thyroid testing
  • Iron studies
  • Liver function tests
  • Chlamydia testing


  • References [1]
ACOG recommendations for coagulopathy screening in menorrhagia
Screen patients for coagulopathy if they meet any 1 of the following 3 criteria:
1. Heavy menstrual bleeding since menarche
2. One of the following:
  • Postpartum hemorrhage
  • Surgery-related bleeding
  • Bleeding with dental work
3. Two or more of the following:
  • Bruising, 1 - 2 times per month
  • Nosebleed, 1 - 2 times per month
  • Frequent gum bleeding
  • Family history of bleeding problems
Initial lab testing
  • CBC
  • activated Partial Thromboplastin Time (aPTT)
  • Prothrombin time (PT-INR)
  • Testing for von Willebrand disease
  • Fibrinogen


  • References [1]
ACOG recommendations for acute treatment of uncontrolled bleeding
Conjugated estrogens injection (Premarin®)
  • Dosing: 25 mg IV every 4 - 6 hours for 24 hours
  • Other
    • Shown to stop bleeding within 8 hours in 72% of patients
    • May cause significant nausea. Give with nausea medication.
    • See female hormone medications for more
Monophasic OCP with 35 mcg of ethinyl estradiol
  • Dosing: One tablet three times a day for 7 days
  • Other
    • Shown to stop bleeding in 88% of patients
    • May cause significant nausea. Give with nausea medication.
    • See oral contraceptive chart for more
Medroxyprogesterone (Provera®)
  • Dosing: 20 mg three times a day for 7 days
  • Other
    • Shown to stop bleeding in 76% of patients
    • May cause significant nausea. Give with nausea medication.
    • See female hormone medications for more
Tranexamic acid (Lysteda®)
  • Dosing
    • Oral: 1.3 grams three times a day for 5 days
    • IV: 10 mg/kg (max 600 mg/dose) every 8 hours for 5 days
  • Other
    • Tranexamic acid binds plasminogen and prevents it from dissolving fibrin
    • Contraindicated in women at increased risk for venous or arterial thromboembolism
    • See the Lysteda® PI for full prescribing information