Abnormal uterine bleeding is a departure from the normal and what do we consider normal? A total volume of 30 to 60 cc. This has been evaluated by doing tests on menstrual pads from a number of women to get a total volume. Once you get above 80 cc of blood - these are the patients who have menorrhagia, menometrorrhagia - and will get into anemia situations over time. A good way of estimating blood loss is with a chart that a woman can use, to circle number of pads she uses, how much bleeding there has been on the pads and so forth. You can add them up and pretty well quantify, on a visual basis, the menstrual bleeding so that you can estimate whether or not this patient really has a bleeding problem or is it something that she’s just misinterpreting. The other thing about normal is the pattern. We normally expect the menses to start anywhere from 21 to 35 days. We count menstrual periods from the start to the start. Many patients do not do this. Many patients will count from the end of their period to the start of their next period. So I ask them to either bring in a menstrual calendar or question them very thoroughly about start to start. If they say, “Oh, yeah, it’s the same day every month”, then it’s right in this 28 to 30 day cycle. The duration is generally 4 to 6 days. I’ve seen some patients that go seven to eight days. Some patients that were shorter than four to six days. But these are what we generally consider as the normal ranges for those characteristics.
Abnormal Uterine Bleeding
Abnormal patterns; we can term them into hypomenorrhea, which is a diminished total flow, oligomenorrhea which are menses occurring less than every 35 days, menorrhagia which is a profuse flow on regular intervals. So anywhere in that 21 to 35 day interval, if she’s having a profuse flow then she’s got menorrhagia. Menometrorrhagia is an excess of flow occurring on an irregular basis. So that’s excessive and irregular. Intermenstrual spotting or bleeding is light, regular, usually about mid-cycle. This is what we generally see with ovulatory spotting, as we call it, or ovulatory bleeding. Where at the time of ovulation estrogen drops a little bit, there’s no progesterone production yet and the patient has a few spots of blood. Premenstrual occurs usually the week or a few days prior to the menses as light, and postmenstrual is when they continue to spot after their normal, regular flow. In doing evaluations and things like that, I count the day that the patient begins their regular flow as being day one of their cycle. Not if they are having this light spotting prior to the menses. A lot of patients will count that as being the day that they start, but I count the day that they actually begin their flow as the first day of their menses.
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We can divide abnormal bleeding into two causes, really, or two general categories. Those that are caused by anatomic problems and those that are dysfunctional or generally hormonal in etiology. Anatomical etiologies - and I think someone probably does the presentation for you on pregnancy and complications, such as placenta previa, abruptio and so forth - cervical polyps can cause it. Leiomyomas, infection, trauma, adenomyosis and of course carcinoma. And these are anywhere in the GI tract. We can see a carcinoma of the vagina, which is fairly rare, carcinoma of the cervix. We see endocervical polyps, cervical polyps, carcinomas of the endocervix, sarcomas and carcinomas of the endometrium and myometrium. Myometrial polyps, submucous leiomyoma will cause menstrual problems and bleeding, and then ovarian dysfunction’s. So those are pretty much the anatomic sites.
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