A2. Bleeding disorders; types and diagnosis

From greek.doctor

Bleeding disorders in gynaecology (abnormal uterine bleeding, AUB) include:

  • Amenorrhoea (see topic A1)
  • Hypomenorrhoea
  • Hypermenorrhoea/menorrhagia
  • Metrorrhagia
  • Oligomenorrhoea
  • Dysmenorrhoea (not sure if considered abnormal uterine bleeding but I’ll include it here)

Bleeding disorders are one of the most common problems in gynaecology, as it may impair daily life, cause iron deficiency anaemia, and make the patient worried about malignant disease. It affects 15 – 20% of fertile women.

Evaluation

In the evaluation of abnormal uterine bleeding, the following are important:

  • Careful history (timing, quantity, associated symptoms)
  • Bimanual examination
  • Tests for iron deficiency and anaemia
  • Transvaginal ultrasound
  • Pap smear
  • Endometrial biopsy
  • Pregnancy test
  • Hysteroscopy

Calendars or apps can be used to track the pattern and estimated quantity of menstruation, which makes diagnosis easier.

Normal menstruation

Normal menstruation is, according to the International Federation of Gynaecology and Obstetrics (FIGO), defined as:

  • Frequency – 24 to 38 days
  • Regularity – no more than 7 to 9 days difference between the shortest and longest cycles
  • Duration – up to 8 days
  • Volume – subjective, defined as volume that does not interfere with the patient’s quality of life

PALM-COEIN

FIGO has a system for classification of potential causes of abnormal uterine bleeding in reproductive-age women, called PALM-COEIN. This is an acronym for nine basic etiologies for abnormal uterine bleeding:

  • Polyp
  • Adenomyosis
  • Leiomyoma
  • Malignancy and hyperplasia
  • –
  • Coagulopathy
  • Ovulatory dysfunction
  • Endometrial dysfunction
  • Iatrogenic
  • Not otherwise classified

The PALM etiologies are structural, while the COEIN etiologies are related to non-structural causes.

Hypermenorrhoea/menorrhagia

Menorrhagia refers to abnormally large amount of bleeding or prolonged bleeding (> 8 days) during regular menstruation. It can be due to:

  • Leiomyoma which protrude into the uterine cavity
    • Thereby increasing the endometrial surface and the bleeding
  • Endometriosis
  • Endometrial polyp
  • Endometrial hyperplasia
  • Endometrial cancer
  • Adenomyosis
  • Coagulation disorder (von Willebrand, anticoagulants)

Menorrhagia is a potential sign of severe disease like cancer and so it must be thoroughly evaluated. Transvaginal ultrasound is usually the first choice. CBC should be performed to look for anaemia. See the respective topics for more details.

Benign menorrhagia can be managed with contraception or tranexamic acid, an antifibrinolytic.

Metrorrhagia

Metrorrhagia refers to uterine bleeding at irregular intervals, most commonly between menstrual periods. It can be due to:

  • Endometrial hyperplasia
  • Endometrial/cervical polyp
  • Endometrial cancer
  • Cervical cancer
  • Vaginal cancer
  • Endometritis/cervicitis
  • Leiomyoma
  • PCOS
  • Oral contraceptives
  • Caesarean scar defect

Metrorrhagia is also a potential sign of severe disease like cancer and so it must be thoroughly evaluated. Transvaginal ultrasound is usually the first choice. See the respective topics for more details.

Hypomenorrhoea

Hypomenorrhoea refers to abnormally small amount of bleeding during regular menstruation. It is usually due to:

  • Side effect of:
    • Hormonal contraception
    • Intrauterine device (IUD)
    • Hormonal implants
  • Anorexia nervosa
  • Professional athletes
  • Hyperprolactinaemia
  • Asherman syndrome

In case the patient does not have any contraception and hyperprolactinaemia is ruled out, they should be evaluated for Asherman syndrome.

Oligomenorrhoea

Oligomenorrhoea refers to irregular and inconsistent menstruation, usually having more than 35 days without a menstrual bleeding or having fewer than 9 menstrual bleedings in a year.

It’s common in women on contraception, but otherwise it’s usually caused by PCOS.

Dysmenorrhoea

Dysmenorrhoea refers to severe pain during menstruation. We can distinguish primary and secondary types.

Primary dysmenorrhoea is idiopathic, and so there is no underlying condition which causes it. It tends to affect adolescents and young adults, and improve with age and after childbirth. One hypothesis of the pathogenesis is that it results from learned behaviour from other family members with dysmenorrhoea. Seeing family members being in strong pain during menstruation might “teach” the patient to be in the same pain during menstruation as well.

Secondary dysmenorrhoea is due to underlying disease, such as:

  • Endometriosis
  • Adenomyosis
  • Uterine leiomyoma (fibroids)
  • Cervical stenosis
  • Intraabdominal adhesions

In case of secondary dysmenorrhoea, the underlying cause should be treated. Hormonal contraceptives can improve dysmenorrhoea.