Abnormal uterine bleeding in premenopausal women

14% of women experience irregular or excessively heavy menstrual bleeding. This abnormal uterine bleeding can be divided into anovulatory and ovulatory patterns.

Anovulatory bleeding

Chronic anovulation can lead to:

- irregular bleeding
- prolonged unopposed estrogen stimulation of the endometrium
- increased risk of endometrial cancer

Causes of chronic anovulation include:

- polycystic ovary syndrome (PCOS)
- uncontrolled diabetes mellitus
- thyroid dysfunction
- hyperprolactinemia
- antipsychotics or antiepileptics

Patients who should undergo endometrial biopsy include:

- women 35 years or older with recurrent anovulation
- women younger than 35 years with risk factors for endometrial cancer
- women with excessive bleeding unresponsive to medical therapy

Treatment with combination oral contraceptives or progestins may regulate menstrual cycles.

Ovulatory abnormal uterine bleeding (menorrhagia)

Ovulatory abnormal uterine bleeding, or menorrhagia, may be caused by:

- thyroid dysfunction
- coagulation defects (most commonly von Willebrand disease)
- endometrial polyps
- submucosal fibroids

Diagnostic evaluation includes transvaginal ultrasonography or saline infusion sonohysterography.

Medical management

The levonorgestrel-releasing intrauterine system is an effective treatment for menorrhagia.

Oral progesterone for 21 days per month and nonsteroidal anti-inflammatory drugs are also effective. Tranexamic acid is a relatively expensive option.

References

Evaluation and management of abnormal uterine bleeding in premenopausal women.
Sweet MG, Schmidt-Dalton TA, Weiss PM, Madsen KP. Am Fam Physician. 2012 Jan 1;85(1):35-43.

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