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For further information, see CMDT Part 18-01: Premenopausal Abnormal Uterine Bleeding

Key Features

Essentials of Diagnosis

  • Accurate diagnosis of abnormal uterine bleeding depends on appropriate categorization and diagnostic tests

  • Pregnancy should always be ruled out as a cause of abnormal uterine bleeding in women of reproductive age

  • The evaluation of abnormal bleeding depends on the age and risk factors of the patient

General Considerations

  • Normal menstrual bleeding

    • Lasts an average of 5 days (range, 2–7 days)

    • Mean blood loss of 40 mL

  • Abnormal uterine bleeding (AUB) refers to menstrual bleeding of abnormal quantity, duration, or schedule

  • A classification system for causes of abnormal uterine bleeding uses the acronym PALM-COEIN

    • Polyp

    • Adenomyosis

    • Leiomyoma

    • Malignancy

    • Coagulopathy-Hyperplasia

    • Ovulatory dysfunction

    • Endometrial

    • Iatrogenic

    • Not yet classified

  • Abnormal uterine bleeding in women aged 19–39 years is often a result of

    • Pregnancy

    • Structural lesions

    • Anovulatory cycles

    • Use of hormonal contraception

    • Endometrial hyperplasia

Clinical Findings

Symptoms and Signs

  • The diagnosis depends on the following:

    • Confirming uterine source of the bleeding

    • Excluding pregnancy and confirming patient is premenopausal

    • Determining if the bleeding pattern suggests regular ovulatory bleeding or anovulatory bleeding

    • Determining contribution of structural abnormalities (PALM), including risk for malignancy/hyperplasia

    • Determining risk of medical conditions that may impact bleeding (eg, inherited bleeding disorders, endocrine disease, risk for infection)

    • Assessing contribution of current medications, including contraceptives or natural product supplements or combinations that may affect bleeding

Differential Diagnosis

  • Ovulation bleeding (spotting episode between menses)

  • Anovulatory cycle (dysfunctional uterine bleeding)

  • Polycystic ovary syndrome (type of anovulatory cycle)

  • Pregnancy

  • Ectopic pregnancy

  • Spontaneous abortion

  • Uterine leiomyomas (fibroids)

  • Endometrial polyp

  • Cervicitis or pelvic inflammatory disease

  • Adenomyosis (uterine endometriosis)

  • Cervical cancer

  • Cervical polyp

  • Endometrial hyperplasia

  • Endometrial cancer

  • Hypothyroidism

  • Hyperprolactinemia

  • Diabetes mellitus

  • Bleeding disorder, eg, von Willebrand disease


Laboratory Tests

  • Complete blood count

  • Pregnancy test

  • Thyroid function tests

  • Vaginal or urine samples should be obtained for polymerase chain reaction or culture to rule out infectious causes

  • If indicated, cervical cytology should also be obtained

  • For adolescents with heavy menstrual bleeding and adults with a positive screening history, coagulation studies (eg, prothrombin time, activated partial thromboplastin time, platelet count) should be considered

Imaging Studies

  • Transvaginal ultrasound is useful to assess for presence of fibroids, suspicion of adenomyosis, and to evaluate endometrial thickness

  • Sonohysterography or hysteroscopy may be used to diagnose endometrial polyps or subserous myomas

  • MRI

    • Not primary imaging method for abnormal uterine bleeding

    • However, can definitively diagnose submucous myomas and adenomyosis

Diagnostic Procedures

  • See Table 18–1 for sampling methods and other gynecologic diagnostic procedures

  • Endometrial sampling is used to determine whether hyperplasia or carcinoma is present

  • Endometrial sampling should be performed ...

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