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Williams Gynecology > Section 1 Benign General Gynecology > Chapter 8. Abnormal
Uterine Bleeding >
Abnormal Uterine Bleeding: Introduction
Regular cyclic menstruation results from the choreographed relationship between the
endometrium and its regulating factors (see Chap. 15, Histologic Menstrual Cycle
Changes). Changes in either of these frequently results in abnormal bleeding. Causes of this
bleeding may include neoplastic growth, hormonal dysfunction, reproductive-tract trauma,
infection, coagulopathies, and complications of pregnancy. As a result, abnormal uterine
bleeding is a common gynecologic complaint that may affect females of all ages.
Definitions
Abnormal bleeding may display several patterns. Menorrhagia is defined as prolonged or
heavy cyclic menstruation. Objectively, menses lasting longer than 7 days or exceeding 80
mL of blood loss are determining values (Hallberg, 1966). Metrorrhagia describes
intermenstrual bleeding. The term breakthrough bleeding is a more informal term for
metrorrhagia that accompanies hormone administration. Frequently women may complain
of both patterns, menometrorrhagia. In some women, there is diminished flow or
shortening of menses, hypomenorrhea. Normal menstruation typically occurs every 28 days
7 days. Cycles with intervals longer than 35 days describe a state of oligomenorrhea.
Finally, the term withdrawal bleeding refers to the predictable bleeding that often results
from abrupt progestin cessation.
Assessing heavy bleeding in a clinical setting has its limitations. For example, several
studies have documented the lack of correlation between patient perception of blood loss
and objective measurement (Chimbira, 1980c; Fraser, 1984). As a result, methods to
objectively assess blood loss have been investigated. Hallberg and associates (1966)
describe a technique to extract hemoglobin from sanitary napkins using sodium hydroxide.
Hemoglobin is converted to hematin and can be measured spectrophotometrically. The
constraints to this approach in a clinical setting are obvious.
Other tools used to estimate menstrual blood loss include hemoglobin and hematocrit
evaluation. Hemoglobin concentration <12 g/dL increases the chance of identifying women
with menorrhagia. A normal level, however, does not exclude menorrhagia, as many
women with clinically significant bleeding have normal values.
Another method involves estimating of the number and type of pads used by a woman
during menses. Warner and colleagues (2004) found positive correlations between objective
menorrhagia with passing clots more than 1.1 inches in diameter and changing pads more

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