Normal and Abnormal Uterine Bleeding

Clinical Case:

A 45-year-old G2P0020, LMP 21 days ago, presents with heavy menstrual bleeding. Prior to 6 months ago her cycles came every 28-30 days, lasted for 6 days, and were associated with cramps that were relieved by ibuprofen. In the last 6 months there has been a change with menses coming every 25-32 days, lasting 7-10 days and associated with cramps not relieved by ibuprofen, passing clots and using 2 boxes of maxi pads each cycle. She is worried about losing her job if the bleeding is not better controlled. She denies dizziness, but complains of feeling weak and fatigued. Her weight has not changed in the last year. She denies any bleeding disorders or reproductive cancers in the family. She uses condoms for contraception. She takes no daily medications and has no other medical problems. She is married and works in a factory. On exam, BP=130/88; P= 100; Ht=5'6'; Wt=150 pounds. She appears pale. Pelvic exam shows normal vulva, vagina and cervix: normal size, mildly tender, mobile uterus; non-tender adnexae without palpable masses. Labs show Hgb: 9.0, HCT: 27%, HCG: negative, Endometrial biopsy: normal secretory endometrium, Pelvic ultrasound: heterogeneous myometrium, endometrial lining 1.4cm and irregular consistent with endometrial polyp, normal ovaries.

Discussion questions:

  1. What possible etiologies could cause this patient's bleeding?
  2. Which of these etiologies is associated with anovulation?
  3. Discuss the mechanism for anovulatory bleeding.
  4. How can you tell if this patient is having ovulatory cycles?
  5. What further tests would indicate if there was an anatomic problem?
  6. Describe 3 possible medical and 2 possible surgical therapies.
  7. Describe the cyclic interaction between the hypothalamus, pituitary and ovaries during the cycle.
  8. Review the role of GnRH the gonadotropins, the ovarian sex steroids during the follicular and luteal phases.


  1. Obstetrics and Gynecology by Beckmann 5 th Edition, 2006; Chapter 36 Amenorrhea and Dysfunctional Uterine Bleeding. Pages 359-364.
  2. Essentials of Obstetrics and Gynecology by Hacker and Moore 4 th Edition, 2004; Chapter 34 Dysfunctional Uterine Bleeding. Pages 409-412.

The occurrence of bleeding at times other than expected menses is a common event. Accurate diagnosis of abnormal uterine bleeding is necessary for appropriate management.

The APGO Educational Objectives related to this topic are the following:

  1. Describe the normal menstrual cycle *
  2. Define abnormal uterine bleeding *
  3. Describe the etiologies of abnormal uterine bleeding*
  4. Describe the evaluation methods of abnormal uterine bleeding*
  5. Describe the therapeutic options for abnormal uterine bleeding
  6. Counsel patients about each therapeutic option and sequelae

*Designated as Priority One in the APGO Medical Student Educational Objectives, 8 th Edition

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