Abnormal Vaginal Bleeding

Key Points

• Anovulation is common in adolescents.

• Bleeding disorders typically present as menorrhagia in adolescence.

• Anovulation is the most common cause of abnormal vaginal bleeding in reproductive-age women.

• The four most common causes of secondary amenorrhea are pregnancy, hyperprolactinemia, thyroid disorders, and iatrogenic.

• Evaluation of abnormal bleeding in women over age 35 should include an endometrial biopsy.

• Anovulatory women are at risk for endometrial hyperplasia or carcinoma from unopposed estrogen and should have regular progesterone-induced withdrawal bleeds.

• Any bleeding after menopause in a woman who is not taking hormone therapy is abnormal.

• Evaluation with an endometrial biopsy or a pelvic ultrasound can exclude endometrial cancer.

Normal menstrual bleeding is defined as regular vaginal bleeding that occurs at intervals from 21 to 35 days. A normal menstrual cycle begins with the follicular phase before ovulation and then the luteal phase after ovulation. Abnormal vaginal bleeding is a common complaint in primary care. The prevalence of some type of abnormal bleeding is 10% to 30% among women of reproductive age. The estimated annual direct and indirect costs of abnormal bleeding are $1 and $12 billion, respectively (Liu et al., 2007). Abnormal bleeding is also a common reason for women to be referred to gynecologists and is an indication for up to 25% of all gynecologic surgery (Goodman, 2000). A life cycle approach to abnormal vaginal bleeding is helpful in determining etiology and treatment options.

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