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Dysfunctional Uterine Bleeding in Emergency Medicine Workup

  • Author: Amir Estephan, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: Nov 08, 2015
 

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 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).[10]

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Imaging Studies

Ultrasonography

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. [11]
  • 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. However, sonohysterography may be superior to transvaginal ultrasonography for detecting intracavitary lesions (eg, polyps, submucosal leiomyomas).[10] 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."[10]

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.

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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[11] :

  • 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, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

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

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

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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

Mark Zwanger, MD, MBA is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

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, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Nedra R Dodds, MD, to the development and writing of this article.

References
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  2. Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG. Abnormal uterine bleeding. Williams Gynecology. New York: McGraw-Hill; 2008. 219-45.

  3. 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.

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  9. [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].

  10. 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].

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

  12. 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].

  13. [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.

  14. [Guideline] Roach L. Uterine Bleeding: ACOG Updates Guidelines. Medscape Medical News. June 21 2013. [Full Text].

  15. 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].

  16. 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].

  17. 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].

  18. 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].

 
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