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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

Metrorrhagia (C0025874)

Definition (MSH)Abnormal uterine bleeding that is not related to MENSTRUATION, usually in females without regular MENSTRUAL CYCLE. The irregular and unpredictable bleeding usually comes from a dysfunctional ENDOMETRIUM.
ConceptsPathologic Function (T046)
ICD9626.6, 626.6
MSHD008796
BasqueHILEROKOARTEKO ODOLJARIOA ETA ZIKLOKO BESTE ZENBAIT NAHASTE
DanishIntermenst blodn og an cyklusforst
DutchIntermenstrueel bloedverlies
EnglishBleed-irreg.intermenst., Bleeding Between Periods, BLEEDING BREAKTHROUGH, BLEEDING INTERMENSTRUAL, Bleeding on the pill, Bleeding unrelated to menstrual cycle, Break - through bleeding, BREAK-THROUGH BLEEDING, Breakthrough bleeding, DUB - Dysfunctional uterine bleeding, DUH - Dysfunctional uterine haemorrhage, DUH - Dysfunctional uterine hemorrhage, Dysfunctional Uterine Bleeding, Dysfunctional Uterine Bleedings, Dysfunctional uterine haemorrhage, Dysfunctional uterine hemorrhage, IMB - Intermenstrual bleeding, Intermenstrual bleeding, Intermenstrual bleeding - irregular, Irreg.intermenst.bleed., Irregular intermenstrual bleeding, METRORRHAGIA, Spotting, SPOTTING BETWEEN MENSES, Spotting between periods
FinnishVALIVUOTO
FrenchSaignement intermenstruel
Germanintermenstruelle Blutung
Hebrewveset - hafraot/i sdirut
Hungariankozti verzes
ItalianSanguinamento intermestruale
NorwegianINTERMENSTRUELL BLODNING - n92.3 + n93.R
PortugueseHemorragia inter-menstrual
Spanishhemorragia intercurrente, Hemorragia intermenstrual, metrorragia, perdidas entre periodos menstruales, sangrado intermenstrual, sangrado intermenstrual anormal, sangrado uterino disfuncional, sangrando no relacionado con el ciclo menstrual
SwedishINTERMENSTRUELL BLODNING
Parent ConceptsHemorrhage (C0019080), Uterine Diseases (C0042131), UTERINE/ENDOMETRIAL DISORDERS (C0549623), Unspecified disorders of menstruation and other abnormal bleeding from female genital tract (C0041827), FEMALE GENITAL SYSTEM (INCLUDING BREAST) (C0497455), Symptoms and Complaints Component (C0497525), Uterine hemorrhage (C0042134), Reproductive System Finding (C1335757), Metrorrhagia (C0025874), Bleeding of vagina (C0151706), Finding related to menstrual cycle (C1298762), Ambiguous concept (C1274012), Duplicate concept (C1274013)
SourcesCOSTAR, CST, DXP, ICD9CM, ICPC, ICPCBAQ, ICPCDAN, ICPCDUT, ICPCFIN, ICPCFRE, ICPCGER, ICPCHEB, ICPCHUN, ICPCITA, ICPCNOR, ICPCPOR, ICPCSPA, ICPCSWE, MSH, MTH, MTHICD9, NCI, NDFRT, QMR, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)


Anovular menstruation (C0404557)

ConceptsPathologic Function (T046)
EnglishAnovular menstruation, Anovulatory bleeding, Anovulatory dysfunctional bleeding, BLEEDING ANOVULATORY
Spanishmenstruacion anovular, menstruacion anovulatoria, sangrado anovulatorio
Parent ConceptsMetrorrhagia (C0025874), Finding related to menstrual cycle (C1298762)
SourcesCST, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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