Abnormal Uterine Bleeding

Abnormal genital tract bleeding in the reproductive-age woman results from a wide variety of underlying conditions, and the task of the clinician is to identify the specific cause accurately and cost-efficiently. There is a high prevalence of mood disorder among women who present with menstrual complaints, and this possibility should be evaluated if clinical findings are not consistent with a diagnosis.
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Differential Diagnosis

The overall differential diagnosis of abnormal bleeding is shown in the box. Pregnancy should always be considered in the presence of abnormal bleeding. Although the history and pelvic examination will be decisive in most cases, the only definitive way to screen for pregnancy is to do a test of human chorionic gonadotropin. The urine tests available are sufficiently sensitive and specific to serve as an adequate screening test and should be done whenever there is any question of pregnancy status.
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Once pregnancy is excluded, abnormal bleeding can be divided into two broad categories: ovulatory and anovulatory bleeding. Of women who present with abnormal bleeding, roughly one third have anovulatory bleeding, one third have heavy ovulatory menstrual periods, and one third have bleeding from other causes associated with ovulatory cycles (eg, intermenstrual bleeding). The terminology used to describe the various abnormal bleeding patterns is shown in the box. The term “dysfunctional uterine bleeding” should only be used to refer to anovulatory abnormal bleeding.
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In most cases the assessment of ovulation can be done by history. The normal range of values for characteristics of menstrual cycle bleeding is shown in Table 13. Ovulatory cycles are characterized by a predictable (±5 days) inter-menstrual interval and a consistent amount and duration of flow. The intermenstrual interval should be measured from the first day of regular bleeding (leaving out premenstrual spotting) to the first day of the next period. An important problem in the assessment of bleeding patterns is that the retrospective recall of the timing of bleeding is often inaccurate. The menstrual calendar, on which the woman is asked to record all bleeding episodes prospectively, is invaluable in assessing chronic menstrual cycle disturbances.

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