Expired CME Article

Abnormal Uterine Bleeding

Authors: Sara B. Fazio, MD, Amy N. Ship, MD


Disorders of the menstrual cycle are common problems in ambulatory medicine. Abnormal uterine bleeding describes bleeding that is excessive or outside the normal menstrual cycle. In the premenopausal woman, the differential diagnosis is broad, and pregnancy must always be considered. Determining whether the bleeding is ovulatory or anovulatory is a central part of the evaluation, as anovulation is one of the most common causes of abnormal uterine bleeding. In patients with anovulatory bleeding, the goal of treatment is to minimize blood loss and prevent complications from chronic unopposed estrogen. In women with oligomenorrhea or amenorrhea, after establishing the etiology, it is necessary to maintain adequate estrogen to support bone health. In the peri- and postmenopausal population, because the incidence of endometrial hyperplasia and malignancy rises, it is important to have a low threshold for endometrial assessment.

Key Points

* Abnormal uterine bleeding is common, and evaluation is best approached by stratifying into pre-, peri- and postmenopausal status.

* In the premenopausal woman, one must determine if excessive or irregular bleeding is ovulatory or nonovulatory; pregnancy must always be considered in the differential.

* In the peri- and postmenopausal woman, there is an increased risk of endometrial hyperplasia and malignancy; thus, evaluation should proceed accordingly.

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1. Wren BG. Dysfunctional uterine bleeding. Aust Fam Physician 1998;27:371–377.
2. Obstetrics AoPoGa. Clinical management of abnormal uterine bleeding. In: Smith RP BL, Ke RW, Strickland JL, ed. APGO Educational Series on Women’s Health, 2002.
3. Bayer SR, DeCherney AH. Clinical manifestations and treatment of dysfunctional uterine bleeding. JAMA 1993;269:1823–1828.
4. Implantation embryogenesis, and placental development. In: Cunningham G, Grant NF, Leveno KJ, et al, ed. Williams Obstetrics. New York, McGraw Hill, 2005.
5. Seeber BE, Barnhart KT. Suspected ectopic pregnancy. Obstet Gynecol 2006;107:399–413.
6. Oriel KA, Schrager S. Abnormal uterine bleeding. Am Fam Physician 1999;60:1371–1380; discussion 1381–1382.
7. Ehrmann DA. Polycystic ovary syndrome. N Engl J Med 2005;352:1223–1236.
8. ACOG Committee on Practice Bulletins—Gynecology. American College of Obstetricians and Gynecologists. ACOG practice bulletin: management of anovulatory bleeding. Int J Gynaecol Obstet 2001;72:263–271.
9. Ryden J, Blumenthal PD, ed. Practical Gynecology: A Guide for the Primary Care Physician (Women’s Health Series). Philadelphia, American College of Physicians, 1998.
10. Uterine leiomyomata. Number 192–May 1994. ACOG technical bulletin. Int J Gynaecol Obstet 1994;46:73–82.
11. Amant F, Moerman P, Neven P, et al. Endometrial cancer. Lancet 2005;366:491–505.
12. Platz CE, Benda JA. Female genital tract cancer. Cancer 1995;75 (1 Suppl):270–294.
13. Pretorius R, Semrad N, Watring W, et al. Presentation of cervical cancer. Gynecol Oncol 1991;42:48–53.
14. Stewart EA. Uterine fibroids. Lancet 2001;357:293–298.
15. Ryan GL, Syrop CH, Van Voorhis BJ. Role, epidemiology, and natural history of benign uterine mass lesions. Clin Obstet Gynecol 2005;48:312–324.
16. Stabinsky SA, Einstein M, Breen JL. Modern treatments of menorrhagia attributable to dysfunctional uterine bleeding. Obstet Gynecol Surv 1999;54:61–72.
17. Munro MG. Dysfunctional uterine bleeding: advances in diagnosis and treatment. Curr Opin Obstet Gynecol 2001;13:475–489.
18. Wellington K, Wagstaff AJ. Tranexamic acid: a review of its use in the management of menorrhagia. Drugs 2003;63:1417–1433.
19. Master-Hunter T, Heiman DL. Amenorrhea: evaluation and treatment. Am Fam Physician 2006;73:1374–1382.
20. Holschen JC. The female athlete. South Med J 2004;97:852–858.
21. Cann CE, Martin MC, Genant HK, et al. Decreased spinal mineral content in amenorrheic women. JAMA 1984;251:626–629.
22. Drinkwater BL, Nilson K, Chesnut CH 3rd, et al. Bone mineral content of amenorrheic and eumenorrheic athletes. N Engl J Med 1984;311:277–281.
23. Davis A. A 21-year-old woman with menstrual irregularity. JAMA 1997;277:1308–1314.
24. Dijkhuizen FP, Mol BW, Brolmann HA, et al. The accuracy of endometrial sampling in the diagnosis of patients with endometrial carcinoma and hyperplasia: a meta-analysis. Cancer 2000;89:1765–1772.
25. Taipale P, Tarjanne H, Heinonen UM. The diagnostic value of transvaginal sonography in the diagnosis of endometrial malignancy in women with peri- and postmenopausal bleeding. Acta Obstet Gynecol Scand 1994;73:819–823.
26. Dubinsky TJ, Parvey HR, Maklad N. The role of transvaginal sonography and endometrial biopsy in the evaluation of peri- and postmenopausal bleeding. AJR Am J Roentgenol 1997;169:145–149.
27. Tongsong T, Pongnarisorn C, Mahanuphap P. Use of vaginosonographic measurements of endometrial thickness in the identification of abnormal endometrium in peri- and postmenopausal bleeding. J Clin Ultrasound 1994;22:479–482.
28. Smith-Bindman R, Kerlikowske K, Feldstein VA, et al. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA 1998;280:1510–1517.
29. Langer RD, Pierce JJ, O’Hanlan KA, et al. Transvaginal ultrasonography compared with endometrial biopsy for the detection of endometrial disease. Postmenopausal Estrogen/Progestin Interventions Trial. N Engl J Med 1997;337:1792–1798.
30. Tabor A, Watt HC, Wald NJ. Endometrial thickness as a test for endometrial cancer in women with postmenopausal vaginal bleeding. Obstet Gynecol 2002;99:663–670.