Abnormal uterine bleeding

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Farman Khan, MD, MRCP [2]

Causes

Common Causes

• Dysfunctional uterine bleeding
• Leiomyomas (fibroids)
• Endometrial hyperplasia
• Abortion
• Cervicitis
• Endometrial Carcinoma
• Endometritis
• Pelvic Inflammatory Disease
• Vaginitis

Causes by Organ System

Cardiovascular	No underlying causes
Chemical / poisoning	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	Blood thinners, breakthrough bleeding in women using hormonal birth control, copper intrauterine device , depo-Provera hormone replacement therapy, tamoxifen, corticosteroids, chemotherapy, clomiphene, dilantin, antipsychotic drugs , antibiotics ( due to toxic epidermal necrolysis or Stevens-Johnson syndrome )
Ear Nose Throat	No underlying causes
Endocrine	Diabetes, hyperthyroidism, hypothyroidism, Cushing's syndrome, Hormone secreting adrenal and ovarian tumors
Environmental	No underlying causes
Gastroenterologic	Liver disease
Genetic	No underlying causes
Hematologic	Clotting disorders, Von Willebrand disease, thrombocytopenia or platelet dysfunction, acute leukemia ,Some factor deficiencies, Advanced liver disease
Iatrogenic	Radiation therapy
Infectious Disease	Chlamydia, gonorrhea, uterine infection, genitourinary tract infection, bacterial vaginosis sexually transmitted diseases, atrophic vaginitis
Musculoskeletal / Ortho	No underlying causes
Neurologic	No underlying causes
Nutritional / Metabolic	No underlying causes
Obstetric/Gynecologic	Adenomyosis, atrophy of the tissue lining the vagina and uterus, cervicitis, ectopic pregnancy, endometrial hyperplasia, endometritis, uterine sarcoma, first few months after the first menstrual period, first few weeks after abortion, first few weeks after delivery, intrauterine device, miscarriage, ovarian cysts, placenta previa, polycystic ovarian syndrome, retained products of conception, uterine fibroids, uterine polyps, diseases involving the vulva for example Crohn's disease, Behcet's syndrome , pemphigoid , pemphigus , erosive lichen planus , lymphoma, skin tags, sebaceous cysts, condylomata, angiokerataoma
Oncologic	Cancer or precancer of the cervix , cancer or precancer of the endometrium, ovarian cancer, uterine cancer, uterine sarcoma
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal / Electrolyte	Chronic renal disease
Rheum / Immune / Allergy	No underlying causes
Sexual	Sexual abuse
Trauma	Sexual intercourse , sexual abuse , foreign bodies (including IUD) , pelvic trauma, Straddle injuries
Urologic	Genitourinary tract infection
Dental	No underlying causes
Miscellaneous	Foreign body, irritation of the genital area due to bubble baths, soaps, lotions or infection, smoking, Excessive exercise

Causes in Alphabetical Order

Adenomyosis Anticoagulants Atrophy of the tissue lining the vagina and uterus Blood thinners Breakthrough bleeding in women using hormonal birth control Cancer or precancer of the cervix Cancer or precancer of the endometrium Cervicitis Chlamydia Chronic renal disease Clotting disorders Diabetes Ectopic pregnancy Endometrial hyperplasia Endometritis First few months after the first menstrual period First few weeks after abortion First few weeks after delivery Foreign body Genitourinary tract infection Gonorrhea Hyperthyroidism

Hypothyroidism Intrauterine device Irritation of the genital area due to bubble baths, soaps, lotions or infection Liver disease Miscarriage Ovarian cancer Ovarian cysts Placenta previa Polycystic ovarian syndrome Radiation therapy Retained products of conception Sexual abuse Trauma Uterine cancer Uterine fibroids Uterine infection Uterine polyps Uterine sarcoma Von Willebrand disease

Treatment

Contraindicated medications

• Choriogonadotropin alfa

Template:Abnormal uterine bleeding Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3] Associate Editor(s)-in-Chief: Nima Nasiri, M.D.[4]

Abnormal uterine bleeding differential diagnosis

• Abnormal uterine bleeding differential diagnosis include:

• Endometrial hyperplasia
• Cervical polyp
• Cervical leiomyoma
• Cervical lymphoma
• Cervical sarcoma
• Metastases to the cervix
• Cervical ectopic pregnancy
• Cervicitis
• Cervical erosion ( Ectropion )
• IUD use
• Pelvic inflammatory disease
• Endometriosis
• Adenomyosis
• Postcoital bleeding
• Clear cell adenocarcinoma
• Hematologic causes:
  • Von willebrand disease
  • Thrombocytopenia
  • Clotting disorder
  • Platelet dysfunction
  • Factors deficiency

Abnormal Uterine bleeidng differential diagnosis
Ob-Gyn neoplasm and diseases	Clinical manifestations									Para-clinical findings					Gold standard
	Symptoms							Physical exam		Lab Findings		Imaging		Histopathology
	Abnormal vaginal bleeding	Abnormal vaginal dyscharge	Pelvic pain	Itching or burning of the vulva	Other Genitourinary/ Gastrointestinal symptoms	B symptoms	Abdominal pain	Gynecological examinations	Abdominal mass	HPV Pap smear STI panel	Other labs	Ultrasound	Other imagings
Cervical cancer	Postmenopausal Intermenstrual Postcoital Bleeding after pelvic exam	+	+	+	Burning during urination Difficulty urinating Pain during sex	+	+	Cervical mass on exam	+	± HPV Atypical cells on Pap smear STI: ±Chlamydia		Large cervical cancer Angiogenesis on Doppler sonography Bladder involvement Lymph node involvement	T2-weighted MRI : Ovoid, heterogeneous tumor distending the cervical canal with stromal involvement. PET/CT scan: Detect tumor size Lymph node involvement, Metastases to bladder or rectum	CIN1: mild dysplasia CIN2: moderate dysplasia CIN3: high degree of dysplasia/metastases	Colposcopy/biopsy
Cervical polyp	Postcoital Intermenstrual Postmenopausal Bleeding after exam	+	−	−	−	−	−	Mass on exam	−	−		Hyper/hypoechogenic masses with or without cysts Filling the endocervical or vaginal canal		Epithelial cells with no nuclear atypia/mitoses	Hysteroscopy /Biopsy
Cervical leiomyoma	Heavy/prolonged menstrual bleeding Intermenstrual bleeding	+	+	−	Urinary retention Constipation Infertility Bowel obstruction Increase in pregnancy/labor complications	−	+	Large,irregular pelvic mass	±	−		Well circumscribed hyperechoic mass	T2-weighted MRI: Hypointense masses Homogeneous enhancement Red degeneration	Spindle shaped smooth muscle cells Mature adipocytes Extracellular matrix consist of collagen,fibronectin.	Clinical diagnosis/ and Ultrasound
Cervical lymphoma	Postmenopausal bleeding	−	+	−	Difficulty urinating Post-coital pain	+	+	Larrge uterine/cervix mass Irregularity	+	−		Well-defined, solid, concentric, hypoechoic mass		Small tumor cells with large nuclei High mitoses and proliferation	Biopsy
Cervical sarcoma	Intermentrual Postmenopausal	±	+	−	Post-coital pain Fullness in pelvic	±	+	Cervical mass Lump protruding from vagina/vulva	+	−					Biopsy
Cervical erosion(Ectropion)	Light bleeding after pelvic exam Spotting	+	+	±	Post-coital pain Painful cramps Pain after sex	−	+		−	−
Cervicitis	Intermenstrual bleeding Postcoital Bleeding after pelvic exam	+	+	Itching	Pain during urination Pain during sex Painful menstruation	May have fever only		Red,inflammed swollen cervix Inflammation/irritation of vulva/vagina	−	STI panel: Chlamydia Gonorrhea Herpes simplex Trichomonas vaginalis
Endometrial carcinoma	Postmenopausal bleeding Intermesntrual bleeding
Endometrial hyperplasia
Endometriosis	Heavy mentrual bleeding	±	Pelvic pain Back pain	−	Painful menstruation Burning/painful urination Painful bowel movement Pain during or after sex Infertility	−	+	Tender uterosacral nodularity Immobile uterus Cervical motion tenderness Retroverted uterus		−					Visual inspection by laparascopy
IUD use	Heavy bleeidng	±	+	Itching	Painful menstruation	−			−	−
Pelvic inflammatory diseases	Bleeding after sex Intermenstrual bleeding	+	+	Itching/burning	Pain during sex Painful menstruation Burning sensation during urination Pain during bowel movement	Fever	±Abdominal pain Pelvic pain	Vaginal/vulvar tender lesion depending on microbial cause	−	STI panel: Chlamydia Gonorrhea
Adnemyosis	Abnormal uterine bleeding	−	+	−	Painful menstruation	−		Polypoid mass protruding into the endocervical canal.		−
Cervical ectopic pregnancy	Amennorhea Bleeding after pelvic exam	−	−	−	Pelvic pain	−	+	Soft and disporportionally enlarged uterus.		−		Empty uterine Thickened endometrium	T2-weighted MRI: Hypointense large mass T1-weighted MRI: Partially hyperintense mass	Necrotic hemorrhagic mass with chorionic villus	Hysterectomy and biopsy
DES exposure (Clear cell adenocarcinoma)	Postcoital bleeding	+								−
Paget's disease of vulva to cervix	Bleeding from lesion Oozing	±	−	Itching/burning Pain in vulva	−	−	−	Scaly eczematoid lesion in vulva. Erythematous plaques with white scaling. Inguinal lymphadenopathy in case of metastases.	−	−				Intraepidermal adenocarcinoma which involves epidermis	Biopsy of lesion
Vaginal cancer	Postcoital bleeding	+			Tenesmus Dysuria Urinary frequency Constipation Pelvic pain			Vaginal lump Inguinal lymphadenopathy		−
Nabothian cyst	Postcoital bleeding	+	−	−	Pain during sex	−		Cystic mass on exam	−	−			T1-weighted Intermediate or slightly high signal intensity T2-weighted High signal intensity on T2-weighted images
Pregnancy and pregnancy related conditions	Clinical manifestations						Para-clinical findings							Gold standard	Additional findings
	Symptoms			Physical examination
							Lab Findings			Imaging			Histopathology
	Abnormal uterine bleeding			Physical exam 1	Physical exam 2	Physical exam 3	Beta-HCG	CBC	Other Labs	Ultrasound
Miscarriage
Abruptio placenta
Placenta previa
Ectopic pregnancy
Molar pregnancy
Hematologic conditions	Clinical manifestations						Para-clinical findings							Gold standard	Additional findings
	Symptoms			Physical examination
							Lab Findings
	Abnormal uterine bleeding			Physical exam 1	Physical exam 2	Physical exam 3	CBC	PT	PTT/INR	Coagulation factors	Bleeding Time
Von willebrand disease
Factors deficiencies
Platelet dysfunction
Metabolic conditions	Clinical manifestations						Para-clinical findings							Gold standard	Additional findings
	Symptoms			Signs
							Lab Findings			Imaging			Histopathology
	Abnormal uterine bleeding	Other symptoms					TSH/T4/T3	FSH/LH		Imaging 1	Imaging 2	Imaging 3
Hyperthyroidism	+	Wet skin/hair thinning Palpitation Insomnia Anxiety Weight loss Heat intolerance Diarrhea		Enlarged thyroid (Goiter) Exophthalmous
Hypothyroidism	+	Fatigue Cold intolerance Decreased sweating Hypothermia Coarse skin Weight gain Constipation Dry skin/hair loss
Adrenal hyperplasia	+
Cushing's disease	+
Polycystic ovarian syndrome	+
Hepatic disease	+
Medication side effects/ Iatrogenic	Clinical manifestations						Para-clinical findings							Gold standard	Additional findings
	Symptoms			Signs
							Lab Findings
	Abnormal uterine bleeding						CBC	Coagulation studies	Other lab values
Anticoagulants
Antipsychotics
Corticosteroids
Oral contraceptive pills
Herbal supplements