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ABNORMAL UTERINE BLEEDING
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–Classify bleeding using the PALM (structural) and COEIN (nonstructural) acronyms:
–History: age of menarche, bleeding patterns, severity of bleeding, pain, medical/surgical history, medications, signs and symptoms of bleeding disorder, impact on quality of life.
–Physical: pelvic exam including external, bimanual, and speculum exam including Pap if needed.
–Labs: pregnancy test, CBC, TSH, chlamydia, and perhaps a coagulation panel and/or von Willebrand testing.
–Order transvaginal ultrasound (TVU) if there is an abnormal physical examination or if symptoms persist despite treatment.
–Perform endometrial biopsy in all patients older than 45 y and patients younger than 45 y with history of unopposed estrogen exposure (including obesity, PCOS), failed medical management, and persistent bleeding. Do not obtain ultrasound measurement of endometrial thickness to rule out malignancy.
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–Offer levonorgestrel IUD as first-line therapy for women with no identified pathology, fibroids < 3 cm, or suspected adenomyosis. (NICE)
–If levonorgestrel is not used, consider trial of therapies in patients without risk of endometrial hyperplasia, neoplasia, or structural abnormalities (ie, adolescents). Therapy options include NSAIDs, progestins, combination oral contraceptives, or tranexamic acid.
–Structural anatomical causes such as fibroids > 3 cm or polyps may require procedural intervention such as endometrial ablation, myomectomy, uterine artery embolization, or hysterectomy.
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► USPSTF 2024, ACS 2016, NCCN 2019, ACP 2019, ACOG 2017, WHO 2014, ACR 2023
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