Uterine Bleeding, Abnormal Premenopausal

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

Diagnosis

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 ...