Dysfunctional Uterine Bleeding Workup

  • Author: Amir Estephan, MD; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: Feb 1, 2010
 

Laboratory Studies

  • When evaluating a woman of reproductive age with vaginal bleeding, pregnancy must always be ruled out by urine or serum human chorionic gonadotropin.
  • In a patient with any hemodynamic instability, excessive bleeding, or clinical evidence of anemia, a complete blood count is essential.
  • Coagulation studies should be considered when indicated by the history or physical examination findings and in patients with underlying liver disease or other coagulopathies.
  • In patients with suspected endocrine disorders, other laboratory studies such as thyroid function tests and prolactin levels may be helpful, although these results may not be available from the ED.
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Imaging Studies

  • Pelvic ultrasonography is an important imaging modality for nonpregnant patients with abnormal vaginal bleeding. It may determine the etiology of the bleeding such as a fibroid uterus, endometrial thickening, or a focal mass.
    • Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy.
      • An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer, and biopsy is often considered unnecessary before treatment.
      • Women with a normal endometrial stripe (5–12 mm) may require biopsy, particularly if they have risk factors for endometrial cancer.
      • When the endometrial stripe is larger than 12 mm, a biopsy should be performed.[6]
    • Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up, ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients, ultrasonographic findings do not immediately affect ED decision-making.[3]
  • Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sac.
  • Computed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic pain.
  • Magnetic resonance imaging is used primarily for cancer staging.
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Procedures

  • Before instituting therapy, many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancy.
  • Endometrial biopsy is indicated for the following patients with abnormal uterine bleeding[6] :
    • Women older than 35 years
    • Obese patients
    • Women who have prolonged periods of unopposed estrogen stimulation
    • Women with chronic anovulation
  • Hysteroscopy is the definitive way to detect intrauterine lesions. It offers a more complete examination of the surface of the endometrium. However, it is usually reserved for treating lesions that were detected by other less invasive means.
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Contributor Information and Disclosures
Author

Amir Estephan, MD  Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, Brooklyn

Amir Estephan, MD, is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO  Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Steven A Conrad, MD, PhD  Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center

Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Mark Zwanger, MD, MBA  Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Pfizer Salary Employment

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. Frick KD, Clark MA, Steinwachs DM, et al. Financial and quality-of-life burden of dysfunctional uterine bleeding among women agreeing to obtain surgical treatment. Womens Health Issues. Jan-Feb 2009;19(1):70-8. [Medline].

  2. Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG. Abnormal uterine bleeding. In: Williams Gynecology. McGraw-Hill; 2008:Chap 8.

  3. Tibbles CD. Selected gynecologic disorders. In: Marx JA, Hockberger RS, Walls RM, Adams JG. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 1. 7th ed. Mosby (Elsevier); 2009:Chap 98.

  4. Pitkin J. Dysfunctional uterine bleeding. BMJ. May 26 2007;334(7603):1110-1. [Medline].

  5. [Guideline] James AH, Kouides PA, Abdul-Kadir R, et al. Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel. Am J Obstet Gynecol. Jul 2009;201(1):12.e1-8. [Medline].

  6. Casablanca Y. Management of dysfunctional uterine bleeding. Obstet Gynecol Clin North Am. Jun 2008;35(2):219-34, viii. [Medline].

  7. [Best Evidence] Hickey M, Higham J, Fraser IS. Progestogens versus oestrogens and progestogens for irregular uterine bleeding associated with anovulation. Cochrane Database Syst Rev. Oct 17 2007;CD001895. [Medline].

  8. Dickersin K, Munro MG, Clark M, et al. Hysterectomy compared with endometrial ablation for dysfunctional uterine bleeding: a randomized controlled trial. Obstet Gynecol. Dec 2007;110(6):1279-89. [Medline].

 
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