Abnormal uterine bleeding

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 frequency, 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 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. 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 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. 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. ==Diagnosis==

Diagnosis of abnormal uterine bleeding starts with a medical history and physical examination. 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, or blood thinners. Medical tests include a blood test, to see whether the abnormal bleeding has caused anemia, and a pelvic ultrasound, to see whether the abnormal bleeding is caused by a structural problem, such as a uterine fibroid. 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 (TSH), pregnancy, and chlamydia is also recommended. More extensive testing might include magnetic resonance imaging and endometrial 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 hormonal birth control, gonadotropin-releasing hormone (GnRH) agonists, tranexamic acid, nonsteroidal anti-inflammatory drugs, and surgery such as endometrial ablation or hysterectomy. 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. == References ==