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Published July 10, 2019

Menstrual and Bleeding Disorders

Common menstrual and bleeding abnormalities include the following:

  • menorrhagia: excessively heavy flow

  • metrorrhagia: uterine bleeding at irregular intervals

  • oligomenorrhea: infrequent menstrual periods

  • amenorrhea: absence of a menstrual period

Menorrhagia and Abnormal Uterine Bleeding in Premenopausal Women

  • The PALM-COEIN classification system: Etiologies of abnormal uterine bleeding can be summarized with the acronym PALM-COEIN, divided into structural causes and nonstructural causes. Remember that, along with pregnancy, infections like chlamydia can also cause bleeding.

The PALM-COEIN Classification System for Abnormal Uterine Bleeding

  • Clinical classification of uterine bleeding: This alternative classification categorizes uterine bleeding clinically as ovulatory and anovulatory bleeding:

    • Ovulatory bleeding: Differential diagnosis includes:

      • normal menses with longer cycles (causing increased estrogen exposure)

      • coagulopathy

      • structural causes (fibroids, malignancy)

      • thyroid disease

      • endometriosis

AAFP Algorithm for Evaluation and Treatment of Ovulatory Bleeding

  • Anovulatory bleeding: Differential diagnosis is the same for oligo/amenorrhea, including pregnancy, thyroid disease, premature ovarian failure, perimenopause, and use of hormonal contraception.

AFP Algorithm for Evaluation and Treatment of Anovulatory Bleeding

  • Up to 13% of women with heavy menstrual bleeding have some variant of von Willebrand’s syndrome, and up to 20% have underlying coagulation disorder. Initial workup includes a thorough history, including heavy bleeding since menarche, postpartum hemorrhage, surgery-related bleeding, bleeding with dental work, easy bruising, and epistaxis.

  • All women older than 45, or women younger than 45 with history of obesity or unopposed estrogen exposure with abnormal uterine bleeding, should be referred for endometrial tissue sampling.

  • Treatment depends on the etiology of the bleeding.

  • For acute bleeding, only one treatment (IV conjugated estrogen) is approved by the FDA.

  • For chronic treatment for menorrhagia, medical options include combined hormonal contraceptive (pill, patch, or ring), oral or injectable (subcutaneous or intramuscular) progestins, a subdermal implant or levonorgestrel IUD, and/or tranexamic acid.

  • See the ACOG guidelines for additional information on treatment options.

Postmenopausal Bleeding

Any woman with vaginal bleeding after menopause requires evaluation to exclude malignancy. All women should be referred to an OB/GYN or clinician capable of performing endometrial biopsy.

ACOG recommendations for postmenopausal bleeding are as follows:

  • Perform initial assessment with endometrial biopsy or transvaginal ultrasonography.

  • Endometrial sampling is not recommended for endometrial thickness ≤4 mm.

  • Further evaluation is required for endometrial thickness ≥4 mm.

Secondary Amenorrhea

  • Secondary amenorrhea is defined as the cessation of regular menses for 3 months or of irregular menses for 6 months.

  • Pregnancy is the most common cause of secondary amenorrhea and should be excluded in all cases; additional workup may include serum levels of luteinizing hormone, FSH, prolactin, and TSH.

AAFP Algorithm for Diagnosis of Secondary Amenorrhea



  • Endometriosis is the presence of endometrial-like tissue outside the uterus. Endometrial implants appear almost anywhere, although they are primarily found in the peritoneum, on the ovaries, and occasionally even on and above the diaphragm.

  • Common clinical presentation includes pelvic pain, dyspareunia, bladder and bowel symptoms, dysmenorrhea, and infertility.

  • The diagnosis and staging of endometriosis can technically only be made surgically. Transvaginal ultrasound and MRI can both detect ovarian endometriomas but are less sensitive at finding peritoneal or ovarian implants.

First-line treatment for endometriosis is traditionally medical management. Ovarian suppression with lactation has recently been found to decrease the risk of incident endometriosis. The following tables describe medical and surgical treatment options for endometriosis, and guidelines for the diagnosis and management of endometriosis-related pain and infertility.

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