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Ovulatory Bleeding
Aka: Ovulatory Bleeding, Menorrhagia
See AlsoMenstrual Cycle Abnormal Uterine Bleeding (Dysfunctional Uterine Bleeding )Abnormal Uterine Bleeding Causes Anovulatory Bleeding (Metrorrhagia )Uterine Bleeding in Pregnancy First Trimester Bleeding Late Pregnancy Bleeding Endometrial Cancer Screening Oral Contraceptive-Related Uterine Bleeding Management Postmenopausal Bleeding Amenorrhea Lower GI Bleed Hematuria
PathophysiologyShortened or prolonged corpus luteum life span Abnormal relative ratio of Estrogen to Progesterone Usually due to low Estrogen levels
Risk FactorsIncreases with age
CausesSee Abnormal Uterine Bleeding Causes Uterine Fibroid s (before Menopause )Endometrial polyps Bleeding Disorder sVon Willebrand Disease (present in 13% of women with Menorrhagia)Hypothyroidism Advanced liver disease
SymptomsPremenstrual Symptoms are present Menstrual Cycle intervals are normal (every 24 to 35 days)Change in Amount of bleedingMenorrhagiaPatient describes very heavy periods Change pad or tampon every 1-2 hours Blood clots >1 inch (2.5 cm) Patient passes over 80 ml blood per cycleThe definition of 80 ml is no longer recommended Warner (2004) Am J Obstet Gynecol 190:1224-9 Prolonged bleedingBleeding duration lasts 7 days or more per cycle
SignsSee Ovulation
Labs: InitialUrine Pregnancy Test Complete Blood Count Thyroid Stimulating Hormone (TSH)Consider Serum Ferritin
Labs: Bleeding Disorder testsIndicationsAdolescents with Menorrhagia Family History of Bleeding Disorder Menses lasting 7 days or more with very heavy bleeding (flooding, associated Anemia )Excessive bleeding with other procedures (e.g. tooth extraction, Postpartum Hemorrhage ) Women planning Hysterectomy for Menorrhagia TestsSee Bleeding Disorder for protocol Complete Blood Count (CBC)ProTime (PT/INR)Partial Thromboplastic Time (PTT) Platelet Function Closure Time Abnormal in Von Willebrand's Disease
ImagingTransvaginal Ultrasound Evaluate for uterine polyps and Uterine Fibroid s Saline infusion Sonohysterography Indicated if Transvaginal Ultrasound is nondiagnostic
EvaluationSee Abnormal Uterine Bleeding ACOG does not recommend routine TSH or serum Prolactin testing for MenorrhagiaMenorrhagia is most often due to fibroids or polyps Important to distinguish from annovulatory bleedingMore often related to endocrine cause Consider Endometrial Cancer Screening Indicated if more than one Endometrial Cancer Risk Factor s or refractory bleeding See Abnormal Uterine Bleeding See Endometrial Cancer Screening
ManagementSee Menorrhagia Management Uterine polypRefer for hysteroscopic uterine polypectomy Uterine Fibroid See Uterine Fibroid for management options
ComplicationsIron Deficiency Anemia Endometrial Hyperplasia and Endometrial Cancer are rarely associated with Ovulatory Bleeding (<1% risk)Consider Endometrial Cancer Screening if more than one Endometrial Cancer Risk Factor s
ReferencesNelson (1997), Fam Prac Recert 19(8):14 Buchanan (2009) Am Fam Physician 80(10): 1075-88 Dilley (2001) Obstet Gynecol 97:630-6 Sweet (2012) Am Fam Physician 85(1): 35-43