METRORRHAGIA

Ask the Following Questions:

1. Are there abnormalities found on the vaginal examination? An enlarged uterus suggests pregnancy, fibroids, retained secundina, hydatiform mole, choriocarcinoma, endometrial carcinoma, or endometrial polyp. An adnexal mass suggests a granulosa cell tumor, salpingitis, or ectopic pregnancy. Cervical lesions that cause metrorrhagia are cervicitis, carcinoma of the cervix, and cervical polyp. Vaginal lesions include vaginal carcinoma and senile vaginitis.
2. Is there a history of hormone therapy? If the patient has been taking estrogen or progesterone, withdrawal or breakthrough bleeding should be considered.
3. Is there pallor or other signs of anemia? Most types of anemia, but particularly iron deficiency anemia, are associated with metrorrhagia.
4. Is there a history of tremor, tachycardia, or edema? Both hyperthyroidism and hypothyroidism may be associated with metrorrhagia.
5. Is there hirsutism or virilism? Look for an adrenal or ovarian neoplasm in these cases.

If all of these questions fail to turn up any positive answers, then dysfunctional uterine bleeding, collagen disease, or a coagulation disorder should be strongly considered.

DIAGNOSTIC WORKUP

Routine studies include a CBC, sedimentation rate, urinalysis, pregnancy test, chemistry panel, ANA test, coagulation profile, thyroid profile, and flat plate of the abdomen. A Pap smear and vaginal smear and culture should also be done.

If these are negative, referral to a gynecologist should be made before undertaking expensive diagnostic tests such as ultrasound or CT scans of the abdomen and pelvis. Alternatively, a trial of cyclical estrogen and progesterone hormones may be done if dysfunctional bleeding is suspected before referral is made. A gynecologist may be able to resolve the diagnostic dilemma with a good pelvic examination or, if that is unsuccessful, may perform laparoscopy or culdocentesis. A dilation and curettage or office endometrial biopsy are among the additional procedures at the gynecologist's disposal. An endocrinologist may be of help in deciding whether pituitary or ovarian dysfunction is responsible. An FSH of greater than 40 ml suggests ovarian failure. The endocrinologist may note hirsutism and order a free testosterone and 17-hydroxy progesterone to rule out adrenal or ovarian neoplasm.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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