Abnormal uterine bleeding is defined as vaginal bleeding after 12 months of having stopped the regular cycles (postmenopausal women)

Unpredictable bleeding after 12 months or more of hormone replacement use.

A more general definition includes prepubertal bleeding (before menarche), postmenopausal bleeding, sinusorrhagia (bleeding during sexual intercourse), menorrhagia, and metrorrhagia.



  • Amenorrhea: Absence of menstruation for more than 90 days.
  • Oligomenorrhea: Uncommon bleeding, irregular,> 38 days
  • Polimenorrhea: Frequent but regular 24 days or less.
  • Intermenstrual bleeding
  • Criptomenorrhea: Apparent absence of menstruation


  • Metrorrhagia: Irregular, not execive,> 7 days
  • Menorragías: Regular, abudante and> 8 days
  • Menometrorrhagia: Usually excessive and prolonged that occurs at frequent and irregular intervals.


  • Hypermenorrhea: regular,> 80 cc
  • Hypomenorrhea: Regular <30 cc

Parameters of a normal menstrual cycle

Frequency in days:

  • Frequent Period <24 days
  • Normal Period 24-38 -days
  • Uncommon Period> 38 days


  • Prolonged> 8 days
  • Normal 4.5-7 days
  • Shortened <4 days


  • Absence: If there is no bleeding
  • Regular: Less than 6 days between periods
  • Irregular: More than 6 days between periods

Volume of loss

  • Abundant> 80 cc
  • Normal 5-80 cc
  • Scarce <5 cc

It must be taken into account that the abnormal uterine bleeding is a SYMPTOM, NOT a diagnosis.

There is no clearly demonstrable pathology


  • Systems
  • local
  • Iatrogenic

system PALM- COEIN

Structural (PALM): Polyps, adenomyosis, leiomyomatosis, malignancy or hyperplasia

The characteristics of the structural

  • Visible
  • Measurable
  • Quantifiable
  • Classifiable

These can be diagnosed by means of:

  • Imaging
  • Direct Vision
  • Pathological anatomy

Structural causes (PALM)

  • Cervix
  • Intrauterine
  • Hormonal

Non-structural (COEIN): Coagulopathies, ovarian dysfunctions (These are more related to the Hipotalamo-Hipofisis-Ovary axis), endometrial, Iatrogenic, Not Classified

We refer to Systemic Diseases, it is due more to endocrine problems

  • Molecular control of menstruation
  • Alterations of the Hipotalamo-Hipofisis-Ovario axis (Endocrine problems, its most frequent cause is anovulation)
  • Alterations of hemostasis


  • Excess estrogen
  • There is no peak of LH
  • Hypothyroidism
  • Hyperprolactinemia
  • Polycystic ovaries

Its most frequent cause is polycystic ovarian syndrome

  • Anovulatory 90%: Disruption of E2; Suppression of E2
  • Ovulatory 10% (The duration of the corpus luteum will be shortened by inadequate stimulation): Disruption of P; Suppression of P


  • 20-29 years 30%
  • > 40 years 45%

Other causes of Bleeding

  • Vitamin K deficiency: Low levels, defective absorption, inhibition of VK-producing GI flora
  • Drug-induced hemorrhage: Heparin and Warfarin
  • Disproteinemias: Myeloma, Macroglobinemia, Von Willebrand Factor
  • Severe liver disease
  • Primary fibrinolysis

Functional menorrhagia

Altered metabolism of prostaglandins

Cause: We speak of functional menorrhagia when abnormalities in the biochemical process.

  • Increase of prostaglanins that are vasodilators vs prostaglandins that are vasoconstrictors.
  • Increase in factors that decrease platelet adhesiveness.

Whenever we do not find a cause of bleeding, we can say that the patient has abnormal uterine bleeding

If we find any etiology this will be your diagnosis

Differential Diagnostics

  • leiomyoma
  • Endocervical polyp, endometrial
  • Adenomyosis
  • Chronic endometritis
  • Endometrial hyperplasia – malignancy
  • Cervical malignancy – Vaginal

Causes of Bleeding according to your period of fertility


  • Neoplasms (Hormone-producing Neoplasms)
  • Trauma (Sexual Abuse)

Fertile age

  • Demonstrable cause?
  • Iatrogenic (Hormones)
  • Systemic diseases
  • Neoplasms: Benign or Malginas. (Utero, Ovaries, etc …)


  • Iatrogenica (Hormone Replacement Therapy)
  • Atrophy
  • Neoplasms: Benign or malignant

Examples of Postmen Bleeding Causes

  • Ovary
  • Uterine body
  • Cervix
  • Vagina
  • Urethra
  • Vulva


Aguda: Acute: An episode of uterine bleeding in a woman of reproductive age, who is not pregnant and who requires immediate attention to prevent further blood loss or subsequent heavy bleeding (Make treatment to reduce and prevent bleeding).

Chronic: Abnormal bleeding that comes from the uterine body; with alteration in duration, quantity or frequency (or all three) with a duration of 3 months. (sinusorragia does NOT fall into this classification). This bleeding can make the patient unsteady.

Intermenstrual: A Bleeding that occurs between menstruations clearly defined as cyclical and predictable; it includes the occurrence of random episodes, as well as those that manifest themselves predictably at the same time in each cycle. (Intermenstrual bleeding from ovulation).

Clinical manifestation

  • Age
  • Cycle characteristics (This is important to compare with the control parameters)
  • Bleeding characteristics
  • symptom
  • Signs
  • Other associated pathologies


  • Pelvic / transvaginal ultrasound / HSG
  • Cervical cytology
  • Serology for STIs
  • Thyroid function
  • Liver tests
  • BHCG
  • Blood count
  • Ferritin
  • Coagulation studies
  • FSH / LH
  • Progesterone (requested on day 21 of the cycle)
  • Hysteroscopy- Bx

All measurement of sex hormones must be done in the recruitment phase (Follicular), In the first 5 days of the cycle


Objective: To avoid or reduce abnormal uterine bleeding. This management will depend if it is an acute bleeding or a chronic Bleeding


Medical treatments:

  • Hormone (The estrogens cause the endometrium to proliferate and will initially control the bleeding)
  • Antibiotics
  • Antifrinolitics (Each time your period arrives)


  • Curetaje
  • Enometrial ablation
  • Hysterectomy

Generalities for handling

  • Pubs
  • Fertile age> 35 years
  • Premenopausal
  • Postmenopausal
  • Acute
  • Chronicle

All these women must have a pathology study that tells us what is happening at that time.

Since if we are going to perform a hormonal treatment we must know if there is a malignant lesion or other cause that is causing bleeding.

Medical Management of Acute Uterine Hemorrhage

Commitment of the general state

  • Hospitalize
  • Stabilize and rule out pregnancy
  • Estrogen IV: 25 mg / 6 hours x 4 doses
  • Concomitant oral estrogen (Viralate estradiol 2mg-21 dragees and Norgestrel 2mg 10 dragees -> This helps to follow the cycle)
  • Continue use with antifibrinolytics 1 gr every 6 hours, NSAIDs or progestins (Do not give more Hormones)
  • No response: Curettage or curettage.

17 Beta-Estradiol is the natural estrogen of women

Post treatment

  • Continue with oral estrogens x 21 days
  • Start progestins on day 16-25 (Medroxyprogesterone acetate 5 mg / day tablets for 10 days)

External consultation

  • Von Willembrand factor (It is the most frequent deficiency)
  • Sangria time
  • Transvaginal echo: endometrial thickness
  • Endometrial biopsy: rule out malignancy

Medications in Outpatient Consultation

  • Oral contraceptives
  • Oral progestins or in IUD
  • NSAIDs: Mefenamic Acid 500mgr c / 6 hours; decreases 30%
  • Tranexamic Acid: Decreases by 50%

Surgical Management

  • Curettage biopsy
  • Hysteroscopy + biopsy
  • Endometrial ablation: thermal or electrical
  • Hysterectomy


Menstruation is a vital sign

  • Menarche 11-14 years
  • Cycles 21-45 days
  • Duration <7 days
  • 3-6 towels or tampons / day

Causes of abnormal Sacred in adolescents

  • Thrombocytopenia is the first cause of bleeding in adolescents.
  • Disorders of platelet function
  • Abnormal collagen
  • Deficiency of coagulation factors
  • Von Willembrand Factor

Clinical history for Von Willembrand

Coagulopathies (Category C)

  • Heavy menstrual bleeding from the menarche
  • One of the following
  • Transfusions- iron substitution
  • Two or more of the following symptoms

Associated Gynecological Pathologies

  • Patient between platelets and the site of injury: Facilitates agglutination and adherence
  • Protects factor VIII from rapid proteolytic degradation
  • Hemorrhagic ovarian cysts
  • Endometriosis

Laboratory exams

  • Sangria time
  • Factor VIII level
  • Analysis of platelet activity
  • Platelet count
  • Specific tests for the von willebrand factor


  • Hormonal
  • No Hormonal

Use of tampons

  • Follow the instructions regarding the insertion.
  • Choose the lowest absorbency level
  • Change your tampon
  • Consider alternating
  • Know the signs of toxic shock syndrome
  • Do not use tampons between periods

Symptoms and signs of Toxico shock syndrome

  • High fever that appears suddenly
  • Muscle pains
  • Diarrhea
  • Dizziness or fainting
  • Rash similar to sunburn
  • Sore throat
  • Redness in the eyes

Monitoring Therapy

Four cycles should be quoted later for “Satisfactory Response”

  • Duration of bleeding <7 days
  • 4 episodes of menstrual bleeding in 4 cycles
  • blood loss <80 cc in each cycle
  • Maximum 1 episode of bleeding> 80 cc
  • No more than 24 days of bleeding in all 4 cycles
  • No increase in the basal number of bleeding days

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