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Basic Information ⬇

Author: Emily Rider-Longmaid, MD, MBE and Sarah Green, MD

Definition

Abnormal uterine bleeding is defined as uterine bleeding in a nonpregnant person that is abnormal in duration, frequency, volume, and/or regularity. In adolescents, menstruation normally occurs every 21 to 45 days and lasts between 2 and 7 days. The normal volume of menstrual blood loss is approximately 30 ml and should not exceed 80 ml per cycle (no more than 5 or 6 saturated pads or tampons per day), and no intermenstrual bleeding should occur.1

Synonyms

Irregular bleeding

Dysfunctional uterine bleeding

Intermenstrual bleeding

Menorrhagia

Heavy menstrual bleeding

ICD 10-CM CODES
N92.0Menorrhagia, heavy menstrual bleeding
N92.1Irregular intermenstrual bleeding, breakthrough bleeding
N92.3Intermenstrual bleeding
N92.4Abnormal vaginal bleeding in premenopausal patient
N92.6Irregular menses
N93.8Dysfunctional uterine bleeding
N93.9Abnormal uterine bleeding
Epidemiology & Demographics
Prevalence:

Among adolescents, the prevalence of dysmenorrhea is approximately 71%,2 and the prevalence of heavy menstrual bleeding is reported between 4% and 63%.3 However, the overall prevalence of abnormal uterine bleeding among adolescents is not known.

Predominant Sex and Age:

Abnormal uterine bleeding occurs in those assigned females at birth and is more likely to occur in the first 2 yr after menarche.

Risk Factors:

Endocrinologic or hematologic disorders, rapid weight change, family history of abnormal uterine bleeding

Genetics:

Genetic causes of endocrinologic or hematologic disorders

Physical Findings & Clinical Presentation

Physical exam findings of irregular menses in adolescence are usually unremarkable. If menstrual bleeding has been heavy (>80 ml per cycle), frequent, or prolonged, signs of anemia may be present. The clinical presentation will anchor on the patient’s history, the key components of which include age at menarche, duration of menses, frequency of menses, presence of intermenstrual bleeding, and the number of pads or tampons saturated on the patient’s heaviest days of bleeding.

Etiology

In contrast to adults with irregular menses, who often present with structural abnormalities, the majority of adolescents have irregular menses due to ovulatory dysfunction.4 The most common cause of ovulatory dysfunction in adolescents in the first 2 yr after menarche is the immature hypothalamic-pituitary-ovarian axis, and this can last up to 5 yr postmenarche.4

Diagnosis ⬆ ⬇

Differential Diagnosis

CategoryCondition
PregnancyIntrauterine pregnancy, ectopic pregnancy
Ovulatory DysfunctionImmature HPO axis (perimenarchal), changes in weight, premature ovarian insufficiency, Turner syndrome, fragile X syndrome
EndocrinopathyPolycystic ovarian syndrome, hyperthyroidism, hypothyroidism, prolactinoma, diabetes, adrenal insufficiency, congenital adrenal hyperplasia, Cushing syndrome
CoagulopathyVon Willebrand disease, coagulation factor deficiencies, immune thrombocytopenia, platelet function disorders
InfectionSexually transmitted infection causing cervicitis, endometritis, or pelvic inflammatory disease
IatrogenicContraception side effect or varied adherence to contraception; continuous cycling (no placebo week) of combined hormonal contraception; neuropsychiatric medications
Structural*Cervical or endometrial polyps or fibroids, adenomyosis, endometriosis (prevalence unknown)
Malignancy*Endometrial, cervical, vaginal, or vulvar malignancy

HPO, Hypothalamic-pituitary-ovarian.

* Rare in adolescents

Workup

CategoryConditionInitial Workup
PregnancyIntrauterine pregnancy, ectopic pregnancyPregnancy test
Ovulatory DysfunctionImmature HPO axis (perimenarchal), changes in weight, premature ovarian insufficiency, Turner syndromeLuteinizing hormone, follicle stimulating hormone, estradiol
EndocrinopathyPolycystic ovarian syndrome, hyperthyroidism, hypothyroidism, prolactinoma, diabetes, adrenal insufficiency, congenital adrenal hyperplasia, Cushing syndromeThyroid stimulating hormone, prolactin, HbA1c; if ≥3 mo without menses, send free testosterone, dehydroepiandrosterone sulfate, androstenedione, 17-hydroxyprogesterone
CoagulopathyVon Willebrand disease, coagulation factor deficiencies, immune thrombocytopenia, platelet function disordersComplete blood count, prothrombin time, partial thromboplastin time, von Willebrand antigen and activity, factor VIII
InfectionSexually transmitted infection causing cervicitis, endometritis, or pelvic inflammatory diseaseUrine or cervical swab for gonorrhea, chlamydia, and trichomonas; HIV, RPR; pelvic exam if concerned for PID
IatrogenicContraception side effect or varied adherence to contraception; continuous cycling (no placebo week) of combined hormonal contraception; neuropsychiatric medicationsReview medication list and patient’s adherence
Structural (rare)Cervical or endometrial polyps or fibroids, adenomyosis, endometriosis (prevalence unknown)Pelvic exam
Malignancy (rare)Endometrial, cervical, vaginal, or vulvar malignancyPelvic exam

HIV, Human immunodeficiency virus; HPO, hypothalamic-pituitary-ovarian; RPR, rapid plasma reagin; PID, pelvic inflammatory disease.

Laboratory Tests

See "Workup."

Imaging Studies

Imaging studies, and specifically the pelvic ultrasound, are not recommended in the initial workup of irregular menses in adolescents. These studies are important in the evaluation of structural abnormalities causing irregular menses; however, only 1.3% of adolescents with irregular menses have an underlying structural etiology.5

Treatment ⬆ ⬇

Nonpharmacologic Therapy

Watchful waiting is appropriate if medically stable and if desired by the patient. Application of heat can be helpful for dysmenorrhea.

Acute General Rx

Irregular menses require acute intervention when heavy menstrual bleeding causes clinically significant anemia. For immediate cessation of menses, any combined oral contraceptive pill or progesterone-only pill should be taken four times a day and weaned down to once per day over the course of 1 to 2 wk. Intravenous estrogen every 4 to 6 h for 24 h is the fastest method for cessation of uterine bleeding.6 Nonhormonal options for immediate cessation of menses include tranexamic acid and, for patients without coagulopathies, NSAIDs.

Chronic Rx

Depo-Provera and hormonal intrauterine devices (IUDs) are highly effective at lightening menstrual bleeding, and in many cases, stopping menstrual bleeding altogether. Combined hormonal contraceptives (pills, patches, and ring) as well as progesterone-only pills are effective at both lightening menstrual bleeding and regulating menstrual frequency. The contraceptive implant achieves amenorrhea in about one-fifth of users.

Complementary & Alternative Medicine

Vitamin D, vitamin E, and fish oil supplementation have all been associated with improvement in dysmenorrhea but not in heavy menstrual bleeing.7,8

Disposition

The management of irregular menses most often occurs in the outpatient setting. If a patient has symptomatic anemia or is soaking through more than one pad every hour, they should be referred to the Emergency Department for further evaluation and management.

Referral

If there is concern for an underlying coagulopathy, the patient should be referred to Hematology for co-management. If there is concern for a structural abnormality, they should be referred to OB/Gyn.

Pearls & Considerations ⬆ ⬇

Comments

If frequent or heavy bleeding, checking ferritin is a helpful way of assessing iron stores even if a patient is not yet anemic. In the appropriate clinical context, oral iron should be given every other day for a ferritin level less than 30 ng/ml.

While dysmenorrhea is difficult to quantify, it can significantly impact a patient’s quality of life and should be treated if desired by the patient.

Use of hormonal contraception should involve shared decision-making with adolescents, incorporating principles of autonomy and reproductive justice.

Patient & Family Education

Youngwomenshealth.org

Reference(s) ⬆

  1. Hernandez A, Dietrich J : Abnormal uterine bleeding in the adolescentdoi:10.1097/AOG.0000000000003693Obstet Gynecol. 135(3):615-621, 2020.
  2. Armour M : The prevalence and academic impact of dysmenorrhea in 21,573 young women: a systematic review and meta-analysisdoi:10.1089/jwh.2018.7615J Womens Health (Larchmt). 28(8):1161-1171, 2019.
  3. Pouraliroudbaneh S et al: Heavy menstrual bleeding and dysmenorrhea in adolescents: a systematic review of self-management strategies, quality of life, and unmet needs, Int J Gynaecol Obstet. 167(1): 16-41, doi:10.1002/ijgo.15554.
  4. Kabra R, Fisher M : Abnormal uterine bleeding in adolescentsdoi:10.1016/j.cppeds.2022.101185Curr Probl Pediatr Adolesc Health Care. 52(5):101185, 2022.
  5. Pecchioli Y : The utility of routine ultrasound in the diagnosis and management of adolescents with abnormal uterine bleedingdoi:10.1016/j.jpag.2016.09.012J Pediatr Adolesc Gynecol. 30(2):239-242, 2017.
  6. Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged womendoi:10.1097/01.AOG.0000428646.67925.9aObstet Gynecol. 121(4):891-896, 2013.
  7. Amzajerdi A : The effect of vitamin D on the severity of dysmenorrhea and menstrual blood loss: a randomized clinical trialdoi:10.1186/s12905-023-02284-5BMC Womens Health. 23(1):138, 2023.
  8. Sadeghi N : Vitamin E and fish oil, separately or in combination, on treatment of primary dysmenorrhea: a double-blind, randomized clinical trialdoi:10.1080/09513590.2018.1450377Gynecol Endocrinol. 34(9):804-808, 2018.