Abnormal (Dysfunctional) Uterine Bleeding in Emergency Medicine Workup

Updated: Dec 07, 2018
  • Author: Amir Estephan, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Workup

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). [11]

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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. [12]

  • 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). [11] 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." [11]

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 [12] :

  • 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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