Abnormal uterine bleeding: getting our terminology straight

Ian S. Frasera, Hilary O.D. Critchleyb and Malcolm G. Munroc

Purpose of review This review highlights the difculties currently caused by the ill-dened and confused use of terminologies to describe symptoms, signs and causes of abnormal uterine bleeding. It also attempts to put usage of modern terminologies in an historical context with important lessons for current usage. Recent ndings Confused terminology has led to difculties in interpreting the results of many clinical trials of new therapies and surgical procedures for abnormal uterine bleeding, and in understanding some studies investigating underlying mechanisms of bleeding. The confusion is so great that a major international expert group has recommended abolition of such terms as menorrhagia, metrorrhagia and dysfunctional uterine bleeding, and replacement with much simpler terms to specically cover cycle regularity, frequency, duration and heaviness of bleeding episodes, and to acknowledge a signicant change in pattern for individual women. New terminologies are required to describe certain underlying causes of abnormal uterine bleeding. Summary Such discussion should be an ongoing process aimed towards good international agreement, which will greatly simplify the interpretation of clinical trials and scientic studies of mechanisms and treatment responses, and will contribute to the process of education at all levels. Keywords abnormal uterine bleeding, denitions, dysfunctional uterine bleeding, menorrhagia, metrorrhagia, terminology
Curr Opin Obstet Gynecol 19:591595. 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins. Department of Obstetrics and Gynaecology, University of Sydney, Australia and Section of Obstetrics and Gynaecology, Department of Reproductive and Developmental Sciences, University of Edinburgh, UK cDepartments of Obstetrics and Gynecology, University of California, Los Angeles, and Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles, USA
b a

Introduction
During the past 510 years there has been an increasing realization that the terminologies that most doctors use to describe disturbances of menstruation are so confused that they probably need to be replaced [1,2,3,4]. Evidence obtained within the past year has conrmed the major degree to which there is variation in the usually undened way in which these terminologies are used for description of menstrual symptoms, signs and causes [2,3,4]. This issue has been seen as having such international importance that one recent report of an agreement process on terminologies and denitions for menstrual disturbances has been published simultaneously in the two major international reproductive medicine journals, Fertility and Sterility and Human Reproduction [2,3]. Review of the very large literature on disturbances of menstruation has demonstrated that it is difcult to reconcile the results of clinical trials of medical and surgical therapies for menstrual symptoms that have been carried out in different countries [2,3,4]. Uncertainties begin to arise as soon as the terms menorrhagia, metrorrhagia and dysfunctional uterine bleeding are mentioned, because they are used in very different ways. These are considered in more detail here. It is worth stating at this point, however, that there are currently two virtually identical phase-3 clinical trials ongoing in the US and in Europe/ Australia looking at the treatment of dysfunctional uterine bleeding with a new estrogenprogestogen oral contraceptive formulation (registration numbers NCT 00293059 and NCT 00307801 at website: http://www. clinicaltrials.gov). These two trials have had to be set up in parallel because of the confusion that currently exists across the Atlantic divide on menstrual terminologies.

Historical aspects of menstrual terminology

Prior to considering modern use and misuse of the terms describing menstrual symptoms, signs and underlying causes, it is pertinent to take a look at the ways in which disturbances of menstruation have been described in the past two to three millennia. From the time of Hippocrates around 430 BC until the early 1800s, the main menstrual symptom appearing in medical writings was excessively heavy bleeding, described variously as excessive evacuations of the menses, inordinate owing, the immoderate ux, an overowing of the courses, menstruation is too profuse, excessive oodings, uterine haemorrhage, and so on [58]. Many of these publications were originally in Latin or Greek, but the
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Correspondence to Professor Ian S. Fraser, Department of Obstetrics and Gynaecology, Queen Elizabeth II Research Institute for Mothers and Infants, University of Sydney, NSW 2006, Australia Tel: +61 2 9351 2478; fax: +61 2 9351 4560; e-mail: helena@med.usyd.edu.au Current Opinion in Obstetrics and Gynecology 2007, 19:591595 Abbreviation AUB abnormal uterine bleeding

2007 Wolters Kluwer Health | Lippincott Williams & Wilkins 1040-872X

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592 Reproductive endocrinology

translations in the 1800s generally faithfully reect the sense of the original wording: for example, uxu mensium immodico; copiosus menses [9,10]. It seems clear that these physicians were mainly dealing with truly excessive bleeding; this is what we might nowadays term acute and severe bleeding. This sense of an acute event was also reected in publications in other languages at that time, such as the ruption des re ` gles [11]. French le The early writers clearly recognized the variability of abnormal uterine bleeding with statements such as the ux is immoderate, either when the periods return too often, when they continue too long, or when too much blood is discharged at one time [12]. Irregular and often light bleeding was frequently referred to as the weeping of the womb [6]. None of these early writers used terms like menorrhagia or metrorrhagia. The term menorrhagia appears to have been used for the rst time in the late 1700s in the lectures of Professor William Cullen, Professor of the Practice of Physic at the University of Edinburgh [13]. The earliest written use that we have been able to trace was in a treatise in Latin by one of Cullens postgraduate students, and attributed to Cullen [14]. This quotation reads, in part, Activorum generum unum nempe Menorrhagia, hujus disputationis argumentum erit. Ejus haec denitio est. The word menorrhagia is derived from the Greek noun mene meaning moon, and the verb regnumi meaning to burst forth, to let loose or break asunder, clearly implying a sudden, acute and severe bleeding. Cullen also recognized the importance of the frequency, duration and quantity of the menses, and of a change in pattern in individuals: the ow of the menses is considered immoderate when it recurs more frequently, when it continues longer, or when during the ordinary continuance it is more abundant than is usual with the same person at other times. He only considered menorrhagia as a disease with those deviations which are excessive in degree, which are permanent and which induce a manifest state of disability [13], but he does not state that this should only be conned to regular episodes of heavy bleeding. The term menorrhagia was obviously taken up with enthusiasm since it was regularly used in many of the textbooks appearing in the nineteenth and early twentieth centuries [15 17]. The sense in which the word is used implies that the reader is expected to understand that it refers to the symptom of heavy menstrual bleeding, although it is not usually dened clearly. The French also rapidly took up the terms menorrhagie and metrorrhagie [18]. The term metrorrhagia probably came into use at the same time, with Cullen using the spelling maetrorrhagia

[13]. Again, its meaning is not usually well dened, although it is taken to indicate some considerable irregularity in the bleeding. The derivation is from the Greek noun, metra, meaning uterus, and the verb regnumi again, perhaps suggesting bleeding bursting forth from the uterus at any time, that is, much less regular than implied by menorrhagia. This would suggest that Cullen was also using this word to indicate acute and heavy bleeding, but at irregular intervals. By contrast, there is very little useful information in the early literature on the underlying causes for abnormal uterine bleeding (AUB). It was only in the late nineteenth century and early twentieth century that sound information began to appear on the importance of benign gynecologic tumors like uterine broids and adenomyosis [17,19], endometriosis [20] and infections, and malignant tumors like cervical and endometrial cancer. The introduction of the confusing modern term dysfunctional uterine bleeding did not occur until 1930 [21], when it rst became realistic to start thinking seriously about possible causes for AUB in a group of women who did not have recognizable local pelvic pathology. For some years previously, a small proportion of writers had been talking about a broad category of unexplained bleeding disturbances as functional uterine bleeding [15]. Graves [21] used the term dysfunctional uterine bleeding to try and explain impairment of endocrine factors, which normally controlled menstrual function. He used terms such as arrhythmic dysfunctional uterine bleeding (irregular), periodic dysfunctional bleeding (more regular and thought to be associated with defective ovulation), menorrhagia with metrorrhagic spotting, and periodic menorrhagias (with more regular heavy bleeding). These suggest that he was using the term broadly to cover regular, irregular, ovulatory and anovulatory bleeding.

Current confusion in use of terminologies

One has to hunt carefully in the literature to discover how much confusion there currently is in the way different groups use the present-day descriptive terms for menstrual symptoms and causes of AUB. The term menorrhagia appears to be universally accepted as a description of some aspect of excessive, heavy or prolonged menstrual bleeding, but there the agreement ends. This is a term that is frequently not dened in the literature. We undertook to explore the way in which authors had used the term menorrhagia in recent publications in the international literature [4]. One hundred publications (in English) appearing on Medline (Ovid Technologies, Inc, New York, USA) between 2000 and 2006 in which the term menorrhagia appeared in the article title were carefully reviewed (Table 1). We categorized each article in four ways: rst, whether the term menorrhagia was dened (even broadly) or not; second, was it primarily used as a

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Abnormal uterine bleeding Fraser et al. 593 Table 1 Analysis of the apparent meaning of usage of the term menorrhagia in 100 publications between 2000 and 2006, where the term menorrhagia appeared in the title of the publication Category 1(a) Dened 1(b) Undened 2(a) Used as symptom of heavy uterine bleeding, irregular or regular, with or without pathology 2(b) Used as symptom of heavy uterine bleeding, regular, with or without pathology 2(c) Used as a symptom of heavy uterine bleeding, regular with no detectable pathology 3(a) Primarily reecting patient complaint 3(b) Primarily reecting the doctors denition 4(a) Used as a diagnosis 4(b) Used as a diagnosis when combined with another term (e.g. idiopathic) Adapted from [4]. Usage 56 44 n 100 34 28 16 n 78 59 19 n 78 5 17 n 22

patient complaint or a doctors determination of the severity of the complaint? third, did it only involve regular heavy bleeding with no pathology or did it include women with pathology or irregular bleeding? fourth, did it sometimes use the term as a diagnosis, either on its own or with a qualifying adjective (e.g. idiopathic menorrhagia)? It is of interest that the sense of how the word was used sometimes changed at different points in the publication. Usage of the term was sometimes so unclear that value judgements had to be made as to which category was the most appropriate, and there was sometimes overlap between categories. Most authors (78%) used menorrhagia to describe a symptom or sign, but 22% used it to indicate a diagnosis or cause of abnormal bleeding. In these 22%, the term was sometimes also used in the sense of a symptom in the same article. There was great variation in whether authors used the term to include heavy bleeding at regular or irregular intervals or in the presence or absence of major pathology. In three-quarters of those who used menorrhagia in the sense of a cause or diagnosis, a qualifying adjective (unexplained, symptomatic, essential, uncomplicated, idiopathic or persistent menorrhagia, etc.) was appended
Table 2 Terms used during the past 100 years to describe increased or heavy menstrual bleeding Menorrhagia: to burst forth each month; excessive uterine bleeding Hypermenorrhea; meno-metrorrhagia: irregular and heavy bleeding Dysfunctional uterine bleeding; functional uterine hemorrhage Excessively heavy menstrual loss; anomalous uterine hemorrhage Ovulatory menorrhagia; anovulatory menorrhagia Functional menorrhagia; essential menorrhagia Idiopathic menorrhagia; primary menorrhagia Uncomplicated menorrhagia; symptomatic menorrhagia Persistent menorrhagia; unexplained menorrhagia Genuine menorrhagia; idiopathic uterine hemorrhage Epimenorrhea: too frequent menstruation Epimenorrhagia: too frequent menstruation with too great a loss Polymenorrhea: frequent menstrual bleeding Polymenorrhagia: frequent and heavy menstrual bleeding Metropathia hemorrhagica: irregular and excessive bleeding associated with endometrial hyperplasia Adapted from [4].

(Table 2). This usage seems to overlap the way in which the term dysfunctional uterine bleeding is often used.

Recommendations on the usage of terminologies

In February 2005, a group of 35 physicians and scientists with a demonstrated interest and expertise in understanding menstrual disorders met in Washington DC, USA, to review current menstrual terminologies, explore their own denitions and usage of these terminologies and develop recommendations that could form the basis of future international agreement on a simple range of terminologies (and denitions) with relevance to doctors, health professionals and patients in different countries and cultures [2,3]. This process, undertaken in Washington, involved extensive preparation with discussion papers, premeeting questionnaires and a Delphi panel process to explore agreement and disagreement [22]. The face-to-face meeting included multiple small-group and plenary meetings, and a comprehensive discussion and rating of views using an electronic keypad voting system. The panellists strongly agreed that the confusion in denitions and usage of many menstrual terminologies was such that they should be abandoned and replaced by a much simpler system. This applied particularly to those terminologies of classical Greek and Latin origin, as they are currently incorporated within the English medical language, such as menorrhagia, metrorrhagia, hypermenorrhea, meno-metrorrhagia, polymenorrhea, and so on. They also agreed that the more modern, but vague and ill-dened term dysfunctional uterine bleeding should also be abandoned. Much discussion took place on possible replacement terms. Participants also strongly agreed that it was important to describe AUB symptoms using a specied simple list of dimensions, and that there should only be three choices of descriptive words for each dimension above and

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594 Reproductive endocrinology Table 3 Suggested normal limits for menstrual parameters in the mid-reproductive years Clinical dimensions of menstruation and menstrual cycle Frequency of menses (days) Regularity of menses (cycle to cycle variation over 12 months; in days) Duration of ow (days) Volume of monthly blood loss (ml) Descriptive terms Frequent Normal Infrequent Absent Regular Irregular Prolonged Normal Shortened Heavy Normal Light Normal limits (5th to 95th percentiles) <24 24 38 >38 Variation 2 to 20 days Variation greater than 20 days >8.0 4.5 8.0 <4.5 >80 5 80 <5

Based primarily on [23 25].

below normal (Table 3). The four key menstrual dimensions should be cycle regularity, frequency of menstruation, duration, and volume of menstrual ow. (1) Regularity should be specied as irregular, regular or absent. (2) Frequency should be specied as frequent, normal or infrequent. (3) Duration should be specied as prolonged, normal or shortened. (4) Volume should be specied as heavy, normal or light. Any additional abnormality should be specied (for example, change in the menstrual pattern, intermenstrual bleeding; premenstrual spotting). The concept of menstrual shape was also discussed, where the patients perception of the pattern of changes in volume from day to day is recorded [26]. It was felt that there are so few data available about this concept that it cannot currently be incorporated into a menstrual assessment scheme, although research on the topic is clearly needed. Two other words of Greek and Latin origin engendered little disagreement within the group based in Washington, and it was felt that their use was relatively well dened and should continue: these were amenorrhea and oligomenorrhea. Suggested replacement terminologies for most of the abandoned terms describing symptoms are summarized in Table 3. This table implies that the main substitute terms for the most common symptoms will be heavy menstrual bleeding, irregular menstrual bleeding, prolonged menstrual bleeding, and combinations of these terms such as irregular heavy menstrual bleeding. The important remaining part of this discussion relates to the use of the word menstrual within each suggested new term. Should this actually be substituted by the word uterine, that is, heavy uterine bleeding, since so many doctors tend to use the word menstrual only when bleeding is regular? This discussion needs to continue, although many doctors are following the recommendation for the word menstrual as rst made in the New Zealand Guidelines for Heavy Menstrual Bleeding [27].

The term dysfunctional uterine bleeding is a little different since physicians in most parts of the world have used this as a diagnosis rather than a symptom [2,3], and full consideration of possible suitable replacement terms will necessitate much international discussion. In reality, dysfunctional uterine bleeding is a term used primarily when there is a lack of current understanding of the underlying disturbances of molecular mechanisms within the endometrium (primary endometrial disorder) or the hypothalamic-pituitary-ovarian axis (primary HPO disorder). Some examples of relevant, but temporary, replacement terms could include idiopathic heavy, regular bleeding, idiopathic heavy irregular bleeding or idiopathic prolonged, irregular bleeding. As ongoing research allows more precise denition of underlying molecular causes, suitable replacement terms will become more accurately descriptive. The use of terms to describe the symptom components of AUB presupposes a clear recognition and agreement on the limits of normality of the menstrual cycle, a surprisingly difcult matter! Issues of perception and tolerance are important in determining patient complaint, and some women have great difculty in determining the normality of their cycles, or even in remembering details of their recent past menstrual history [28]. Hence, normality for research purposes requires prospective daily diary recording of menstrual parameters [29], supplemented by objective measurement of menstrual hemoglobin loss where heavy bleeding is being studied [25]. The group that met in Washington felt that normal limits for the menstrual cycle experience should be based primarily on population studies describing normal data on the basis of the 5th to 95th percentiles [2,3] (Table 3). There are numerous difculties in explaining some of the anomalies that this raises, but it appears to be a sound basis for future studies and future international discussion.

Conclusion
Few clinicians have actually been aware of the extent of worldwide disagreement on use of terms and denitions, such as menorrhagia, metrorrhagia and dysfunctional

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Abnormal uterine bleeding Fraser et al. 595

uterine bleeding. This confusion has prevented much collaborative research on mechanisms and international clinical trials. It is recommended that these terminologies should be abandoned and replaced by simple descriptive terms that cover regularity of the cycle, frequency of menstruation and volume and duration of the menstrual ow, and that AUB should include signicant change in the pattern of any individual womans own cycle. Ideally, these terms should also be understandable by women in the community and be capable of translation into other languages. These recommendations should be the starting point for further international debate and the development of a more extensive living document that includes classications, investigations and consideration of cultural and quality of life issues.

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Heberden W. Menstrua, Commentaries on the History and Cure of Diseases. London: T. Payne; 1802. Neumann S. Dissertatio inauguralis medica de uxu mensium immodico. Jena: Croeker; 1746.

10 Musitanus C. De morbis mulierum tractatus, cui quaestiones duae, altera De semine cum masculeo, tum foemineo, altera de sanguine menstruo, ut pote ad opus apte facientis sunt praexae, quae ad earundem naturam mulierum, anatomen, conceptum, uteri gestationem, fetus animationem, & hominis ortum attinnt, ubertim simul explanatur. Geneva: Chouet; 1709. orie nouvelle du ux menstrual et traite des maladies de la te te. 11 Emett R. The Paris: Chez Vincent; 1757. 12 Manning H. A Treatise on Female Diseases. Of the immoderate ux of the menses. London: Baldwin; 1775. 13 Cullen W. First Lines of the Practice of Physic. Edinburgh: Bell and Bradfute; 1816. 14 Perroneau R. Disputatio medica, inauguralis, de menstruorum prouvio immodico. Edinburgh: Balfour & Smellie; 1775. 15 Churchill F. Menorrhagia. Outlines of the Principal Diseases of Women. Dublin and London: Keene; 1838. 16 McKay WJS. The History of Ancient Gynaecology. London: Bailliere, Tindall & Cox; 1901. 17 Kelly H, Cullen TS. Myomata of the Uterus. Philadelphia: WB Saunders; 1909. re e dans ses rapports 18 Briere de Boisment AJF. De la menstruation, conside re; 1842. physiologique et pathologique. Paris: Baillie 19 Cullen TS. Adenoma of the Uterus. Philadelphia: WB Saunders; 1908. 20 Sampson JA. Perforating hemorrhagic (chocolate) cysts of the ovary. Arch Surg 1921; 3:245 323. 21 Graves WP. Some observations on etiology of dysfunctional uterine bleeding. Am J Obstet Gynecol 1930; 20:500 518. 22 Brook RH, Chassin MR, Fink A, et al. A method for the detailed assessment of the appropriateness of medical technologies. Int J Technol Assess Healthcare 1986; 2:53 63. 23 Treloar AE, Boynton RE, Behn BG, Brown BW. Variation of the human menstrual cycle through reproductive life. Int J Fertil 1967; 12:77 126. 24 Belsey EM, Pinol AP. World Health Organization Task Force on Long-Acting Systemic Agents for Fertility Regulation. Menstrual bleeding patterns in untreated women. Contraception 1997; 55:57 65. 25 Hallberg L, Hogdahl A-M, Nilsson L, Rybo G. Menstrual blood loss: a population study. Acta Obstet Gynecol Scand 1966; 45:320 351. 26 Snowden R, Christian B, editors. Patterns and Perceptions of Menstruation. A World Health Organization International Collaborative Study. London: Croom Helm; 1983. 27 New Zealand Working Party for Guidelines for the Management of Heavy Menstrual Bleeding. An evidence-based guideline for the management of heavy menstrual bleeding. NZ Med J 1999; 112:174 177. 28 Fraser IS, McCarron G, Markham R. A preliminary study of factors inuencing perception of menstrual blood loss volume. Am J Obstet Gynecol 1984; 149:788 793. 29 Rodriguez G, Faundes-Latham A, Atkinson LE. An approach to the analysis of menstrual patterns in the critical evaluation of contraceptives. Stud Fam Plann 1976; 7:42 51.

References and recommended reading

Papers of particular interest, published within the annual period of review, have been highlighted as:  of special interest  of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 000 000). 1 Fraser IS, Inceboz US. Dening disturbances of the menstrual cycle. In: OBrien PMS, Cameron I, MacLean AB, editors. Disorders of the Menstrual Cycle, 1st ed. London: RCOG Press; 2000. pp. 141 152.

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Fraser IS, Critchley HOD, Munro MG, Broder MG. Can we achieve international agreement on terminologies and denitions used to describe abnormalities of menstrual bleeding? Hum Reprod 2007; 22:635 643; Simultaneous publication in Fertility and Sterility. These two papers [2,3] report on a major international attempt to nd a process leading to international agreement on the terminologies and denitions to be used to describe symptoms and causes of abnormal uterine bleeding.

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Fraser IS, Critchley HOD, Munro MG, Broder M. A process designed to lead to international agreement on terminologies and denitions to describe abnormalities of menstrual bleeding. Fertil Steril 2007; 87:466 476; Simultaneous publication in Human Reproduction. These two papers [2,3] report on a major international attempt to nd a process leading to international agreement on the terminologies and denitions to be used to describe symptoms and causes of abnormal uterine bleeding. 4 Woolcock J, Critchley HOD, Munro MG, Fraser IS. A comprehensive review of the worldwide confusion on menstrual terminologies, denitions and classications. Fertil Steril (in press). Aristotles Masterpieces. Of the overowing of the menses. Directions for Midwives, Counsel and Advice for Childbearing Women. London: Booksellers; translated and revised 1817. Gruner OC. A Treatise on the Canon of Medicine of Avicenna. London: Luzac; 1930. Sydenham T. Medical observations concerning the history and the cure of acute diseases. The Works of Thomas Sydenham, 1666. London: The Sydenham Society; 1868.

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