Coagulopathies and Other Hematologic Causes of Abnormal in Reproductive-Age Women As with adolescents, hematologic causes of abnormal bleeding should be considered in women with heavy menstrual bleeding, particularly in those who had abnormal bleeding since menarche. Of all women with menorrhagia, 5% to 20% have a previously undiagnosed bleeding disorder, primarily von Willebrand’s disease (171). Table 14.8 presents guidelines for a gynecologist’s suspicion of a bleeding disorder and pursuit of a diagnosis (81). Abnormal liver function, which can be seen with alcoholism or other chronic liver diseases, results in inadequate production of clotting factors and can lead to excessive menstrual bleeding.
Infections Causes As in adolescents, menorrhagia can be the first sign of endometritis in women infected with sexually transmissible organisms. Women with cervicitis, particularly chlamydial cervicitis, can experience irregular bleeding and postcoital spotting (see Chapter 18). Therefore, cervical testing for C. trachomatis should be considered, especially for adolescents, women in their 20s, and women who are not in a monogamous relationship. Endometritis can cause excessive menstrual ﬂow. Thus, a woman who seeks treatment for menorrhagia and increased menstrual pain and has a history of light-to-moderate previous menstrual ﬂow may have an upper genital tract infection or PID (endometritis, salpingitis, oophoritis). Occasionally, chronic endometritis will be diagnosed when an endometrial biopsy is obtained for evaluation of abnormal bleeding in a patient without specific risk factors for PID.
Neoplasia Abnormal bleeding is the most frequent symptom of women with invasive cervical cancer. A visible cervical lesion should be evaluated by biopsy rather than awaiting the results of cervical cytology testing, because the results of cervical cytology testing may be falsely negative with invasive lesions as a result of tumor necrosis. Unopposed estrogen is associated with a variety of abnormalities of the endometrium, from cystic hyperplasia to adenomatous hyperplasia, hyperplasia with cytologic atypia, and invasive carcinoma. Although vaginal neoplasia is uncommon, the vagina should be evaluated carefully when abnormal bleeding is present. Attention should be directed to all surfaces of the vagina, including anterior and posterior areas that may be obscured by the vaginal speculum on examination.
For all women, the evaluation of excessive and abnormal menses includes a thorough medical and gynecologic history, the exclusion of pregnancy, the consideration of possible malignancy, and a careful gynecologic examination. For women of normal weight between the ages of approximately 20 and 35 years who do not have clear risk factors for STDs, who have no signs of androgen excess, who are not using exogenous hormones, and who have no other findings on examination, management may be based on a clinical diagnosis. Additional laboratory or imaging studies may be indicated if the diagnosis is not apparent on the basis of examination and history.
Laboratory Studies In any patient with heavy menstrual bleeding, an objective measurement of hematologic status should be performed with a complete blood count to detect anemia or thrombocytopenia. A pregnancy test should be performed to rule out pregnancy-related problems. In addition, because of the possibility of a primary coagulation problem, screening coagulation studies should be considered (Table 14.8). The consensus report of an international expert panel recommends measurement of CBC, platelet count and function, PT, activated PTT, VWF (measured with ristocetin cofactor activity and antigen, factor VIII) and fibrinogen to be assessed in collaboration with a hematologist (81).