Ovulatory bleeding that is not cycle related comprises a heterogeneous group of disorders that causes intermenstmal bleeding, including infection, neoplasms, genital trauma, and nongynecologic sources. Usually, bleeding in this category will be of recent onset, and the history will be suggestive of the cause. Postcoital bleeding requires evaluation of the cervix for infection (eg, chlamydia, gonorrhea) and a Pap test to determine neoplasia. The physical examination is particularly important to assess possible trauma, tumors, cervical polyps, ulceration, uterine enlargement or irregularity, adnexal masses, or evidence of inflammation. Evaluation of the uterus by biopsy and either transvaginal ultrasonography or hysteroscopy may be necessary if no cause is identified.
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Some women experience vaginal spotting at the time of expected ovulation, which perhaps is related to the brief, abrupt decline in estradiol that follows its preovulatory surge. These women should undergo a general evaluation when they present with this complaint. If the evaluation is negative and the spotting is consistent in timing and amount from month to month, no further evaluation is needed.

History of the Present Illness

The history establishes the woman’s baseline menstrual cycle pattern and characterizes in detail the changes that led to the current consultation. The latter should include when the abnormal bleeding began; the characteristics of the new bleeding pattern; and the presence of additional symptoms such as pain, fever, or other systemic complaints. Historic features that suggest pregnancy should be elicited. The medical history should focus on current medications, birth control method, past surgery, and other gynecologic diagnoses.
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Certain problems are more likely to occur in specific age groups. For example, pregnancy and infection are more common among women under age 30 years; cancer, leiomyomas, and endometrial polyps tend to cluster in women older than age 40 years. Clotting abnormalities are most common among teenage girls with heavy menstrual bleeding. However, overreliance should not be placed on risk by age because any diagnoses may occur in any menstruating woman.
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Once a pregnancy-associated problem is eliminated, the clinician should be able to use the historic information to focus on one of the categories of the differential diagnosis. The remaining evaluation should be based on this classification.

Anovulatory Bleeding

Anovulatory episodes are commonly associated with normal events in a woman’s reproductive life cycle. After menarche, girls may not establish regular ovulatory cycles for several months. At the other end of the spectrum, some women develop anovulatory cycles as their ovarian function declines with the approach of menopause. Reestablishment of ovulation after interrupting events such as use of hormonal contraception and pregnancy is usually prompt except in two situations. Women who breastfeed will resume ovulation unpredictably; the timing is probably related to the frequency of breastfeeding. Depot medroxyprogesterone acetate, now commonly used as a contraceptive method, does not clear from the system immediately after it is discontinued, and menstruation may not resume until several months after the last injection.
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Chronic anovulation is more likely attributable to an endogenous disorder like polycystic ovary syndrome or other androgen disorders. Acute anovulation can be caused by stress, intercurrent illness, medication use (eg, spironolactone), or endocrine disturbances (eg, prolactinoma, adrenal hormone excess, thyroid hormone problems).

The major focus of the patient evaluation should be to identify any underlying cause of the ovulatory dysfunction. This will involve the measurement of various hormones (eg, gonadotropins, androgens, adrenal and thyroid hormones), with the specific selection depending on the clinical presentation. In addition, women with longstanding anovulation should be assessed for endometrial hyperpla-sia and anemia.
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Terminology of Abnormal Vaginal Bleeding Ovulatory

Menorrhagia/hypermenorrhea–heavy flow (>80 mL), longer flow (>7 days), or both
Intermenstrual bleeding–bleeding between otherwise-normal menses
Midcycle bleeding–bleeding at time of expected ovulation
Premenstrual spotting–light bleeding preceding regular menses
Polymenorrhea–periods too close together (<21 days)
Anovulatory
Metrorrhagia–irregular bleeding at frequent intervals
Menometrorrhagia–irregular heavy bleeding
Oligomenorrhea–bleeding at intervals of >40 days
Amenorrhea–no bleeding for at least 90 days
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Sometimes the history alone will be inconclusive regarding ovulation; in these cases, additional methods can be helpful. Recording of basal body temperature can be used to determine whether the expected postovulatory rise in basal temperature is present. Serum progesterone, measured in the midluteal phase, should be greater than 2 U/mL if ovulation has occurred. The level of luteinizing hormone rises just before ovulation, and this surge can be measured in the urine with an over-the-counter home testing kit. Finally, the endometrium undergoes predictable histologic changes in response to progesterone secretion, and these can be identified in a sample of the endometrium obtained by office biopsy or aspiration.
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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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