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 difficulties currently caused by the
ill-defined 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 findings
Confused terminology has led to difficulties 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 specifically cover cycle regularity,
frequency, duration and heaviness of bleeding episodes,
and to acknowledge a significant 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 scientific
studies of mechanisms and treatment responses, and will
contribute to the process of education at all levels.
Keywords
abnormal uterine bleeding, definitions, dysfunctional
uterine bleeding, menorrhagia, metrorrhagia, terminology
Curr Opin Obstet Gynecol 19:591595.
2007 Wolters Kluwer Health | Lippincott Williams & Wilkins.
a
Department of Obstetrics and Gynaecology, University of Sydney, Australia and
b
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
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
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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 confirmed the major
degree to which there is variation in the usually undefined
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 import-
ance that one recent report of an agreement process on
terminologies and definitions 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 difficult to recon-
cile 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 ute-
rine 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 var-
iously as excessive evacuations of the menses, inordinate
flowing, the immoderate flux, an overflowing of the
courses, menstruation is too profuse, excessive floodings,
uterine haemorrhage, and so on [58]. Many of these
publications were originally in Latin or Greek, but the
591
 592 Reproductive endocrinology
translations in the 1800s generally faithfully reflect the
sense of the original wording: for example, fluxu mensium
immodico; copiosus menses [9,10]. It seems clear that these
physicians were mainly dealing with truly excessive bleed-
ing; this is what we might nowadays term acute and severe
bleeding. This sense of an acute event was also reflected in
publications in other languages at that time, such as the
French le ruption des re`gles [11].
The early writers clearly recognized the variability of
abnormal uterine bleeding with statements such as the
flux 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 first 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 definitio 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 flow of the menses is con-
sidered 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 menor-
rhagia 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 confined 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 [1517]. The sense in which the word is used im-
plies that the reader is expected to understand that it refers
to the symptom of heavy menstrual bleeding, although it
is not usually defined 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
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[13]. Again, its meaning is not usually well defined,
although it is taken to indicate some considerable irregu-
larity 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 nine-
teenth century and early twentieth century that sound
information began to appear on the importance of benign
gynecologic tumors like uterine fibroids and adenomyosis
[17,19], endometriosis [20] and infections, and malignant
tumors like cervical and endometrial cancer.
The introduction of the confusing modern term dysfunc-
tional uterine bleeding did not occur until 1930 [21], when
it first 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 disturb-
ances 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 bleed-
ing, but there the agreement ends. This is a term that is
frequently not defined 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: first, whether the term menorrhagia was defined
(even broadly) or not; second, was it primarily used as a

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) Defined
1(b) Undefined
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 reflecting patient complaint
3(b) Primarily reflecting the doctors definition
4(a) Used as a diagnosis
4(b) Used as a diagnosis when combined with another term (e.g. idiopathic)
Adapted from [4].
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 some-
times 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 some-
times changed at different points in the publication. Usage
of the term was sometimes so unclear that value judge-
ments 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].
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Abnormal uterine bleeding Fraser et al. 593
Usage
56
44
n 100
34
28
16
n 78
59
19
n 78
5
17
n 22
(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 understand-
ing menstrual disorders met in Washington DC, USA, to
review current menstrual terminologies, explore their own
definitions and usage of these terminologies and develop
recommendations that could form the basis of future
international agreement on a simple range of terminologies
(and definitions) with relevance to doctors, health
professionals and patients in different countries and cul-
tures [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
definitions 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, metro-
rrhagia, hypermenorrhea, meno-metrorrhagia, poly-
menorrhea, and so on. They also agreed that the more
modern, but vague and ill-defined term dysfunc-
tional 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 specified simple list of
dimensions, and that there should only be three choices of
descriptive words for each dimension above and
 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 flow (days)
Volume of monthly blood loss (ml)
Based primarily on [2325].
below normal (Table 3). The four key menstrual
dimensions should be cycle regularity, frequency of
menstruation, duration, and volume of menstrual flow.
(1) Regularity should be specified as irregular, regular
or absent.
(2) Frequency should be specified as frequent, normal
or infrequent.
(3) Duration should be specified as prolonged, normal
or shortened.
(4) Volume should be specified as heavy, normal or light.
Any additional abnormality should be specified (for
example, change in the menstrual pattern, intermen-
strual 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 cur-
rently 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 dis-
agreement within the group based in Washington, and it
was felt that their use was relatively well defined 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, pro-
longed 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 bleed-
ing is regular? This discussion needs to continue, although
many doctors are following the recommendation for
the word menstrual as first made in the New Zealand
Guidelines for Heavy Menstrual Bleeding [27].
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Descriptive terms Normal limits (5th to 95th percentiles)
Frequent <24
Normal 2438
Infrequent >38
Absent
Regular Variation  2 to 20 days
Irregular Variation greater than 20 days
Prolonged >8.0
Normal 4.58.0
Shortened <4.5
Heavy >80
Normal 580
Light <5
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 definition 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 surpris-
ingly difficult matter! Issues of perception and tolerance
are important in determining patient complaint, and
some women have great difficulty 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], supple-
mented by objective measurement of menstrual hemo-
globin 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 difficulties 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 definitions,
such as menorrhagia, metrorrhagia and dysfunctional

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
flow, and that AUB should include significant 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 classifications, investigations and con-
sideration of cultural and quality of life issues.
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. 000000).
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2 Fraser IS, Critchley HOD, Munro MG, Broder MG. Can we achieve international


agreement on terminologies and definitions used to describe abnormalities of
menstrual bleeding? Hum Reprod 2007; 22:635643; Simultaneous publica-
tion in Fertility and Sterility.
These two papers [2

,3

] report on a major international attempt to find a process
leading to international agreement on the terminologies and definitions to be used
to describe symptoms and causes of abnormal uterine bleeding.
3 Fraser IS, Critchley HOD, Munro MG, Broder M. A process designed to lead


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abnormalities of menstrual bleeding. Fertil Steril 2007; 87:466476; Simul-
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These two papers [2

,3

] report on a major international attempt to find a process
leading to international agreement on the terminologies and definitions to be used
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