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Overview of Causes of Genital Tract Bleeding in Women

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Overview of Causes of Genital Tract Bleeding in Women 06/06/12 Overview of causes of genital tract bleeding in women Official reprint from UpToDate® www.uptodate.com ©2012 UpToDate® Overview of causes of genital tract bleeding in women Author Section Editor Deputy Editor Annekathryn Goodman, MD Robert L Barbieri, MD Sandy J Falk, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Apr 2012. | This topic last updated: ene 17, 2012. INTRODUCTION — Abnormal bleeding noted in the genital area is often attributed to a uterine source, but may arise from disease at any anatomic site in the lower genital tract (vulva, vagina, cervix) or upper genital tract (uterine corpus, fallopian tubes, ovaries). The source of bleeding may also be a nongynecologic organ, such as the urethra, bladder, or bowel. The differential diagnosis of genital tract bleeding is listed in the table (table 1). It is useful to separate these causes according to age group (table 2) and site (see below). An overview of the differential diagnosis of genital tract bleeding in women will be reviewed here. The evaluation and management of women with this complaint are discussed separately. (See "Initial approach to the premenopausal woman with abnormal uterine bleeding" and "Terminology and evaluation of abnormal uterine bleeding in premenopausal women" and "The evaluation and management of uterine bleeding in postmenopausal women".) UTERINE BLEEDING — The likelihood of a particular etiology of uterine bleeding depends upon the age of the patient and the pattern of bleeding (cyclic or noncyclic). Pregnancy — Bleeding is a common symptom of a variety of disorders related to pregnancy. All reproductive age women with vaginal bleeding should have a pregnancy test as part of their initial evaluation. (See "Overview of the etiology and evaluation of vaginal bleeding in pregnant women".) Menstruation — The uterus is the only organ for which bleeding can be a normal physiologic phenomenon (menstruation). (See "Physiology of the normal menstrual cycle".) Normal menstrual bleeding is characterized by [1]: Duration between two and seven days Flow less than 80 mL Occurring in cycles of 24 to 35 days Moliminal symptoms are often present and include an increase in thin cervical mucus secretions at mid-cycle and premenstrual symptoms such as menstrual cramps, breast tenderness, fluid retention, and appetite or mood changes. (See "Evaluation of the menstrual cycle and timing of ovulation".) Menorrhagia — Excessive menstrual blood flow is termed menorrhagia. Menorrhagia may be due to local disturbances in prostaglandins (elevated endomyometrial vasodilatory prostaglandins and decreased vasoconstrictive prostaglandins), or may be related to any of the uterine etiologies described below. (See "Chronic menorrhagia or anovulatory uterine bleeding".) Anovulation — In premenopausal nonpregnant women, anovulation is a common cause of abnormal uterine bleeding (AUB). Anovulatory bleeding is characterized by noncyclical bleeding of variable flow and duration. Molimina are typically absent. Many women with chronic anovulation have an adequate amount of biologically active estrogen since androgens can be converted peripherally to estrogens in the absence of normal ovarian function; however, their anovulatory cycles www.uptodate.com/contents/overview-of-causes-of-genital-tract-bleeding-in-women?view=print 1/17 06/06/12 Overview of causes of genital tract bleeding in women lack the progesterone secretion normally present in the luteal phase. This puts them at risk of developing endometrial hyperplasia and endometrial cancer. (See "Classification and diagnosis of endometrial hyperplasia" and "Endometrial carcinoma: Epidemiology and risk factors", section on 'Risk factors'.) Causes of anovulation are listed in the table (table 3). Anovulation should be suspected in the following settings: Adolescents — Anovulatory cycles are the most common cause of AUB in adolescent girls due to a slowly maturing hypothalamic-pituitary axis during the first two to three postmenarchal years [2]. (See "Definition and evaluation of abnormal uterine bleeding in adolescents", section on 'Abnormal uterine bleeding (AUB) in adolescents' and "Differential diagnosis and approach to the adolescent with abnormal uterine bleeding" and "Management of abnormal uterine bleeding in adolescents".) Menopausal transition — Anovulation is also a common cause of AUB in women in the menopausal transition. Ovulatory cycles and the normal cyclic production of estrogen and progesterone become disturbed as women approach menopause. Ovulation occurs intermittently, interspersed with anovulatory (estrogen only) cycles of varying length. As a result, menses become irregular. The duration and volume of blood loss can be short and light, but prolonged heavy bleeding can occur during longer periods of anovulation. (See "Clinical manifestations and diagnosis of menopause".) Polycystic ovary syndrome — Chronic anovulation in reproductive-age women is most often attributable to an endogenous disorder, such as the polycystic ovary syndrome (PCOS), which is characterized by oligomenorrhea (irregular infrequent menstrual cycles) and hyperandrogenism (hirsutism, acne, and male pattern balding). Obesity and insulin resistance are common. Women with PCOS have an adequate amount of biologically active estrogen since androgens can be converted peripherally to estrogens even in the absence of normal ovarian function, but low levels of progesterone. Thus, constant mitogenic stimulation of the endometrium leads to endometrial hyperplasia, intermittent estrogen unscheduled (breakthrough) bleeding, and menorrhagia. (See "Diagnosis of polycystic ovary syndrome in adults" and "Treatment of polycystic ovary syndrome in adults".) Endocrine disorders — Endocrine disorders may be associated with hormonal changes that affect ovulation. These disorders are uncommon causes of AUB, with the exception of polycystic ovary syndrome, which occurs in 6 percent of reproductive age women [1]. Both hypo- and hyper- thyroid activity are associated with AUB. Women with hypothyroidism, even when subclinical, may have heavy or prolonged uterine bleeding [3]. Hypothyroidism can cause hyperprolactinemia; this usually results in amenorrhea and galactorrhea, but women may develop anovulatory bleeding prior to amenorrhea. Hyperthyroidism may cause anovulation due to alterations in sex hormone binding globulin [4]. (See "Overview of the clinical manifestations of hyperthyroidism in adults" and "Clinical manifestations of hypothyroidism".) Menstrual irregularities are common in women with Cushing's syndrome [5]. Menstrual abnormalities correlate with increased serum cortisol and decreased serum estradiol concentrations, but not with serum androgen concentrations. The menstrual irregularities may be due to suppression of secretion of gonadotropin-releasing hormone by hypercortisolemia. High doses of corticosteroids have a similar effect. (See "Epidemiology and clinical manifestations of Cushing's syndrome".) Hormone secreting adrenal and ovarian tumors are rare causes of anovulation and menstrual irregularities. (See individual topic reviews). Endocrine changes leading to anovulation may also be caused by strenuous exercise/activity (eg, running, ballet dancing), sudden weight change, or significant stress. Other disorders — The level or activity of sex hormones may be affected by disorders unrelated to endocrine glands, such as advanced liver or renal disease, that alter hormone metabolism or binding. Anovulation and AUB may result. www.uptodate.com/contents/overview-of-causes-of-genital-tract-bleeding-in-women?view=print 2/17 06/06/12 Overview of causes of genital tract bleeding in women Neoplasia and other disorders of the hypothalamus and pituitary often cause anovulation, but amenorrhea is more common than AUB because estrogen levels are low. (See "Etiology, diagnosis, and treatment of secondary amenorrhea".) Anatomic abnormalities — A significant number of women who complain of abnormal uterine bleeding have uterine abnormalities. This was illustrated in a study of 370 women aged 22 to 82 years with abnormal uterine bleeding unresponsive to treatment with progestin therapy [6]. Hysteroscopy revealed an abnormal uterine cavity in two-thirds of these women: endometrial hyperplasia (23 percent), polyps (22 percent), submucous myomata (11 percent), synechiae (6 percent), endometrial atrophy (2 percent), and adenocarcinoma (1 percent). When anatomic abnormalities are the cause of abnormal bleeding, cyclic menses with molimina typically occur. However, the duration and flow of the menstrual period may be altered or there may be bleeding between menstrual periods. Anatomic abnormalities can often be diagnosed by imaging studies, but excision is sometimes required for confirmation of the diagnosis and treatment. (See "Terminology and evaluation of abnormal uterine bleeding in premenopausal women".) Polyp — Uterine polyps are usually benign endometrial growths of unknown etiology that are a common cause of abnormal uterine bleeding in women in the menopausal transition and early postmenopausal women. Irregular bleeding is the most frequent symptom, occurring in about one-half of symptomatic cases. Bleeding after straining or heavy lifting is common. Less frequent symptoms include heavy or prolonged bleeding, postmenopausal bleeding, prolapse through the cervical os, and unscheduled (breakthrough) bleeding during hormonal therapy. Polyps can be stimulated
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