Abnormal Uterine Bleeding Causes

Aka: Abnormal Uterine Bleeding Causes, PALM-COEIN Mnemonic

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II. Causes: PALM-COEIN Mnemonic

  1. Structural: PALM
    1. Polyps (Endometrial Polyps, Cervical Polyps)
    2. Adenomyosis
    3. Leiomyoma (Uterine Fibroids)
    4. Malignancy (or Endometrial Hyperplasia)
  2. Nonstructural: COEIN
    1. Coagulopathy
    2. Ovulatory Dysfunction (Anovulatory Bleeding)
    3. Endometrial Causes (diagnosis of exclusion)
    4. Iatrogenic (e.g. Hormonal Contraception, Hormone Replacement Therapy)
    5. Not yet classified
  3. References
    1. Munro (2011) Int J Gynaecol Obstet 113(1): 3-13 [PubMed]

III. Causes: Age-Specific Uterine Bleeding Causes

  1. Prepubertal Years (before Menarche)
    1. Newborn girls
      1. Occurs within 6 weeks of delivery
      2. Maternal placental Estrogen withdrawal bleeding
    2. Vaginal foreign body with secondary Vaginitis
      1. Presents as non-malodorous discharge and Vaginal Bleeding
      2. Peak Incidence: 3 to 9 years old
      3. Accounts for 4% of pediatric gynecologic ambulatory visits
    3. Vaginitis (most comon)
      1. Contact Vulvovaginitis from soaps, bubble bath, scented toilet paper
      2. Bacterial Vulvovaginitis (Shigella, Streptococcus Pyogenes)
    4. Accidental straddle injuries (vulvar Hematoma, vulvar Lacerations)
      1. See Vaginal Injury in Girls
      2. Bike accidents or straddle injuries
      3. Bed frames
      4. Playground equipment
      5. Bathtub fixtures
    5. Sexual abuse
      1. See Sexual Abuse in Children
    6. Prolapse of Urethral meatus
    7. Ingestion of Estrogen containing products
    8. Vulvar Lichen Sclerosus (mean age 7 years old)
    9. Precocious Puberty (Menses before age 8 years)
    10. Malignancy
  2. Early Reproductive Years
    1. Anovulatory cycles with Menarche (initially 55-85%)
      1. Persists 18 months on average
      2. Menorrhagia at Menarche is a common presentation of underlying Bleeding Disorder (up to 24% of cases)
        1. Consider focused evaluation for cause including Von Willebrand Disease (most common)
    2. Primary Coagulation Disorders (19%)
      1. See below
    3. Pregnancy related disorders
      1. See Uterine Bleeding in Pregnancy
    4. Pelvic Infections
    5. Penetrating Trauma (e.g. coitus, narrow sharp objects, water jets)
      1. Exclude deep space Lacerations (e.g. rectovaginal wall)
    6. Cervical and Endometrial Polyps
  3. Later reproductive and postmenopausal years (includes age >35 years)
    1. See Postmenopausal Bleeding
    2. See Menopause
    3. Uterine Fibroids
      1. Most common cause of heavy Vaginal Bleeding in women of reproductive age
    4. Extra-uterine source
      1. Cervical, vaginal, vulvar and Adnexal bleeding
      2. Hematuria (Urethra, Bladder, ureter or Kidney)
      3. Lower Gastrointestinal Bleeding (e.g. Rectal Bleeding)
    5. Evaluate for Malignancy!
      1. Postmenopausal Bleeding is due to malignancy (esp Endometrial Cancer) in up to 40% of cases
      2. Peak Incidence of Endometrial Cancer is age 60-64 years
    6. Atrophic Vaginitis
      1. Most common cause of Postmenopausal Bleeding
    7. Postmenopausal Endometrial Hyperplasia
      1. If no Estrogen Replacement, find Estrogen source

IV. Causes: Coagulation Bleeding Disorders (common)

  1. See Coagulopathy in Pregnancy
  2. See Coagulation Bleeding Disorders
  3. See Platelet Dysfunction
  4. Von Willebrand's Disease (most common)
  5. Thrombocytopenia
    1. Aplastic Anemia
    2. Idiopathic Thrombocytopenic Purpura
    3. Systemic Lupus Erythematosus (SLE)
    4. Sepsis
  6. Glanzmann's Disease
  7. Fanconi's Anemia
  8. Thalassemia major
  9. Acute Leukemia
  10. Renal Disease
  11. Acute or Chronic Liver Disease
    1. Decreased synthesis of Coagulation Factors
    2. Estrogen metabolism is also reduced in Cirrhosis

V. Causes: Pregnancy-related uterine bleeding complications

  1. See Uterine Bleeding in Pregnancy
  2. Life threatening causes <20 weeks
    1. Ruptured Ectopic Pregnancy
    2. Pregnancy termination complications
  3. Life threatening causes >20 weeks
    1. Placental Abruption
    2. Placenta Previa
    3. Uterine Rupture
    4. Postpartum Hemorrhage

VI. Causes: Endocrine-related uterine bleeding complications

  1. Thyroid
    1. Hyperthyroidism
    2. Increased Sex Hormone Binding Globulin
      1. Increased Testosterone
      2. Polycystic Ovary Syndrome
    3. Hypothyroidism
      1. Increased Prolactin
  2. Adrenal
    1. Addison's Disease
    2. Cushing's Syndrome
    3. Excessive Androgen Production
  3. Miscellaneous
    1. Prolactinoma (hyperprolantinemia)
    2. Polycystic Ovary Syndrome
    3. Congenital Adrenal Hyperplasia

VII. Causes: Medication-related Uterine Bleeding Disorders

  1. See Medication Causes of Abnormal Uterine Bleeding

VIII. Causes: Structural-related uterine Bleeding Disorders

  1. Local infection
    1. Cervicitis
    2. Endometritis
    3. Salpingitis
  2. Adenomyosis
  3. Endometrial and Endocervical Polyps
  4. Endometrial Hyperplasia
  5. Endometrial Cancer
  6. Ovarian Cancer
  7. Functional ovarian tumors (produce sex Hormones)
  8. Cervical Dysplasia
  9. Cervical Cancer
  10. Submucosal or intramural leiomyoma
  11. Uterine Fibroids
  12. Sarcoidosis
  13. Tuberculosis of the endometrium
  14. Vaginal Trauma (foreign body, sexual abuse, Laceration)

IX. Causes: Non-uterine bleeding

  1. Gastrointestinal Bleeding or Anal Bleeding
  2. Hematuria
  3. Urethral bleeding (e.g. Urethritis, Urethral Prolapse)
  4. Vaginal Bleeding (e.g. vaginal lesions, Trauma, Retained Foreign Body)

X. Management

  1. See Abnormal Uterine Bleeding (Dysfunctional Uterine Bleeding)
  2. Anovulatory Bleeding Management (Metrorrhagia Management)
  3. Ovulatory Bleeding Management (Menorrhagia Management)

XI. References

  1. Mace (2013) Crit Dec Emerg Med 27(2): 13-21

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