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5MinuteClinicalConsultPremium2018,The
26th_Edition
LippincottWilliams&Wilkins,
2017
Abnormal(Dysfunctional)Uterine
Bleeding
StephenD.CagleMD
MatthewJ.Snyder,DO
BASICS
DESCRIPTION
Abnormaluterinebleeding(AUB)isirregularmenstrualbleeding(usuallyheavy,prolonged,orfrequent)itisadiagnosisof
exclusionafterestablishmentofnormalanatomyandtheabsenceofothermedicalillnesses.
TheInternationalFederationofGynecologyandObstetrics(FIGO)revisedtheterminologysystemandnowusesAUBratherthan
dysfunctionaluterinebleeding(DUB).
Commonlyassociatedwithanovulation
EPIDEMIOLOGY
Adolescentandperimenopausalwomenareaffectedmostoften.
Incidence
5%ofreproductiveagewomenwillseeadoctorinanygivenyearforAUB.
Prevalence
http://ovidmd.ovid.com.am.enformation.ro/Chapter?ovidid=ovid:/fts/bookdb/02008467/26th_Edition/2/OVIDBOOK[1]/TXTBKBD[1]/CHAPTER[2]&q=mullerian+duct 1/12
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1030%ofreproductiveagewomenhaveAUB.
ETIOLOGYANDPATHOPHYSIOLOGY
Anovulationaccountsfor90%ofAUB.
Lossofcyclicendometrialstimulation
Elevatedestrogenlevelsstimulateendometrialgrowth.
Noorganizedprogesteronewithdrawalbleeding
Endometriumeventuallyoutgrowsbloodsupply,breaksdown,andsloughsfromuterus.
610%willhavepolycysticovariansyndrome(PCOS).
AdolescentAUBisusuallyduetoanimmaturehypothalamicpituitaryovarian(HPO)axisthatleadstoanovulatorycycles.
ThemnemonicPALMCOEINwasdevelopedasthenewnomenclaturetodescribeAUBinreproductiveagedwomen.
PALMdescribesstructuralcausesofabnormaluterinebleeding,andCOEINdescribesnonstructuralcausesofAUB.
PALM:polyp,adenomyosis,leiomyoma,andmalignancyand/orhyperplasia
COEIN:coagulopathy,ovulatorydisorders,endometrial,iatrogenic,andnotyetclassified.
Reproductivepathologyandstructuraldisorders
Uterus:leiomyomas,endometritis,hyperplasia,polyps,trauma
Adnexa:salpingitis,functionalovariancysts
Cervix:cervicitis,polyps,STIs,trauma
Vagina:trauma,foreignbody
Vulva:lichensclerosus,STIs
Malignancyofthevagina,cervix,uterus,andovaries
Systemicdiseases
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Hematologicdisorders(e.g.,vonWillebranddisease,thrombocytopenia)
Diseasescausinganovulation
Hyperthyroidism/hypothyroidism
Adrenaldisorders
Pituitarydisease(prolactinoma)
PCOS
Eatingdisorders
Medications(iatrogeniccauses)
Anticoagulants
Steroids
Tamoxifen
Hormonalmedications:intrauterinedevices(IUDs)
Selectiveserotoninreuptakeinhibitors(SSRIs)
Antipsychoticmedications
OthercausesofAUBnotdefinedinPALMCOEIN
Pregnancy:ectopicpregnancy,threatenedorincompleteabortion,orhydatidiformmole
Advancedorfulminantliverdisease
Chronicrenaldisease
Inflammatoryboweldisease
Excessiveweightgain
Increasedexercise
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Genetics
Unclearbutcanincludeinheriteddisordersofhemostasis
RISKFACTORS
Riskfactorsforendometrialcancer(whichcancauseAUB)
Age>40years
Obesity
PCOS
Diabetesmellitus
Nulliparity
Earlymenarcheorlatemenopause(>55yearsofage)
Hypertension
Chronicanovulationorinfertility
Unopposedestrogentherapy
Historyofbreastcancerorendometrialhyperplasia
Tamoxifenuse
Familyhistory:gynecologic,breast,orcoloncancer
DIAGNOSIS
HISTORY
Menstrualhistory
Onset,severity(quantifiedbypad/tamponuse,presenceandsizeofclots),timingofbleeding(unpredictableorepisodic)
http://ovidmd.ovid.com.am.enformation.ro/Chapter?ovidid=ovid:/fts/bookdb/02008467/26th_Edition/2/OVIDBOOK[1]/TXTBKBD[1]/CHAPTER[2]&q=mullerian+duct 4/12
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Menorrhagiawithonsetofmenarcheissuggestiveofacoagulationdisorder.
Menopausalstatus
Associationwithotherfactors(e.g.,coitus,contraception,weightloss/gain)
Gynecologichistory:gravidityandparity,STIhistory,previousPapsmearresults
Reviewofsystems(excludesymptomsofpregnancyandofbleedingdisorders,bleedingfromotherorifices,stress,exercise,recent
weightchange,visualchanges,headaches,galactorrhea)
Medicationhistory:Evaluateforuseofaspirin,anticoagulants,hormones,andherbalsupplements(1,2).
ALERT
Postmenopausalbleedingisanybleedingthatoccurs>1yearafterthelastmenstrualperiodcancermustalwaysberuledout(2)[C].
PHYSICALEXAM
DiscoveranatomicororganiccausesofAUB.
Evaluatefor
Bodymassindex(obesity)
Pallor,vitalsigns(anemia)
Visualfielddefects(pituitarylesion)
Hirsutismoracne(hyperandrogenism)
Goiter(thyroiddysfunction)
Galactorrhea(hyperprolactinemia)
Purpura,ecchymosis(bleedingdisorders)
Pelvicexam
EvaluateforuterineirregularitiesandTannerstage.
http://ovidmd.ovid.com.am.enformation.ro/Chapter?ovidid=ovid:/fts/bookdb/02008467/26th_Edition/2/OVIDBOOK[1]/TXTBKBD[1]/CHAPTER[2]&q=mullerian+duct 5/12
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Checkforforeignbodies.
Ruleoutrectalorurinarytractbleeding.
IncludePapsmearandtestsforSTIs(2)[C].
PediatricConsiderations
Premenarchalchildrenwithvaginalbleedingshouldbeevaluatedforforeignbodies,physical/sexualabuse,possibleinfections,and
signsofprecociouspuberty.
DIFFERENTIALDIAGNOSIS
SeeEtiology.
DIAGNOSTICTESTS&INTERPRETATION
InitialTests(lab,imaging)
Everyone:urinehumanchorionicgonadotropin(hCGruleoutpregnancyand/orhydatidiformmole)andcompletebloodcount
(CBC)(1)
Foracutebleeding,atypeandcrossshouldbeobtained(3)[C].
Ifdisorderofhemostasisissuspected,apartialthromboplastintime(PTT),prothrombintime(PT),activatedpartial
thromboplastintime(aPTT),andfibrinogenlevelisappropriate(3)[C].
Ifanovulationissuspected:thyroidstimulatinghormone(TSH)level,prolactinlevel(1)
Considerothertestsbasedondifferentialdiagnosis.
Folliclestimulatinghormone(FSH)leveltoevaluateforhypoorhypergonadotropism
Coagulationstudiesandfactorsifcoagulopathyissuspected(1)
17Hydroxyprogestroneifcongenitaladrenalhyperplasiaissuspected
Testosteroneand/ordehydroepiandrosteronesulfate(DHEAS)ifPCOS
ScreeningforSTI
http://ovidmd.ovid.com.am.enformation.ro/Chapter?ovidid=ovid:/fts/bookdb/02008467/26th_Edition/2/OVIDBOOK[1]/TXTBKBD[1]/CHAPTER[2]&q=mullerian+duct 6/12
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Endometrialbiopsy(EMB)shouldbeperformedaspartoftheinitialevaluationforpostmenopausaluterinebleedingandin
premenopausalwomenwithriskfactorsforendometrialcarcinoma.Medicalmanagementcanbeinitiatedinpremenopausal
womenwithnormalTVUSandlowriskformalignancy(1)[A].
TVUS,sonohysterography,andhysteroscopymaybesimilarlyeffectiveindetectionofintrauterinepathologyinpremenopausal
womenwithAUB(1)[A].
Ifnormalfindingsfollowingimaginginpatientswithoutknownriskfactorsforendometrialcarcinoma,abiopsyshouldbe
performedifnotdonesopreviously(2)[C].
DiagnosticProcedures/Other
Papsmeartoscreenforcervicalcancerifage>21years(2)[C]
EMBshouldbeperformedin
Womenage>35yearswithAUBtoruleoutcancerorpremalignancy
Postmenopausalwomenwithendometrialthickness>5mm
Womenaged18to35yearswithAUBandriskfactorsforendometrialcancer(seeRiskFactors)
Performonorafterday18ofcycle,ifknownsecretoryendometriumconfirmsovulationoccurred.
Dilationandcurettage(D&C)
Performifbleedingisheavy,uncontrolled,orifemergentmedicalmanagementhasfailed.
PerformifunabletoperformEMBinoffice(2)[C].
Hysteroscopyifanotherintrauterinelesionissuspected
TestInterpretation
Papsmearcouldrevealcarcinomaorinflammationindicativeofcervicitis.MostEMBsshowproliferativeordyssynchronous
endometrium(suggestinganovulation)butcanshowsimpleorcomplexhyperplasiawithoutatypia,hyperplasiawithatypia,or
endometrialadenocarcinoma.
TREATMENT
http://ovidmd.ovid.com.am.enformation.ro/Chapter?ovidid=ovid:/fts/bookdb/02008467/26th_Edition/2/OVIDBOOK[1]/TXTBKBD[1]/CHAPTER[2]&q=mullerian+duct 7/12
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Attempttoruleoutothercausesofbleedingpriortoinstitutingtherapy.
GENERALMEASURES
NSAIDs(naproxensodium500mgBID,mefenamicacid500mgTID,ibuprofen600to1,200mg/day)(1)[B]
Decreasesamountofbloodlossandpaincomparedwithplacebo,withnooneNSAIDclearlysuperior
MEDICATION
FirstLine
Acute,emergent,nonovulatorybleeding
Conjugatedequineestrogen(Premarin):25mgIVq4h(max6doses)or2.5mgPOq6hshouldcontrolbleedingin12to24
hours(4)[A].
D&CifnoresponseaftertwotofourdosesofPremarinorsoonerifbleeding>1pad/hr(2)[C]
Thenchangetooralcontraceptivepill(OCP)orprogestinforcycleregulation,thatis,IUD(5)[A]
Acute,nonemergent,nonovulatorybleeding
CombinationOCPwith30gestrogengivenasataper.Anexampleofatapereddose:4pills/dayfor4days3pills/dayfor
3days2pills/dayfor2days,dailyfor3weeksthen1weekoff,thencycleonOCPforatleast3months.
Nonacute,nonovulatorybleeding(rankedinorderbasedondecisionanalysisasbestoptionbasedonefficacy,cost,sideeffects,
andconsumeracceptability)(5)[A]
LevonorgestrelIUD(Mirena)isthemosteffectiveformofprogesteronedeliveryandisnotinferiortosurgicalmanagement.
Progestins:medroxyprogesteroneacetate(Provera)10mg/dayfor5to10dayseachmonth.Dailyprogesteronefor21days
percycleresultsinsignificantlylessbloodloss.
OCPs:20to35gestrogenplusprogesterone
Donotuseestrogenifcontraindications,suchassuspicionforendometrialhyperplasiaorcarcinoma,historyofdeepvein
thrombosis(DVT),orthepresenceofsmokinginwomen>35yearsofage(relativecontraindication),arepresent.
Precautions
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Failedmedicaltreatmentrequiresfurtherworkup.
ConsiderDVTprophylaxiswhentreatingwithhighdoseestrogens(2)[C].
SecondLine
Leuprolide(varyingdosesanddurationofaction)gonadotropinreleasinghormone(GnRH)agonist
Danazol(200to400mg/dayforamaximumof9months)ismoreeffectivethanNSAIDsbutislimitedbyandrogenicsideeffects
andcost.IthasbeenessentiallyreplacedbyGnRHagonists.
Antifibrinolyticssuchastranexamicacid(Lysteda)650mg,2tabletsTID(max5daysduringmenstruation)(1)[A]
MetforminorClomidaloneorincombinationinwomenwithPCOSwhodesireovulationandpregnancy
ISSUESFORREFERRAL
Ifanobviouscauseforvaginalbleedingisnotfoundinapediatricpatient,refertoapediatricendocrinologistorgynecologist.
Patientswithpersistentbleedingdespitemedicaltreatmentrequirereevaluationandpossiblereferral.
ADDITIONALTHERAPIES
Antiemeticsiftreatingwithhighdoseestrogenorprogesterone(2)[C]
Ironsupplementationifanemia(usuallyirondeficiency)isidentified
SURGERY/OTHERPROCEDURES
Hysterectomyincasesofendometrialcancerorifmedicaltherapyfailsorifotheruterinepathologyisfound
Endometrialablationislessexpensivethanhysterectomyandisassociatedwithhighpatientsatisfactionfailureofprimary
medicaltreatmentisnotnecessary(1,4)[A].
Thisisapermanentprocedureandshouldbeavoidedinpatientswhodesirecontinuedfertility.
ADMISSION,INPATIENT,ANDNURSINGCONSIDERATIONS
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Significanthemorrhagecausingacuteanemiawithsignsofhemodynamicinstabilitywithacutebleeding,replacevolumewith
crystalloidandblood,asnecessary(1)[A].
Padcountsandclotsizecanbehelpfultodetermineandmonitoramountofbleeding.
Dischargecriteria
Hemodynamicstability
Controlofvaginalbleeding(2)[C]
ONGOINGCARE
FOLLOWUPRECOMMENDATIONS
Oncestablefromacutemanagement,recommendfollowupevaluationin4to6monthsforfurtherevaluation(5).
RoutinefollowupwithaprimarycareorOB/GYNprovider
PatientMonitoring
WomentreatedwithestrogenorOCPsshouldkeepamenstrualdiarytodocumentbleedingpatternsandtheirrelationtotherapy.
DIET
Norestrictions,althougha5%reductioninweightcaninduceovulationinanovulationcausedbyPCOS.
PATIENTEDUCATION
Explainpossible/likelyetiologies.
Answerallquestions,especiallythoserelatedtocancerandfertility.
http://www.acog.org/Patients
PROGNOSIS
Varieswithpathophysiologicprocess
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Mostanovulatorycyclescanbetreatedwithmedicaltherapyanddonotrequiresurgicalintervention.
COMPLICATIONS
Irondeficiencyanemia
Uterinecancerincasesofprolongedunopposedestrogenstimulation
REFERENCES
SweetMG,SchmidtDaltonTA,WeissPM,etal.Evaluationandmanagementofabnormaluterinebleedinginpremenopausal
women.AmFamPhysician.201285(1):3543.
BibliographicLinks
CommitteeonPracticeBulletinsGynecology.Practicebulletinno.128:diagnosisofabnormaluterinebleedinginreproductive
agedwoman.ObstetGynecol.2012120(1):197206.
OvidFullText|BibliographicLinks
AmericanCollegeofObstetriciansandGynecologists.ACOGCommitteeOpinionNo.557:managementofacuteabnormaluterine
bleedinginnonpregnantreproductiveagedwomen.ObstetGynecol.2013121(4):891896.
OvidFullText|BibliographicLinks
DeVoreGR,OwensO,KaseN.UseofintravenousPremarininthetreatmentofdysfunctionaluterinebleedingadoubleblind
randomizedcontrolstudy.ObstetGynecol.198259(3):285291.
BuyNow|BibliographicLinks
MarjoribanksJ,LethabyA,FarquharC.Surgeryversusmedicaltherapyforheavymenstrualbleeding.CochraneDatabaseSyst
Rev.2006(2):CD003855.
BibliographicLinks
AdditionalReading
FarquharC,EkeromaA,FurnessS,etal.Asystematicreviewoftransvaginalultrasonography,sonohysterographyand
hysteroscopyfortheinvestigationofabnormaluterinebleedinginpremenopausalwomen.ActaObstetGynecolScand.
200382(6):493504.
KouidesPA,ConardJ,PeyvandiF,etal.Hemostasisandmenstruation:appropriateinvestigationforunderlyingdisordersof
hemostasisinwomenwithexcessivemenstrualbleeding.FertilSteril.200584(5):13451351.
LethabyAE,CookeI,ReesM.Progesteroneorprogestogenreleasingintrauterinesystemsforheavymenstrualbleeding.Cochrane
DatabaseSystRev.2005(4):CD002126.
http://ovidmd.ovid.com.am.enformation.ro/Chapter?ovidid=ovid:/fts/bookdb/02008467/26th_Edition/2/OVIDBOOK[1]/TXTBKBD[1]/CHAPTER[2]&q=mullerian+duct 11/12
18.06.2017 Abnormal(Dysfunctional)Uterine...:OvidMD
LethabyA,FarquharC,CookeI.Antifibrinolyticsforheavymenstrualbleeding.CochraneDatabaseSystRev.2000
(4):CD000249.
LethabyA,IrvineG,CameronI.Cyclicalprogestogensforheavymenstrualbleeding.CochraneDatabaseSystRev.2008
(1):CD001016.
SeeAlso
DysmenorrheaMenorrhagia(HeavyMenstrualBleeding)
Algorithm:Menorrhagia
Codes
ICD10
N93.9Abnormaluterineandvaginalbleeding,unspecified
N93.8Otherspecifiedabnormaluterineandvaginalbleeding
N91.2Amenorrhea,unspecified
ClinicalPearls
AUBisirregularbleedingthatoccursintheabsenceofpathology,makingitadiagnosisofexclusion.
Anovulationaccountsfor90%ofAUB.
AnEMBshouldbeperformedinallwomen>35yearsofagewithAUBtoruleoutcancerorpremalignancy,anditshouldbe
consideredinwomenaged18to35yearswithAUBandriskfactorsforendometrialcancer.
Itisappropriatetoinitiatemedicaltherapyinfemales<35yearsofagewithnoapparentriskofendometrialcancerpriorto
performinganEMB.
Copyright20112017
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