History and exam
Key diagnostic factors
common
uterine bleeding
Any deviation from the parameters of the normal menstrual cycle, including inter-menstrual and post-coital bleeding, constitutes AUB.
Other diagnostic factors
common
use of medications
A detailed history of medicine use, particularly hormonal contraception (e.g., combined or progestogen only), drugs interfering with the hypothalamic-pituitary-ovarian axis (e.g., GnRH agonists and antagonists, SSRIs, tricyclic antidepressants), non-prescription supplements, and complementary medicines, is important.
menstrual irregularity
Suggestive of anovulation. Sexual activity, use of contraception, and missed periods are all a crucial part of the diagnosis of AUB in order to exclude pregnancy-associated bleeding problems.
It is prudent to carry out a urine pregnancy test in all women of reproductive age who present with AUB.
anaemia
Acute or chronic AUB is associated with acute or chronic anaemia. Acute bleeding may present with signs of haemodynamic collapse, and chronic bleeding may be associated with non-specific manifestations of iron deficiency anaemia, such as fatigue, dyspnoea, and pallor on examination.
uncommon
premenstrual molimina
Breast fullness and tenderness, fluid retention, and mild mood swings may be associated with ovulation.
Absence of these symptoms is suggestive of anovulatory cycles.
hirsutism, acne, acanthosis nigricans
Signs of hyperandrogenic state, such as encountered in women with polycystic ovary syndrome (PCOS).
existing medical illness
Thyroid disorders, coagulopathy.
Risk factors
strong
women at the extremes of reproductive age (just after puberty and before menopause)
Disturbances of the hypothalamic-pituitary-ovarian (HPO) axis are physiologically encountered in a high proportion of women at both ends of the reproductive age period. Following puberty, it may take the HPO axis a few years before reaching full maturity and regular ovulation.[22][25] In the years before menopause, depletion of the ovarian follicles causes more anovulatory cycles.[26]
polycystic ovary syndrome
Polycystic ovary syndrome (PCOS) is the most common reproductive endocrine disorder affecting women in the reproductive age group. The hallmark of the syndrome includes androgen excess with chronic anovulation.[40] Hormonal derangement in PCOS includes continuous exposure of the endometrium to oestrogen. This exposure results in endometrial proliferation unopposed by progesterone (due to lack of ovulation).[41] PCOS is often a consequence of other endocrine disorders.
endocrine disorders
Other endocrine disorders that may cause ovulatory dysfunction, such as hypothyroidism and hyperprolactinaemia, are frequently associated with AUB.[24]
other anovulatory disorders
Anovulation can be caused by conditions such as hyperprolactinaemia or hypothalamic anovulation (e.g., related to excessive exercise, mental and physical stress, or a sudden loss or increase in weight), which may be associated with AUB.[24][42][43] This is due to oestrogen-driven endometrial proliferation that is unopposed by progesterone.
obesity
Excessive oestrogen production as a result of peripheral oestrogen synthesis from androgen precursors in adipose tissue, as well as the frequently encountered anovulation in obese women, are believed to increase the risk of AUB.[44]
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