Anatomic Causes Anatomic causes of abnormal bleeding occur more frequently in women of reproductive age than in women in other age groups. Uterine leiomyomas and endometrial polyps are common conditions that most often are asymptomatic; however, they remain important causes of abnormal bleeding (162). Uterine leiomyomas occur in as many as one-half of all women older than age 35 years and are the most common tumors of the genital tract (151,152,162). The incidence varies from 30% to 70%, depending on criteria for study, whether clinical symptoms, ultrasound, or histologic assessment (163). One study of a randomly selected population estimated a cumulative prevalence of greater than 80% in black women and nearly 70% in white women (164). Abnormal bleeding is the most common symptom for women with leiomyomas. Although the number and size of uterine leiomyomas do not appear to inﬂuence the occurrence of abnormal bleeding, submucosal myomas are the most likely to cause bleeding. The mechanism of abnormal bleeding related to leiomyomas is not well established (see Chapter 15 for further discussion of uterine fibroids).
Endometrial polyps are a cause of intermenstrual bleeding, heavy menstrual bleeding, irregular bleeding, and postmenopausal bleeding and are associated with the use of tamoxifen and with dysmenorrhea and infertility. As with leiomyomas, most endometrial polyps are asymptomatic. The incidence of endometrial polyps increases with age throughout the reproductive years (162). The diagnosis may be suspected on the basis of endometrial thickening on transvaginal pelvic ultrasound, and patterns of feeder blood vessels may aid in distinguishing endometrial polyps from intracavity fibroids and from endometrial malignancy (162,165,166). Visualization with hysteroscopy or sonohysterography or the microscopic assessment of tissue obtained by a biopsy done in the office or a curettage specimen is required for confirmation. Whether and when to recommend removal is not well established, particularly if a polyp is asymptomatic and is found incidentally. One study of randomly selected Danish women using transvaginal ultrasound and sonohysterography found polyps in 5.8% of asymptomatic premenopausal women and 11.8% of asymptomatic postmenopausal women, In this study abnormal bleeding was present in 38% of those without polyps versus 13% with polyps (167). Endometrial polyps can regress spontaneously, although it is not clear how frequently this occurs. In one study of asymptomatic women, the 1-year regression rate was 27% (168). Smaller polyps are more likely to resolve, and larger polyps may be more likely to result in abnormal bleeding (169). Whereas polyps may resolve spontaneously over time, a clinically important question is whether they are likely to undergo malignant transformation. Because even asymptomatic polyps usually are removed at the time of identification, this question is difficult to answer. The chance of malignancy or premalignant changes in endometrial polyps appears to be quite low in premenopausal women and higher among postmenopausal women, with bleeding reports range from premalignant change in 0.2% to 24% and malignancy in 0% to 13% (170).
Abnormal bleeding, either intermenstrual or postcoital, can be caused by cervical lesions. Bleeding can result from endocervical polyps and infectious cervical lesions, such as condylomata, herpes simplex virus ulcerations, chlamydial cervicitis, or cervicitis caused by other organisms. Other benign cervical lesions, such as wide eversion of endocervical columnar epithelium or nabothian cysts, may be detected on examination but rarely cause bleeding.
Diagnosis of Abnormal Bleeding in Reproductive-Age Women