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

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)
• Postmenopausal bleeding - recurrence of bleeding after menopause
• Polymenorrhea: Frequent and light bleeding
• Postcoital bleeding: vaginal bleeding after intercourse, suggesting cervical pathology
• Postmenopausal bleeding: Any bleeding that occurs >6 mo after cessation of menstruation

Differential Diagnosis

Nonpregnant Vaginal Bleeding

Systemic Causes

• Cirrhosis
• Coagulopathy (Von Willebrand, ITP)
• Group A strep vaginitis (prepubertal girls)
• Hormone replacement therapy
• Hypothyroidism
• Secondary anovulation

Reproductive Tract Causes

• Adenomyosis
• Atrophic endometrium
• Dysfunctional uterine bleeding
• Endometriosis
• Fibroids
• Foreign Body
• Infection (vaginitis, PID)
• IUD
• Neoplasia
• 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 admin
• Estrogen-progestin OCP until gyn follow up

Severe Bleeding

• Maintain hemodynamics
• Consider IV conjugated estrogen (Premarin) 25mg IV q4-6 hrs until bleeding stops
• Continued severe bleeding requires D&C

References

Authors

Kevin Lu, Ross Donaldson, Michael Holtz, Neil Young, Daniel Ostermayer