Gynecology Book

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Anovulatory BleedingAka: Metrorrhagia

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  1. See Also
    1. Abnormal Uterine Bleeding
  2. Epidemiology
    1. Anovulation causes 90% Dysfunctional Uterine Bleeding
    2. Age breakdown of Anovulatory Bleeding
      1. Women over age 40 years represent 50% of this group
      2. Adolescent women represent 20% of anovulatory group
  3. Associated Risks
    1. Endometrial Cancer from unopposed Estrogen
      1. Relative Risk: 3 fold
  4. Pathophysiology
    1. Unopposed Estrogen (Progesterone deficiency)
    2. See Menses
  5. Causes
    1. Immature Hypothalamic-Pituitary-Ovarian axis
      1. Frequently seen in Adolescents
      2. Follicle Stimulating Hormone released
        1. Stimulates Unopposed Estrogen release
        2. Lacks Luteinizing hormone (LH) surge
          1. No Ovulation
          2. Progesterone deficiency
        3. Results in breakthrough bleeding
    2. Polycystic Ovary Syndrome (Stein Leventhal Syndrome)
    3. Pending ovarian failure (Peri-Menopause)
    4. Body Habitus and Nutritional Status
      1. Obesity
      2. Very low calorie diets
      3. Eating disorder (e.g. Anorexia)
    5. Intense Exercise (Female Athlete Triad)
      1. Norepinephrine affects Luteinizing hormone (LH) pulse
    6. Psychological stress
  6. Symptoms
    1. Change in Amount and Frequency of Menstrual Bleeding
      1. Low Levels of Unopposed Estradiol or Estrogens
        1. Lighter and Less Frequent Menses
      2. High Levels of Unopposed Estradiol or Estrogens
        1. Prolonged periods of Amenorrhea
        2. Heavy Withdrawal Bleeding
    2. Lack of premenstrual signs
      1. Progesterone absent: no bloating or Breast Pain
  7. Protocol
    1. History and Physical
      1. Rule-out Systemic or Structural disease
      2. See Dysfunctional Uterine Bleeding causes
    2. Labs
      1. Urine Pregnancy Test (hCG)
      2. Thyroid Stimulating Hormone (TSH)
      3. Serum Prolactin
      4. Complete Blood Count (CBC)
    3. PostMenopause
      1. See Postmenopausal Bleeding
    4. Age >35 years or Endometrial Cancer Risk Factors
      1. Consider Transvaginal Ultrasound
        1. Reassuring if endometrial stripe <5 mm
        2. Does not replace biopsy in high risk patient
      2. Endometrial Biopsy: if negative then treat as below
    5. Age <35 years and no Endometrial Cancer Risk Factors
      1. Trial of hormone supplementation
        1. See Metrorrhagia Management
        2. Oral Contraceptive
        3. Cyclic Progesterone
      2. If results in normal cycles then
        1. Discontinue after 3-6 months
        2. If abnormal bleeding then Oral Contraceptive
    6. Indications for referral
      1. Desired Fertility
      2. Unresolved uterine bleeding
  8. Management
    1. See Metrorrhagia Management

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