ESSENTIALS OF DIAGNOSIS
-Blood loss of over 80 mL per cycle.
-Excessive bleeding, often with the passage of clots, may occur at regular menstrual intervals (menorrhagia) or irregular intervals (dysfunctional uterine bleeding).
-Etiology most commonly dysfunctional uterine bleeding on a hormonal basis.
General Considerations Normal menstrual bleeding lasts an average of 4 days (range, 2–7 days), with a mean blood loss of 40 mL. Blood loss of over 80 mL per cycle is abnormal and frequently produces anemia. Excessive bleeding, often with the passage of clots, may occur at regular menstrual intervals (menorrhagia) or irregular intervals (dysfunctional uterine bleeding). When there are fewer than 21 days between the onset of bleeding episodes, the cycles are likely to be anovular. Ovulation bleeding, a single episode of spotting between regular menses, is quite common. Heavier or irregular intermenstrual bleeding warrants investigation.
Dysfunctional uterine bleeding is usually caused by overgrowth of endometrium due to estrogen stimulation without adequate progesterone to stabilize growth; this occurs in anovular cycles. Anovulation commonly occurs in teenagers, in women aged late 30s to late 40s, and in extremely obese women or those with polycystic ovary syndrome.
Common gynecologic diagnostic procedures.
Colposcopy Visualization of cervical, vaginal, or vulvar epithelium under 5–50× magnification with and without dilute acetic acid to identify abnormal areas requiring biopsy. An office procedure. D&C Dilation of the cervix and curettage of the entire endometrial cavity, using a metal curette or suction cannula and often using forceps for the removal of endometrial polyps. Performed to diagnose endometrial disease and to stop heavy bleeding. Can usually be done in the office under local anesthesia. Endometrial biopsy Removal of one or more areas of the endometrium by means of a curette or small aspiration device without cervical dilation. Diagnostic accuracy similar to D&C. An office procedure performed under local anesthesia. Endocervical curettage Removal of endocervical epithelium with a small curette for diagnosis of cervical dysplasia and cancer. An office procedure performed under local anesthesia. Hysteroscopy Visual examination of the uterine cavity with a small fiberoptic endoscope passed through the cervix. Biopsies, excision of myomas, and other procedures can be performed. Can be done in the office under local anesthesia or in the operating room under general anesthesia. Hysterosalpingography Injection of radiopaque dye through the cervix to visuaize the uterine cavity and oviducts. Mainly used in investigation of infertility. Laparoscopy Visualization of the abdominal and pelvic cavity through a small fiberoptic endoscope passed through a subumbilical incision. Permits diagnosis, tubal sterilization, and treatment of many conditions previously requiring laparotomy. General anesthesia is usually used.
Clinical Findings A. SYMPTOMS AND SIGNS The diagnosis of the disorders underlying the bleeding usually depends on the following: (1) A careful description of the duration and amount of flow, related pain, and relationship to the last menstrual period (LMP). The presence of blood clots or the degree of inconvenience caused by the bleeding may be more useful indicators. (2) A history of pertinent illnesses or weight change. (3) A history of all medications the patient has taken in the past month. (4) A history of coagulation disorders in the patient or family members. (5) A careful pelvic examination to look for pregnancy, uterine myomas, adnexal masses, or infection.
B. LABORATORY STUDIES Cervical smears should be obtained as needed for cytologic and culture studies. Blood studies should include a complete blood count, sedimentation rate, and glucose levels to rule out diabetes. Diabetes may occasionally initially present with abnormal bleeding. A test for pregnancy and studies of thyroid function and coagulation disorders should be considered in the clinical evaluation. Tests for ovulation in cyclic menorrhagia include basal body temperature records, serum progesterone measured 1 week before the expected onset of menses, and analysis of an endometrial biopsy specimen for secretory activity shortly before the onset of menstruation.
C. IMAGING Ultrasound may be useful to evaluate endometrial thickness or to diagnose intrauterine or ectopic pregnancy or adnexal masses. Endovaginal ultrasound with saline infusion sonohysterography may be used to diagnose endometrial polyps or subserous myomas. MRI can definitively diagnose submucous myomas and adenomyosis.
D. CERVICAL BIOPSY AND ENDOMETRIAL CURETTAGE Biopsy, curettage, or aspiration of the endometrium and curettage of the endocervix may be necessary to diagnose the cause of bleeding. These and other invasive gynecologic diagnostic procedures are described in Table 17-1. Polyps, endometrial hyperplasia, and submucous myomas are commonly identified in this way. If cancer of the cervix is suspected, colposcopically directed biopsies and endocervical curettage are indicated as first steps.
Dubinsky TJ: Value of sonography in the diagnosis of abnormal vaginal bleeding. J Clin Ultrasound 2004;32:348. P.730 Hurskainen R et al: Levonorgestrel-releasing intrauterine system in the treatment of heavy menstrual bleeding. Curr Opin Obstet Gynecol 2004;16:487.