Abnormal uterine bleeding is vaginal bleeding from the

uterus The uterus (from Latin ''uterus'', : uteri or uteruses) or womb () is the hollow organ, organ in the reproductive system of most female mammals, including humans, that accommodates the embryonic development, embryonic and prenatal development, f ...

that is abnormally frequent, lasts excessively long, is heavier than normal, or is irregular. The term "dysfunctional uterine bleeding" was used when no underlying cause was present.

Quality of life Quality of life (QOL) is defined by the World Health Organization as "an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards ...

may be negatively affected. The underlying causes may be structural or non-structural and are classified in accordance with the FIGO system 1 & 2. Common causes include:

Ovulation Ovulation is an important part of the menstrual cycle in female vertebrates where the egg cells are released from the ovaries as part of the ovarian cycle. In female humans ovulation typically occurs near the midpoint in the menstrual cycle and ...

problems, fibroids, the lining of the uterus growing into the uterine wall, uterine polyps, underlying bleeding problems, side effects from

birth control Birth control, also known as contraception, anticonception, and fertility control, is the use of methods or devices to prevent pregnancy. Birth control has been used since ancient times, but effective and safe methods of birth control only be ...

, or

cancer Cancer is a group of diseases involving Cell growth#Disorders, abnormal cell growth with the potential to Invasion (cancer), invade or Metastasis, spread to other parts of the body. These contrast with benign tumors, which do not spread. Po ...

. Susceptibility to each cause is often dependent on an individual's stage in life (''prepubescent, premenopausal, postmenopausal''). More than one category of causes may apply in an individual case. The first step in work-up is to rule out a

tumor A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...

or pregnancy. Vaginal bleeding during pregnancy may be abnormal in certain circumstances. Please see

Obstetrical bleeding Obstetrical bleeding is bleeding in pregnancy that occurs Antepartum bleeding, before, during, or Postpartum bleeding, after childbirth. Bleeding before childbirth is that which occurs after 24 weeks of pregnancy. Bleeding may be vaginal or less ...

and

early pregnancy bleeding Early pregnancy bleeding (also called first trimester bleeding) is vaginal bleeding before 13 weeks of gestational age. Early pregnancy bleeding is common and can occur in up to 25% of pregnancies. Many individuals with first trimester bleeding ...

for more information.

Medical imaging Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to revea ...

or hysteroscopy may help with the diagnosis. Treatment depends on the underlying cause. Options may include

hormonal birth control Hormonal contraception refers to birth control methods that act on the endocrine system. Almost all methods are composed of steroid hormones, although in India one selective estrogen receptor modulator is marketed as a contraceptive. The origin ...

, gonadotropin-releasing hormone agonists,

tranexamic acid Tranexamic acid is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation. It is also used for hereditary angioedema. It is taken eithe ...

nonsteroidal anti-inflammatory drug Non-steroidal anti-inflammatory drugs (NSAID) are members of a Indication (medicine), therapeutic drug class which Analgesic, reduces pain, Anti-inflammatory, decreases inflammation, Antipyretic, decreases fever, and Antithrombotic, prevents bl ...

s, and surgery such as endometrial ablation or

hysterectomy Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes ( salpi ...

. Over the course of a year, roughly 20% of reproductive-aged women self-report at least one symptom of abnormal uterine bleeding.

Signs and symptoms

Although uterine bleeding can be alarming and abnormal, there are many instances in which uterine bleeding is normal. ''FIGO System 1'' is the first part of the classification system developed by the ''International Federation of Gynecology and Obstetrics'' to standardize the differences between normal uterine bleeding and abnormal uterine bleeding based on f''requency, duration, regularity and individual flow volume''.

Normal uterine bleeding

* Monthly Menstrual cycle occurring every 21 – 35 days. (''Most common cause of'' ''uterine bleeding''). * Neonatal uterine bleeding can occur in newborn females due to rapidly decreasing estrogen levels. * Postpartum lochia is a bloody discharge that occurs post pregnancy and can last for several weeks. * Uterine procedures such as biopsies, myomectomies,

intrauterine device An intrauterine device (IUD), also known as an intrauterine contraceptive device (IUCD or ICD) or coil, is a small, often T-shaped birth control device that is inserted into the uterus to prevent pregnancy. IUDs are a form of long-acting rever ...

insertion and Pap smears can cause light bleeding that may last for several days.

Abnormal uterine bleeding

* Menstrual bleeding starts before 21 days or after 35 days * Menstrual bleeding that lasts more than 7 days * Heavy menstrual cycle bleeding that necessitates changing pad or tampon roughly every hour (about 80 mL of blood loss) . * Any bleeding between menstrual cycles, after sexual intercourse or bleeding after six months of menopause * Premenopausal menstrual bleeding that stops for more than 3 months

Causes and mechanisms

The causes of abnormal uterine bleeding are divided into nine categories (PALM COEIN) under the ''FIGO System 2'' which is the second part of the classification system developed by the '' International Federation of Gynecology and Obstetrics''. More than one category of causes may apply in an individual case. Causes of abnormal uterine bleeding can also be narrowed down according to age group because each stage of life brings unique changes to an individual's uterine structure and systemic hormones. Prepubescent group includes all persons with a uterus that have not yet started menstruation (''monthly bleeding''). Newborn uterine bleeding is a normal occurrence and should gradually stop as estrogen leaves the infant's body. Any bleeding outside of the newborn period is abnormal and should be investigated for a cause, including sexual abuse. Premenopausal group includes all persons with a uterus that have started and are currently experiencing menstruation. * Adolescents between the ages of 13 and 19 commonly experience irregular menstrual cycles as their hormones and ovulation cycle regulates. Birth control, coagulopathies, pregnancy, abnormal uterine lining growths and infection are also common causes of abnormal bleeding in this age range. * Adults between the ages of 20 and 40 most commonly experience abnormal uterine bleeding due to

pregnancy Pregnancy is the time during which one or more offspring gestation, gestates inside a woman's uterus. A multiple birth, multiple pregnancy involves more than one offspring, such as with twins. Conception (biology), Conception usually occurs ...

and hormonal birth control. Uterine structural abnormalities (''See PALM in chart below'') ovulatory and endometrial dysregulation are also common causes. Uterine cancer is a rare cause of abnormal uterine bleeding in this group.

Postmenopausal Menopause, also known as the climacteric, is the time when menstrual periods permanently stop, marking the end of the reproductive stage for the female human. It typically occurs between the ages of 45 and 55, although the exact timing can ...

group includes all persons with a uterus that have stopped menstruation for more than one year or 12 consecutive months. Declining ovulatory function or menopause, is the most common cause of abnormal bleeding. Menstrual bleeding becomes gradually less frequent and lighter until it completely stops. Uterine cell wall thinning and overgrowth as well as cancer are common causes for abnormal uterine bleeding concern. The mechanisms, or reasons, that each of the PALM COEIN abnormalities cause uterine bleeding is not well understood, but the table below includes some scientific hypothesis and observations that give a strong indication of what may be happening. For more in-depth information about each of these causes, click on the links in the table below. Wikipedia Student Program

Diagnosis

Diagnosis of abnormal uterine bleeding starts with a

medical history The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and ev ...

and

physical examination In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a Disease, medical condition. It generally consists of a series of ...

. Normal menstrual bleeding patterns vary from woman to woman, so the medical history covers specific details about the woman's individual menstrual bleeding pattern, such as its predictability, length, volume, and whether she experiences cramps or other pain. The healthcare provider will also check to see whether she or any family members have any potentially related health conditions, and whether she is taking medication that might increase or decrease menstrual bleeding, such as herbal supplements, hormonal contraceptives, over-the-counter drugs such as

aspirin Aspirin () is the genericized trademark for acetylsalicylic acid (ASA), a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain, fever, and inflammation, and as an antithrombotic. Specific inflammatory conditions that aspirin is ...

, or

blood thinners An anticoagulant, commonly known as a blood thinner, is a chemical substance that prevents or reduces the coagulation of blood, prolonging the clotting time. Some occur naturally in blood-eating animals, such as leeches and mosquitoes, which h ...

. Medical tests include a blood test, to see whether the abnormal bleeding has caused

anemia Anemia (also spelt anaemia in British English) is a blood disorder in which the blood has a reduced ability to carry oxygen. This can be due to a lower than normal number of red blood cells, a reduction in the amount of hemoglobin availabl ...

, and a pelvic

ultrasound Ultrasound is sound with frequency, frequencies greater than 20 Hertz, kilohertz. This frequency is the approximate upper audible hearing range, limit of human hearing in healthy young adults. The physical principles of acoustic waves apply ...

, to see whether the abnormal bleeding is caused by a structural problem, such as a

uterine fibroid Uterine fibroids, also known as uterine leiomyomas, fibromyoma or fibroids, are benign smooth muscle tumors of the uterus, part of the female reproductive system. Most people with fibroids have no symptoms while others may have painful or h ...

. Ultrasound is specifically recommended in those over the age of 35 or those in whom bleeding continues despite initial treatment. Laboratory assessment of

thyroid stimulating hormone The thyroid, or thyroid gland, is an endocrine gland in vertebrates. In humans, it is a butterfly-shaped gland located in the neck below the Adam's apple. It consists of two connected lobes. The lower two thirds of the lobes are connected by ...

(TSH),

, and

chlamydia Chlamydia, or more specifically a chlamydia infection, is a sexually transmitted infection caused by the bacterium ''Chlamydia trachomatis''. Most people who are infected have no symptoms. When symptoms do appear, they may occur only several w ...

is also recommended. More extensive testing might include

magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and ...

and

endometrial The endometrium is the inner epithelium, epithelial layer, along with its mucous membrane, of the mammalian uterus. It has a basal layer and a functional layer: the basal layer contains stem cells which regenerate the functional layer. The funct ...

sampling. Endometrial sampling is recommended in those over the age of 45 who do not improve with treatment and in those with intermenstrual bleeding that persists. The PALM-COEIN system may be used to classify the uterine bleeding.

Management

Treatment depends on the underlying cause. Options may include

, gonadotropin-releasing hormone (GnRH) agonists,

s, and surgery such as endometrial ablation or

. Polyps, adenomyosis, and cancer are generally treated by surgery. Iron supplementation may be needed.

Terminology

The terminology "dysfunctional uterine bleeding" is no longer recommended. Historically dysfunctional uterine bleeding meant there was no structural or systemic problems present. In abnormal uterine bleeding underlying causes may be present.

Epidemiology

About one-third of all medical appointments with gynecologists involve abnormal uterine bleeding, with the proportion rising to 70% in the years around

menopause Menopause, also known as the climacteric, is the time when Menstruation, menstrual periods permanently stop, marking the end of the Human reproduction, reproductive stage for the female human. It typically occurs between the ages of 45 and 5 ...

References

External links

* Merck Manua
Abnormal Uterine Bleeding
{{Diseases of the pelvis and genitals Noninflammatory disorders of female genital tract Wikipedia medicine articles ready to translate