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	Other Genitourinary/ Gastrointestinal symptoms	Abdominal pain	Pelvic pain	B symptoms	Gynecological examinations	Abdominal mass	HPV Pap smear STI panel	Other labs	Ultrasound	Other imagings
Cervical cancer	Postmenopausal Intermenstrual Postcoital Bleeding after pelvic exam	Dysuria Urinary hesitancy Dyspareunia Vaginal discharge Itching or burning of the vulva	+	+	+	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	Vaginal discharge Dyspareunia	−	−	−	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 Vaginal discharge	+	+	−	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 ± Vaginal discharge	+	+	±	Cervical mass Lump protruding from vagina/vulva	+	−					Biopsy
Cervical erosion(Ectropion)	Light bleeding after pelvic exam Spotting	Post-coital pain Painful cramps Dyspareunia Vaginal discharge Itching of vulvovaginal area	+	+	−	Red, glandular area around os of cervix	−	−
Cervicitis	Intermenstrual bleeding Postcoital Bleeding after pelvic exam	Pain during urination Pain during sex Painful menstruation Vaginal discharge Itching of vulva	+	+	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	Vaginal discharge Pain during urination Pain during sex Fulness in pelvic Difficulty emptying bladder	+	+
Endometrial hyperplasia	Postmenopausal bleeding Intermenstrual bleeding Amenorrhea	Dysmenorrhea Amenorrhea Dyspareunia Heavy menstrual bleeding	+	+						Thickened endometrium		Simple(cystic) hyperplasia Complex hyperplasia Simple hyperplasia with atypia Complex hyperplasia with atypia (glands are highly irregular in size and shape)	Biopsy
Endometriosis	Heavy mentrual bleeding	Painful menstruation Burning/painful urination Painful bowel movement Pain during or after sex Infertility Watery vaginal discharge	+	Pelvic pain Back pain	−	Tender uterosacral nodularity Immobile uterus Cervical motion tenderness Retroverted uterus		−					Visual inspection by laparascopy
IUD use	Heavy bleeidng	Painful menstruation ±Vaginal discharge		+	−		−	−
Pelvic inflammatory diseases	Bleeding after sex Intermenstrual bleeding	Fever Pelvic pain Dyspareunia Dysmenorrhea Dysuria Dyscchezia Smelly grey/white/yellow vaginal discharge Itching and burning of vulvovaginal area	±	+	−	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	Vaginal discharge						−
Paget's disease of vulva to cervix	Bleeding from lesion Oozing	±Vaginal discharge Pain in vulva Itching or burning sensation 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 discharge				Vaginal lump Inguinal lymphadenopathy		−
Nabothian cyst	Postcoital bleeding	Pain during sex Vaginal discharge		−	−	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	Other symptoms
Miscarriage	+	Pelvic/back pain		↑ β-HCG ↓ RBC
Abruptio placenta	+	Pelvic/back pain Abdominal pain	Uterine tenderness ↓ Fetal heart rate ↓ Fetal movement
Placenta previa	+								Transvaginal sonography
Ectopic pregnancy	+			↑ β-HCG
Molar pregnancy	+			↑↑ β-HCG ↑ Inhibin-A ↑ Activin-A	Ultrasound: Complex and echogenic intrauterine mass Containing many small cystic spaces Classical "snow storm" appearance			Hydropic villi Empty uterus
Hematologic conditions	Clinical manifestations			Para-clinical findings					Gold standard	Additional findings
	Symptoms		Physical examination
				Lab findings		Imaging		Histopathology
	Abnormal uterine bleeding	Other symptoms
Von willebrand disease	+	Epistaxis Easy bruising Gum/dental bleeding Heavy menses Fatigue Blood in stool Blood in urine	Bruises on skin	↓ RBC ↓ Serum Iron + FOBT RBC in Urinalysis ↓ VWF Normal PT, Normal or ↑ PTT		N/A
Factors deficiencies	+			`↓ Factors νιιι, ιx, xι ↑ PTT , Normal PT Normal VWF		N/A
Platelet dysfunction	±			Thrombocytopenia Normal PT , Normal PTT		N/A
Metabolic conditions	Clinical manifestations			Para-clinical findings					Gold standard	Additional findings
	Symptoms		Physical examination
				Lab findings			Imaging	Histopathology
	Abnormal uterine bleeding	Other symptoms
Hyperthyroidism	+	Wet skin/hair thinning Palpitation Insomnia Anxiety Weight loss Heat intolerance Diarrhea	Enlarged thyroid (Goiter) Exophthalmos	High T3,T4 Low TSH			Ultrasound: Homogenous hypo-echogenicity	Thyroid follicles	Total T4 For Grave's disease: TSH receptor antibody	Osteoprosis Atrial fibrillation
Hypothyroidism	+	Fatigue Cold intolerance Decreased sweating Hypothermia Coarse skin Weight gain Constipation Dry skin/hair loss	Dry skin Bradycardia Hair loss Myxedema Delayed relaxation phase of deep tendon reflexes	Low T3,T4 Normal/ low TSH ↑ Total cholesterol ↑ LDL ↑ VLDL			Ultrasound: Homogenous hypo-echogenicity	Thyroid follicles	TSH
Adrenal hyperplasia	+	Acne Virilization Irregular menses Percocious puberty Muscle weakness Fatigue	Depending upon deficient enzyme: Ambiguous genitalia in male or female Hypertension/ Hypotension Primary amenorrhea Absence of secondary sexual characteristics Minimal body hair	Depending upon enzyme deficiencies may include the following: Androstenedione Testosterone 11-deoxycortisol Dehydroepiandrosterone sulfate (DHEAS) 17-hydroxypregnenolone Pregnenolone Renin/Aldosterone
Cushing's disease	+	Acne Hirsutism/hair loss Weight gain Moon facies Skin bruising Abdominal striae Insomnia, Amenorrhea Decrease libido	Facial plethora Acanthosis nigricans Ecchymosis Violacious striae Muscle weakness Kyphosis Hypertension Edema Slow deep tendon reflex relaxation Emotional lability Depression Lipodystrophy Glucose intolerance or diabetes mellitus	Low/Normal ACTH High cortisol			T1-weighted MRI: Pituitary macroadenoma
Polycystic ovarian syndrome	+	Hirsutism Weight gain Pelvic pain Acne Hair thinning Mood swings Irregular mens Amenorrhea Oligomenorrhea Infertility		↑ DHEAS and androstenedione, testosterone ↓ HDL, ↑ Total cholesterol, LDL, TG ↑ Prolactin in some women ↑ LH/ Normal or ↓ FSH
Hepatic disease	+
Medication side effects/ Iatrogenic	Clinical manifestations			Para-clinical findings					Gold standard	Additional findings
	Symptoms		Physical examination
				Lab Findings			Imaging	Histopathology
	Abnormal uterine bleeding	Other symptoms
Anticoagulants	+
Antipsychotics	+
Corticosteroids	+
Oral contraceptive pills	Break through bleeding
Herbal supplements