Sections

Abnormal (Dysfunctional) Uterine Bleeding

Sections Abnormal (Dysfunctional) Uterine Bleeding
Overview
Presentation
DDx
Workup
Treatment
Medication
Questions & Answers
Tables
References

Workup

Laboratory Studies

Laboratory studies for patients with abnormal uterine bleeding (AUB) may include human chorionic gonadotropin (HCG), complete blood count (CBC), Pap smear, endometrial sampling, thyroid functions and prolactin, liver functions, coagulation studies/factors, and other hormone assays as indicated.^[43]

Human chorionic gonadotropin

The most common cause of abnormal uterine bleeding during the reproductive years is abnormal pregnancy. Rule out threatened abortion, incomplete abortion, and ectopic pregnancy.

Complete blood count

Document blood loss. Charting the number of menstrual pads used per day, or keeping a menstrual calendar is helpful.

Obtain a baseline CBC count for hemoglobin and hematocrit to evaluate for anemia. Obtain a differential with platelet count if hematologic disease is suspected.

Pap smear

Pap smear should be up to date. Cervical cancer still is the most common gynecologic cancer affecting women of reproductive age in the world population.

Endometrial sampling

Perform a biopsy to rule out endometrial hyperplasia or cancer in high-risk women aged ≥45 years and in younger women at extreme risk for endometrial hyperplasia/carcinoma due to unopposed estrogen (PCOS, obesity), failed medical management, and persistent AUB. Women with chronic eugonadal anovulation, obesity, hirsutism, diabetes, or chronic hypertension are at particular risk.

Most biopsies will confirm the absence of secretory endometrium.

Thyroid and liver function tests

Perform thyroid function tests and prolactin because hyperthyroidism, hypothyroidism, and hyperprolactinemia are associated with ovulatory dysfunction. Identify and treat these conditions.

Obtain liver function tests if alcoholism or hepatitis is suspected. Any condition affecting liver metabolism of estrogen can be associated with abnormal uterine bleeding.

Coagulation factors

Von Willebrand disease and factor XI deficiency initially might manifest during adolescence.

Primary or secondary thrombocytopenia can be factors in the mature patient.

Tailor the choice of laboratory tests to the presenting clinical situation. Generally speaking, when coagulopathies are present, heavy bleeding is regular and associated with ovulation.

Other hormone assays

For the patient with recurrent anovulatory bleeding, the mainstay of management is treatment of correctable disease.

Obtain a hormonal complete evaluation in women with signs of hyperandrogenism, such as those with polycystic ovarian syndrome, 21 hydroxylase deficiency, or ovarian or adrenal tumors, as dictated by their respective conditions.

Women in menopausal transition usually can be followed without an extensive hormonal evaluation.

Imaging Studies

Generally, patients with abnormal uterine bleeding can be managed appropriately without the use of expensive imaging studies.

Ultrasonography, especially saline infusion sonography, can be used to examine the status of the endometrium, myometrium, and ovaries. Endometrial hyperplasia, endometrial carcinoma, endometrial polyps, uterine fibroids, and ovarian cysts/masses can be suspected or diagnosed with this technology.

Procedures

Rule out endometrial carcinoma in all patients at high risk for the condition, including patients with the following characteristics:

Morbid obesity
Diabetes or chronic hypertension
Age >45 years
Longstanding, chronic eugonadal anovulation

Traditionally, carcinoma was ruled out by endometrial sampling via dilation and curettage (D&C). More recently, endometrial sampling in the office via aspiration, curetting, or hysteroscopy has become popular and is also relatively accurate.

Saline infusion sonography can be helpful in distinguishing individuals who have bleeding with thick endometrium from those with thin, denuded endometrium, endometrial polyps, uterine fibroids, or other uterine pathology.

Most endometrial biopsy specimens will show proliferative or dyssynchronous endometrium.

Treatment & Management

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Table. Physical Findings in AUB

Table. Physical Findings in AUB

Examination	Finding	Differential
Vital signs	Tachycardia	Anemia Hypovolemia
Weight	Obesity	PCOS, weight-related anovulation
Eyes	Exophthalmos Periorbital edema	Graves disease Hypothyroidism
Neck	Thyromegaly	Hypothyroidism
Breasts	Galactorrhea	Hyperprolactinemia
Skin	Increased skin tags Acanthosis nigricans Hirsutism Ecchymosis, purpura	PCOS Insulin resistance PCOS, CAH, Cushing syndrome, androgen-secreting tumor Bleeding disorder
Pelvic examination	Cervical polyp/cervicitis/cervical ectropion Globally enlarged uterus Irregular uterus Adnexal mass	Adenomyosis Fibroids Ovarian cyst or mass
AUB = abnormal uterine bleeding; CAH = congenital adrenal hyperplasia; PCOS = polycystic ovary syndrome.

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Author

Thomas Michael Price, MD Associate Professor, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Director of Reproductive Endocrinology and Infertility Fellowship Program, Duke University Medical Center

Thomas Michael Price, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, Phi Beta Kappa, Society for Reproductive Investigation, Society for Reproductive Endocrinology and Infertility, American Society for Reproductive Medicine

Disclosure: Received research grant from: Insigtec Inc<br/>Received consulting fee from Clinical Advisors Group for consulting; Received consulting fee from MEDA Corp Consulting for consulting; Received consulting fee from Gerson Lehrman Group Advisor for consulting; Received honoraria from ABOG for board membership.

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.

Frances E Casey, MD, MPH Associate Professor, Director of Family Planning Services, Department of Obstetrics and Gynecology, VCU Medical Center

Frances E Casey, MD, MPH is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Reproductive Health Professionals, National Abortion Federation, Physicians for Reproductive Health, Society of Family Planning

Disclosure: Nothing to disclose.

Chief Editor

Richard Scott Lucidi, MD, FACOG Associate Professor of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine

Richard Scott Lucidi, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Anthony Charles Sciscione, DO Professor, Department of Obstetrics and Gynecology, Drexel University College of Medicine; Director, Maternal and Fetal Medicine, Christiana Care Health System; Director, Delaware Center for Maternal and Fetal Medicine

Anthony Charles Sciscione, DO is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association

Disclosure: Nothing to disclose.

Millie A Behera, MD Assistant Professor (Adjunct), Division of Reproductive Endocrinology and Fertility, Department of Obstetrics and Gynecology, Duke University Medical Center; Medical Director, Bloom Reproductive Institute

Millie A Behera, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, AAGL

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author John T Queenan, Jr, MD, to the development and writing of this article.