Dysfunctional Uterine Bleeding in Emergency Medicine Workup
- Author: Amir Estephan, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD more...
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 emergency department.
Women with persistent bleeding with a previous benign pathology (eg, proliferative endometrium) require further testing to rule out nonfocal endometrial pathology or a structural pathology (eg,polyp, leiomyoma).
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. 
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. 
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sac. However, sonohysterography may be superior to transvaginal ultrasonography for detecting intracavitary lesions (eg, polyps, submucosal leiomyomas). The American College of Obstetricians and Gynecologists (ACOG) notes that "some experts recommend transvaginal ultrasonography as the initial screening test for abnormal uterine bleeding and magnetic resonance imaging (MRI) as a second-line test to be used when the diagnosis is inconclusive, when further delineation would affect patient management, or when coexisting uterine myomas are suspected."
Computed tomography scanning and MRI
Computed tomography scanning is used primarily for evaluation of other causes of acute abdominal or pelvic pain. MRI is used primarily for cancer staging.
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 :
Women older than 35 years
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.
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. 2009 Jan-Feb. 19(1):70-8. [Medline].
Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG. Abnormal uterine bleeding. Williams Gynecology. New York: McGraw-Hill; 2008. 219-45.
Tibbles CD. Selected gynecologic disorders. Marx JA, Hockberger RS, Walls RM, Adams JG. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. Mosby (Elsevier); 2009. Vol 1: Chap 98.
Pitkin J. Dysfunctional uterine bleeding. BMJ. 2007 May 26. 334(7603):1110-1. [Medline].
Tower AM, Frishman GN. Cesarean scar defects: an underrecognized cause of abnormal uterine bleeding and other gynecologic complications. J Minim Invasive Gynecol. 2013 Sep-Oct. 20 (5):562-72. [Medline].
van der Voet LF, Bij de Vaate AM, Veersema S, Brolmann HA, Huirne JA. Long-term complications of caesarean section. The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding. BJOG. 2014 Jan. 121 (2):236-44. [Medline].
Deligeoroglou E, Karountzos V, Creatsas G. Abnormal uterine bleeding and dysfunctional uterine bleeding in pediatric and adolescent gynecology. Gynecol Endocrinol. 2012 Sep 5. [Medline].
Davidson BR, Dipiero CM, Govoni KD, Littleton SS, Neal JL. Abnormal uterine bleeding during the reproductive years. J Midwifery Womens Health. 2012 May-Jun. 57(3):248-54. [Medline].
[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. 2009 Jul. 201(1):12.e1-8. [Medline].
Committee on Practice Bulletins—Gynecology. Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012 Jul. 120 (1):197-206. [Medline].
Casablanca Y. Management of dysfunctional uterine bleeding. Obstet Gynecol Clin North Am. 2008 Jun. 35(2):219-34, viii. [Medline].
Hickey M, Higham J, Fraser IS. Progestogens versus oestrogens and progestogens for irregular uterine bleeding associated with anovulation. Cochrane Database Syst Rev. 2007 Oct 17. CD001895. [Medline].
[Guideline] American College of Obstetricians and Gynecologists. Management of abnormal uterine bleeding associated with ovulatory dysfunction. National Guideline Clearinghouse. Available at http://guideline.gov/content.aspx?id=47451. Accessed: Oct 31 2014.
[Guideline] Roach L. Uterine Bleeding: ACOG Updates Guidelines. Medscape Medical News. June 21 2013. [Full Text].
Ammerman SR, Nelson AL. A new progestogen-only medical therapy for outpatient management of acute, abnormal uterine bleeding: a pilot study. Am J Obstet Gynecol. 2013 Jun. 208(6):499.e1-5. [Medline].
Laberge P, Leyland N, Murji A, et al, for the Society of Obstetricians and Gynaecologists of Canada. Endometrial ablation in the management of abnormal uterine bleeding. J Obstet Gynaecol Can. 2015 Apr. 37 (4):362-79. [Medline].
Smithling KR, Savella G, Raker CA, Matteson KA. Preoperative uterine bleeding pattern and risk of endometrial ablation failure. Am J Obstet Gynecol. 2014 Nov. 211 (5):556.e1-6. [Medline].
Dickersin K, Munro MG, Clark M, et al. Hysterectomy compared with endometrial ablation for dysfunctional uterine bleeding: a randomized controlled trial. Obstet Gynecol. 2007 Dec. 110(6):1279-89. [Medline].