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.

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 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