The parameters for normal menstruation have been defined as a result of an international process designed to simplify terminologies and definitions for abnormalities of menstrual<unk> . The causes of abnormal<unk>  vary by age. In children<unk>  in children is of concern if it occurs before the expected time of menarche and in the absence of appropriate pubertal development.<unk>  before the onset of pubertal development deserves evaluation. It could result from local causes or from hormonal factors. In children, it may be challenging to determine the source of<unk> , and "vaginal"<unk>  may actually arise from the bladder or urethra, or from the rectum.<unk>  in the first week of life after birth is a common observation, and pediatricians typically discuss this with new mothers at the time of hospital discharge. During childhood, other possible causes include the presence of a foreign body in the vagina, trauma (either accidental or non accidental, i.e. child sexual abuse or molestation), urethral prolapse, vaginal infection (vaginitis), vulvar ulcers, vulvar skin conditions such as lichen sclerosus, and rarely, a tumor (benign or malignant vaginal tumors, or hormone-producing ovarian tumors). Hormonal causes include central precocious puberty, or peripheral precocious puberty (McCune-Albright syndrome), or primary hypothyroidism. While the symptom is typically alarming to parents, most causes are benign, although sexual abuse or tumor are particularly important to exclude. An examination under anesthesia (EUA) may be necessary to exclude a vaginal foreign body or tumor, although instruments designed for office hysteroscopy can sometimes be used in children with topical anesthesia for office vaginoscopy, precluding the need for sedation or general anesthesia and operating room time. Premenopausal Background In premenopausal women,<unk>  can be from the uterus, from vulvar or vaginal lesions, or from the cervix. A gynecologic examination can be performed to determine the source of<unk> .<unk>  may also occur as a result of a pregnancy complication, such as a spontaneous abortion (miscarriage), ectopic pregnancy, or abnormal growth of the placenta, even if the woman is not aware of the pregnancy. This possibility must be kept in mind with regard to diagnosis and management. Generally, the causes of abnormal uterine<unk>  in premenopausal women who are not pregnant include fibroids, polyps, hormonal disorders such as polycystic ovary syndrome (PCOS), blood clotting disorders, and cancer. Infections such as cervicitis or pelvic inflammatory disease (PID) can also result in<unk> . Postcoital<unk>  is<unk>  that occurs after sexual intercourse. Lastly, a normal and common side effect of birth control includes vaginal spotting or<unk> . Clinical guidelines (FIGO classification) A more specific clinical guideline, called the PALM-COEIN system, has been developed by FIGO (International Federation of Gynecology and Obstetrics) to classify the causes of abnormal uterine<unk> . This acronym stands for Polyp, Adenomyosis, Leiomyoma, Malignancy and Hyperplasia, Coagulopathy, Ovulatory Disorders, Endometrial Disorders, Iatrogenic Causes, and Not Classified. The FIGO Menstrual Disorders Group, with input from international experts, recommended a simplified description of abnormal<unk>  that discarded imprecise terms such as menorrhagia, metrorrhagia, hypermenorrhea, and dysfunctional uterine<unk>  (DUB) in favor of plain English descriptions of<unk>  that describe the<unk>  in terms of cycle regularity, frequency, duration, and volume. The PALM causes are related to uterine structural, anatomic, and histolopathologic causes that can be assessed with imaging techniques such as ultrasound or biopsy to view the histology of a lesion. The COEIN causes of abnormal<unk>  are not related to structural causes. * Polyps: Endometrial polyps are benign growths that are typically detected during gynecologic ultrasonography and confirmed using saline infusion sonography or hysteroscopy, often in combination with an endometrial biopsyproviding histopathologic confirmation. Endocervical polyps are visible at the time of a gynecologic examination using a vaginal speculum, and can often be removed with a minor office procedure. * Adenomyosis: Adenomyosis is a condition in which endometrial glands are present within the muscle of the uterus (myometrium), and the pathogenesis and mechanism by which it causes abnormal<unk>  have been debated. * Leiomyoma (fibroids): Uterine leiomyoma, commonly termed uterine fibroids, are common, and most fibroids are asymptomatic. The presence of leiomyomas may not be the cause of abnormal<unk> , although fibroids that are submucosal in location are the most likely to cause abnormal<unk> . * Malignancy (pre-cancer and cancer): The Malignancy and Hyperplasia category of the PALM-COEIN system includes malignancies of the genital tract, including cancers of the vulva, the vagina, the cervix, and the uterus. Endometrial hyperplasia, included in this PALM category of abnormal<unk> , is more common in women who are obese or who have a history of chronic anovulation. When endometrial hyperplasia is associated with atypical cells, it can progress to cancer or occur concurrently with it. While endometrial hyperplasia and endometrial canceroccur most commonly among post-menopausal women, most patients with endometrial cancer have abnormal<unk> , and thus the diagnosis must be considered in women during the reproductive years. * Coagulopathies (blood clotting disorders): Heavy menstrual<unk>  can be related to Coagulopathies. Von Willebrand disease is the most common coagulopathy, and most women with von Willebrand disease have heavy menstrual<unk> . Of women with heavy menstrual<unk> , up to 20% will have a<unk>  disorder. Heavy menstrual<unk>  since menarche is a common symptom for women with<unk>  disorders, and in retrospective studies,<unk>  disorders have been found in up to 62% of adolescents with heavy menstrual<unk> . * Ovulatory dysfunction: Ovulatory dysfunction or anovulation is a common cause of abnormal<unk>  that may lead to irregular and unpredictable<unk> , as well as variations in the amount of flow including heavy<unk> . Endocrine, or hormonal, causes of ovulatory disorders include polycystic ovary syndrome (PCOS), thyroid disorders, hyperprolactinemia, obesity, eating disorders including anorexia nervosa or bulimia, or to an imbalance between exercise and caloric intake. * Endometrial: Endometrial causes of abnormal<unk>  include infection of the endometrium, endometritis, which may occur after a miscarriage (spontaneous abortion) or a delivery, or may be related to a sexually-transmitted infection of the uterus, fallopian tubes or pelvis generally termed pelvic inflammatory disease (PID). Other endometrial causes of abnormal<unk>  may relate to the ways that the endometrium heals itself or develops blood vessels. * Iatrogenic (caused by medical treatment or procedures): The most common Iatrogenic cause of abnormal<unk>  relates to treatment with hormonal medications such as birth control pills, patches, rings, injections, implants, and intrauterine devices (IUDs). Hormone therapy for treatment of menopausal symptoms can also cause abnormal<unk> . Unscheduled<unk>  that occurs during such hormonal treatment is termed "breakthrough<unk> " (BTB) Breakthrough<unk>  may result from inconsistent use of hormonal treatment, although in the initial months after initiation of a method, it may occur even with perfect use, and may ultimately affect adherence to the medication regimen. The risk of breakthrough<unk>  with oral contraceptives is greater if pills are missed. * Not classified: The Not Classified category of the PALM-COEIN system includes conditions that may be rare, or whose contribution to abnormal<unk>  has not been well established or understood. Pregnancy<unk>  occurs during 15-25% of first trimester pregnancies. Of these, half go on to miscarry and half bring the fetus to term. There are a number of causes including complications to the placenta, such as placental abruption and placenta previa. Other causes include miscarriage, ectopic pregnancy, molar pregnancy, incompetent cervix, uterine rupture, and preterm labor.<unk>  in early pregnancy may be a sign of a threatened or incomplete miscarriage. In the second or third trimester a placenta previa (a placenta partially or completely overlying the cervix) may bleed quite severely. Placental abruption is often associated with uterine<unk>  as well as uterine pain. Postmenopausal Endometrial atrophy, uterine fibroids, and endometrial cancer are common causes of postmenopausal<unk> . About 10% of cases are due to endometrial cancer. Uterine fibroids are benign tumors made of muscle cells and other tissues located in and around the wall of the uterus. Women with fibroids do not always have symptoms, but some experience<unk>  between periods, pain during sex, and lower back pain.
Vaginal bleeding
Vaginal discharge
Abnormal uterine bleeding
Heavy menstrual bleeding
Internal bleeding
Birthgasm
Cervical enlargement
Abdominal pain