Abnormal Uterine Bleeding

Aka: Abnormal Uterine Bleeding, Dysfunctional Uterine Bleeding, Vaginal Bleeding

1. See Also
   1. Menstrual Cycle
   2. Abnormal Uterine Bleeding Causes
   3. Anovulatory Bleeding (Metrorrhagia)
   4. Ovulatory Bleeding (Menorrhagia)
   5. Uterine Bleeding in Pregnancy
   6. Endometrial Cancer Screening
   7. Oral Contraceptive-Related Uterine Bleeding Management
   8. Postmenopausal Bleeding
   9. Amenorrhea
   10. Lower GI Bleed
   11. Hematuria
2. Epidemiology
   1. Lifetime risk of Menorrhagia: 33%
   2. Women with Menorrhagia who consult their doctors: 20%
   3. Women who have at least one Endometrial Biopsy sampling: 15%
   4. Women who have Hysterectomy by age 40 years: 10%
   5. Number of hysterectomies for Menorrhagia: 200,000/year
3. Physiology
   1. See Menstrual Cycle
4. Causes
   1. See Abnormal Uterine Bleeding Causes
5. Types
   1. Anovulatory Bleeding or Metrorrhagia (90%)
      1. Unopposed Estrogen (Progesterone deficiency)
      2. Risk of Endometrial Hyperplasia and ultimately Endometrial Cancer
   2. Ovulatory Bleeding or Menorrhagia (10%)
      1. Inappropriate endometrial response to normal cycle
      2. Shortened or prolonged life span of corpus luteum
      3. Common causes
         1. Abnormal Estrogen : Progesterone ratio (low Estrogen)
         2. Bleeding Disorder (Von Willebrand Disease)
6. Symptoms
   1. Anovulatory Bleeding
      1. Change in Amount and Frequency of bleeding
         1. Low Levels of Unopposed Estradiol or Estrogens
            1. Lighter and Less Frequent Menses
         2. High Levels of Unopposed Estradiol or Estrogens
            1. Prolonged periods of Amenorrhea
            2. Heavy Withdrawal Bleeding
      2. Lack of premenstrual signs
         1. Progesterone absent: no bloating or Breast Pain
   2. Ovulatory Bleeding
      1. Premenstrual Symptoms are present
      2. Normal Menstrual Cycle intervals (occur every 24 to 35 days)
      3. Change in Amount of bleeding
         1. Menorrhagia
            1. Patient describes very heavy periods
            2. Change pad or tampon every 1-2 hours
            3. Blood clots >1 inch (2.5 cm)
            4. Patient passes over 80 ml blood per cycle
               1. The definition of 80 ml is no longer recommended
               2. Warner (2004) Am J Obstet Gynecol 190:1224-9
         2. Prolonged bleeding
            1. Bleeding duration lasts 7 days or more per cycle
7. Evaluation: History
   1. Red Flags suggestive of serious pathology
      1. Post-coital Bleeding (Cervical Cancer)
      2. Perimenopause, postmenopausal patient (Endometrial Cancer)
         1. See Postmenopausal Bleeding
         2. See Endometrial Cancer Screening
   2. Pelvic Pain
      1. See Uterine Bleeding in Pregnancy
      2. Consider Pelvic Inflammatory Disease
      3. Consider trauma (e.g. sexual abuse)
   3. Pregnancy Symptoms
   4. Bleeding Disorder
      1. Von Willebrand Disease
   5. Endocrinopathy
      1. Hypothyroidism and Hyperthyroidism symptoms
      2. Hyperandrogenism (e.g. PCOS)
      3. Hyperprolactinemia (e.g. Galactorrhea)
8. Labs: Selected based on Menorrhagia versus Metrorrhagia
   1. Initial testing
      1. Urine Pregnancy Test (bHCG)
      2. Pap Smear
      3. Chlamydia PCR screen
      4. Thyroid Stimulating Hormone (TSH)
      5. Serum Prolactin
      6. Complete Blood Count (CBC) with platelets
      7. Consider Ureaplasma culture
   2. Additional Testing to Consider
      1. Glucose to Insulin Ratio
      2. Hyperandrogenism labs
      3. Coagulation studies
         1. ProTime (PT)
         2. Partial Thromboplastin Time (PTT)
         3. Platelet Closure Time (Von Willebrand's Disease suspected)
9. Diagnostics: Evaluation over age 35 years
   1. Combination approach may be best
      1. Endometrial Cancer Screening
         1. Endometrial Biopsy or
         2. Dilatation and Curretage
      2. Structural evalutaion
         1. Transvaginal Ultrasound or
         2. Hysteroscopy
   2. Non-Invasive investigation
      1. Transvaginal Ultrasound
         1. Consider Endometrial Biopsy for stripe >5 mm
         2. Cancer is very unlikely if stripe <4 mm
         3. Saline infusion improves sensitivity
            1. False positive rate is increased
      2. Endometrial Biopsy
         1. See Endometrial Biopsy for efficacy
         2. Sensitive and specific for Endometrial Cancer
            1. Misses endometrial polyps and focal lesions
         3. Insufficient samples are common (no glandular cell)
            1. Requires other study (non-diagnostic)
   3. Invasive procedures (performed by gynecology)
      1. See Endometrial Cancer Screening
      2. Dilatation and Curettage
         1. No significant advantage over Endometrial Biopsy
      3. Saline Infusion Sonography
      4. Hysteroscopy
         1. Insufflation with carbon dioxide or warmed saline
            1. Risk of tumor dissemination
         2. Flexible 3 mm hysteroscope (Same size as Pipelle)
         3. Improves diagnosis with D&C and Endometrial Biopsy
            1. Identifies most structural lesions (e.g. polyps)
10. Evaluation: Protocols
    1. See Anovulatory Bleeding
    2. See Ovulatory Bleeding
    3. See Postmenopausal Bleeding
    4. Endometrial Cancer Screening
11. References
    1. Nelson (1997), Fam Prac Recert 19(8):14
    2. Buchanan (2009) Am Fam Physician 80(10): 1075-88
    3. Sweet (2012) Am Fam Physician 85(1): 35-43
12. Resources: Patient Education
    1. Information from your Family Doctor
       1. http://www.familydoctor.org/handouts/470.html