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Abnormal Uterine Bleeding
Abnormal Uterine Bleeding
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!BNORMALUTERINEBLEEDINGISACOMMONPRESENTINGSYMPTOMINTHEFAMILYPRACTICESETTING)NWOMEN
OFCHILDBEARINGAGEAMETHODICALHISTORYPHYSICALEXAMINATIONANDLABORATORYEVALUATIONMAYENABLE / ! PATIENT INFOR
THEPHYSICIANTORULEOUTCAUSESSUCHASPREGNANCYANDPREGNANCY
RELATEDDISORDERSMEDICATIONSIATRO
MATION HANDOUT ON
ABNORMAL UTERINE
GENICCAUSESSYSTEMICCONDITIONSANDOBVIOUSGENITALTRACTPATHOLOGY$YSFUNCTIONALUTERINEBLEEDING
BLEEDING WRITTEN BY
ANOVULATORYOROVULATORY ISDIAGNOSEDBYEXCLUSIONOFTHESECAUSES)NWOMENOFCHILDBEARINGAGEWHO THE AUTHORS OF THIS
AREATHIGHRISKFORENDOMETRIALCANCERTHEINITIALEVALUATIONINCLUDESENDOMETRIALBIOPSYSALINE
INFUSION ARTICLE IS PROVIDED
SONOHYSTEROGRAPHYORDIAGNOSTICHYSTEROSCOPYISPERFORMEDIFINITIALSTUDIESAREINCONCLUSIVEORTHEBLEED
ON PAGE
INGCONTINUES7OMENOFCHILDBEARINGAGEWHOAREATLOWRISKFORENDOMETRIALCANCERMAYBEASSESSED
INITIALLYBYTRANSVAGINALULTRASONOGRAPHY0OSTMENOPAUSALWOMENWITHABNORMALUTERINEBLEEDINGSHOULD
BEOFFEREDDILATATIONANDCURETTAGEIFTHEYAREPOORCANDIDATESFORGENERALANESTHESIAORDECLINEDILATATION
ANDCURETTAGETHEYMAYBEOFFEREDTRANSVAGINALULTRASONOGRAPHYORSALINE
INFUSIONSONOHYSTEROGRAPHY
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!
BNORMALUTERINEBLEEDINGIS WOMEN WHO HAVE BEEN RECEIVING HORMONE
ACOMMONBUTCOMPLICATED THERAPY FOR MONTHS OR MORE
CLINICAL PRESENTATION /NE 4HIS ARTICLE PRESENTS A PRACTICAL APPROACH
NATIONAL STUDY FOUND THAT TODETERMININGTHECAUSEOFABNORMALUTERINE
MENSTRUAL DISORDERS WERE BLEEDINGANDBRIEFLYREVIEWSMEDICALANDSUR
THE REASON FOR PERCENT OF MILLION GICAL MANAGEMENT
VISITS TO PHYSICIAN OFFICES FOR GYNECOLOGIC
CONDITIONSOVERATWO
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MOREA REPORTED PERCENT OF GYNECOLOGIC OF !BNORMAL 5TERINE "LEEDING
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UTERINE BLEEDING BEFORE MENARCHE ! PEL
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THE $EPARTMENT OF &AMILY IS ABNORMAL )N WOMEN OF CHILDBEARING SHOULD BE PERFORMED BECAUSE A REPORTED
AND #OMMUNITY -EDICINE AGE ABNORMAL UTERINE BLEEDING INCLUDES PERCENT OF CASES INVOLVE FOCAL LESIONS OF
AT 3OUTHERN )LLINOIS 5NIVER
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RECOMMENDATION LABELS UNPREDICTABLEBLEEDINGINPOSTMENOPAUSAL ESTROGEN ELEVATION MENSTRUAL FLOW CEASES
$OWNLOADED FROM THE !MERICAN &AMILY 0HYSICIAN 7EB SITE AT WWWAAFPORGAFP #OPYRIGHT¥ !MERICAN !CADEMY OF &AMILY 0HYSICIANS &OR THE PRI
VATE NONCOMMERCIAL USE OF ONE INDIVIDUAL USER OF THE 7EB SITE !LL OTHER RIGHTS RESERVED #ONTACT COPYRIGHTS AAFPORG FOR COPYRIGHT QUESTIONS ANDOR
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BLEEDING DEPENDS ON THE PATIENTS AGE AND THE %NDOMETRIAL CANCER IS RARE IN
TO
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PRESENCE OF RISK FACTORS FOR ENDOMETRIAL CANCER OLD FEMALES 4HEREFOREMOST ADOLESCENTS WITH
WHICHINCLUDEANOVULATORYCYCLESOBESITYNULLI
DYSFUNCTIONAL UTERINE BLEEDING CAN BE TREATED
PARITY AGE GREATER THAN YEARS AND TAMOXIFEN SAFELY WITH HORMONE THERAPY AND OBSERVATION
THERAPY )NITIALLYMEDICALMANAGEMENTISREC
WITHOUT DIAGNOSTIC TESTING
OMMENDEDFORPREMENOPAUSALWOMENATLOWRISK 4HE RISK OF DEVELOPING ENDOMETRIAL CANCER
FOR ENDOMETRIAL CARCINOMA WHO ARE DIAGNOSED INCREASES WITH AGE 4HE OVERALL INCIDENCE OF
WITH PRESUMED DYSFUNCTIONAL UTERINE BLEEDING THIS CANCER IS CASES PER IN WOMEN
$IABETES IS A DEMONSTRATED RISK FACTOR FOR AGED TO YEARS 4HE INCIDENCE MORE THAN
ENDOMETRIAL CANCER 7OMEN WITH LONG OR DOUBLES FROM CASES PER IN THOSE
IRREGULAR CYCLES ARE AT RISK FOR DEVELOPING TYPE AGED TO YEARS TO CASES PER
DIABETES AND THEREFORE SHOULD UNDERGO DIABETES IN THOSE AGED TO YEARS )N WOMEN AGED
SCREENING TO YEARS THE INCIDENCE OF ENDOMETRIAL
4HE !UTHORS CARCINOMA IS CASES PER 4HUS THE
*!.%4 2 !,"%23 -$ IS ASSOCIATE PROFESSOR AND ASSOCIATE CHAIR IN THE $EPARTMENT OF !MERICAN #OLLEGE OF /BSTETRICIANS AND 'YNE
&AMILY AND #OMMUNITY -EDICINE AT 3OUTHERN )LLINOIS 5NIVERSITY 3)5 3CHOOL OF -EDICINE COLOGISTS RECOMMENDS ENDOMETRIAL EVALUATION
3PRINGFIELD WHERE SHE IS ALSO DIRECTOR OF THE FAMILY PRACTICE RESIDENCY PROGRAM $R !LBERS
RECEIVED HER MEDICAL DEGREE FROM 3)5 3CHOOL OF -EDICINE AND COMPLETED A FAMILY PRAC
IN WOMEN AGED YEARS AND OLDER WHO HAVE
TICE RESIDENCY AT -AYO 'RADUATE 3CHOOL OF -EDICINE 2OCHESTER -INN ABNORMALUTERINEBLEEDING ;3/2#CONSENSUS
3(!2/. + (5,, -$ CURRENTLY IS ON PROFESSIONAL DEVELOPMENT LEAVE FROM 3)5 3CHOOL OF
GUIDELINE=
-EDICINE WHERE SHE IS ASSISTANT PROFESSOR IN THE $EPARTMENT OF &AMILY AND #OMMUNITY %NDOMETRIAL EVALUATION INCLUDING IMAGING
-EDICINE AND CLINICAL ASSISTANT PROFESSOR IN THE $EPARTMENT OF -EDICAL %DUCATION $R (ULL AND TISSUE SAMPLING FOR SUBTLE GENITAL TRACT
EARNED HER MEDICAL DEGREE AT 3)5 3CHOOL OF -EDICINE AND COMPLETED A FAMILY PRACTICE
RESIDENCY AT 5NION (OSPITAL &AMILY 0RACTICE #ENTER 4ERRE (AUTE )ND
PATHOLOGYISRECOMMENDEDINPATIENTSWHOAREAT
HIGH RISK FOR ENDOMETRIAL CANCER AND IN PATIENTS
2/"%24 - 7%3,%9 -! IS DIRECTOR OF RESEARCH AND PROGRAM DEVELOPMENT IN THE
$EPARTMENT OF &AMILY AND #OMMUNITY -EDICINE AT 3)5 3CHOOL OF -EDICINE (E RECEIVED
AT LOW RISK WHO CONTINUE BLEEDING ABNORMALLY
A MASTERS DEGREE IN SOCIOLOGYANTHROPOLOGY FROM 3ANGAMON 3TATE 5NIVERSITY 3PRING
DESPITE MEDICAL MANAGEMENT
FIELD )LL
!DDRESS CORRESPONDENCE TO *ANET 2 !LBERS -$ 3OUTHERN )LLINOIS 5NIVERSITY 3CHOOL OF )MAGING AND 4ISSUE 3AMPLING
-EDICINE 3PRINGFIELD &AMILY 0RACTICE 2ESIDENCY 0ROGRAM . TH 3T 3PRINGFIELD ), 4HE SENSITIVITY OF ENDOMETRIAL BIOPSY FOR THE
E
MAIL JALBERS SIUMEDEDU 2EPRINTS ARE NOT AVAILABLE FROM THE AUTHORS
DETECTIONOFENDOMETRIALABNORMALITIESHASBEEN
REPORTED TO BE AS HIGH AS PERCENT (OW
EVERTHIS OFFICE
BASED PROCEDURE MAY MISS UP TO CANCER IT NO LONGER IS CONSIDERED TO BE THERA
PERCENT OF FOCAL LESIONS INCLUDING POLYPS PEUTIC FOR ABNORMAL UTERINE BLEEDING FURTHER
AND FIBROIDS BECAUSE ONLY A SMALL PART OF THE MORE IT IS LIMITED IN ITS ABILITY TO ACCESS THE
ENDOMETRIUM MAY BE SAMPLED AT ANY ONE TIME TUBAL CORNUA OF THE UTERUS (YSTEROSCOPY WITH
!LTHOUGHENDOMETRIALBIOPSYHASHIGHSENSITIVITY BIOPSY PROVIDES MORE INFORMATION THAN DILATA
FORENDOMETRIALCARCINOMA ITSSENSITIVITYFOR TION AND CURETTAGE ALONE AND RIVALS THE COM
DETECTING ATYPICAL ENDOMETRIAL HYPERPLASIA MAY BINATION OF SALINE
INFUSION SONOHYSTEROGRAPHY
BE AS LOW AS PERCENT ;2EFERENCE 3/2 ANDENDOMETRIALBIOPSYINITSABILITYTODIAGNOSE
" META
ANALYSIS OF LOWER QUALITYINCONSISTENT POLYPS SUBMUCOUS FIBROIDS AND OTHER SOURCES
STUDIES= OF ABNORMAL UTERINE BLEEDING
4RANSVAGINAL ULTRASONOGRAPHY MAY REVEAL 0OSTMENOPAUSALWOMENWITHABNORMALUTERINE
LEIOMYOMA ENDOMETRIAL THICKENING OR FOCAL BLEEDINGINCLUDINGTHOSEWHOHAVEBEENRECEIV
MASSES!LTHOUGHTHISIMAGINGMODALITYMAYMISS ING HORMONE THERAPY FOR MORE THAN MONTHS
ENDOMETRIALPOLYPSANDSUBMUCOUSFIBROIDSITIS SHOULD BE OFFERED DILATATION AND CURETTAGE FOR
HIGHLYSENSITIVEFORTHEDETECTIONOF ENDOMETRIAL EVALUATIONOFTHEENDOMETRIUMPERCENTSEN
CANCERPERCENT ANDENDOMETRIALABNORMAL
SITIVITY FOR THE DETECTION OF CANCER WITH A TO
ITYPERCENT ;3/2!META
ANALYSISOF CON
PERCENT FALSE
NEGATIVE RATE 0OSTMENOPAUSAL
SISTENT GOOD
QUALITY STUDIES= #OMPARED WITH WOMEN WHO ARE POOR CANDIDATES FOR GENERAL
DILATATION AND CURETTAGE ENDOMETRIAL EVALUA
ANESTHESIAANDTHOSEWHODECLINEDILATATIONAND
TION WITH TRANSVAGINAL ULTRASONOGRAPHY MISSES CURETTAGE MAY BE OFFERED TRANSVAGINAL ULTRASO
PERCENT MORE CANCERS BUT IT MAY BE THE NOGRAPHYORSALINE
INFUSIONSONOHYSTEROGRAPHY
MOST COST
EFFECTIVE INITIAL TEST IN WOMEN AT LOW WITH ENDOMETRIAL BIOPSY
RISKFORENDOMETRIALCANCERWHOHAVEABNORMAL &URTHERRESEARCHISNECESSARYTODETERMINETHE
UTERINEBLEEDINGTHATDOESNOTRESPONDTOMEDI
BESTMETHODFOREVALUATINGTHEENDOMETRIUMIN
CAL MANAGEMENT PATIENTS WITH ABNORMAL UTERINE BLEEDING(OW
3ALINE
INFUSION SONOHYSTEROGRAPHY BOLSTERS EVER BASED ON CURRENT EVIDENCE SALINE
INFU
THE DIAGNOSTIC POWER OF TRANSVAGINAL ULTRASO
SIONSONOHYSTEROGRAPHYWITHENDOMETRIALBIOPSY
NOGRAPHY 4HIS TECHNIQUE ENTAILS ULTRASOUND APPEARSTOPROVIDETHEMOSTCOMPLETEEVALUATION
VISUALIZATION AFTER TO M, OF STERILE SALINE WITH THE LEAST RISK &IGURES AND
HAS BEEN INSTILLED IN THE ENDOMETRIAL CAVITY )TS
SENSITIVITYANDSPECIFICITYFORENDOMETRIALCANCER -EDICAL -ANAGEMENT
ARE COMPARABLE WITH THE HIGH SENSITIVITY AND !./65,!4/29 $93&5.#4)/.!,
SPECIFICITY OF DIAGNOSTIC HYSTEROSCOPY ;3/2 54%2).% ",%%$).'
" META
ANALYSIS WITH SIGNIFICANT HETEROGENE
/RAL CONTRACEPTIVE PILLS /#0S ARE USED FOR
ITY= 3ALINE
INFUSION SONOHYSTEROGRAPHY IS MORE CYCLE REGULATION AND CONTRACEPTION )N PATIENTS
ACCURATE THAN TRANSVAGINAL ULTRASONOGRAPHY WITH IRREGULAR CYCLES SECONDARY TO CHRONIC
IN DIAGNOSING INTRACAVITARY LESIONS AND IS ANOVULATION OR OLIGO
OVULATION /#0S HELP TO
MORE ACCURATE THAN HYSTEROSCOPY IN DIAGNOSING PREVENT THE RISKS ASSOCIATED WITH PROLONGED
ENDOMETRIALHYPERPLASIA 4HECOMBINATIONOF UNOPPOSED ESTROGEN STIMULATION OF THE ENDO
DIRECTEDENDOMETRIALBIOPSYANDSALINE
INFUSION METRIUM/#0SEFFECTIVELYMANAGEANOVULATORY
SONOHYSTEROGRAPHY RESULTS IN A SENSITIVITY OF BLEEDINGINPREMENOPAUSALANDPERIMENOPAUSAL
TO PERCENT AND A SPECIFICITY OF TO WOMEN4REATMENTWITHCYCLICPROGESTINSFORFIVE
PERCENT FOR THE IDENTIFICATION OF ENDOMETRIAL TODAYSPERMONTHISPREFERREDWHEN/#0USE
ABNORMALITY ;2EFERENCES AND 3/2 " IS CONTRAINDICATED SUCH AS IN SMOKERS OVER AGE
DIAGNOSTIC COHORT STUDIES= AND WOMEN AT RISK FOR THROMBOEMBOLISM
!LTHOUGH DILATATION AND CURETTAGE HAS BEEN 4ABLE
THE GOLD STANDARD FOR DIAGNOSING ENDOMETRIAL
.O 9ES
.ORMAL 0ATHOLOGY OR
'YNECOLOGIC
FOCAL LESION
REFERRAL
!TYPIA OR (YPERPLASIA .ORMAL
"LEEDING CANCER
CONTINUES 'YNECOLOGIC
REFERRAL #YCLE WITH "LEEDING
PROGESTINS CONTINUES
'YNECOLOGIC
'YNECOLOGIC REFERRAL
REFERRAL
!NOTHER BIOPSY 'YNECOLOGIC
IN TO MONTHS REFERRAL
&)'52%%VALUATIONOFWOMENOFCHILDBEARINGAGEWITHPRESUMEDDYSFUNCTIONALUTERINEBLEEDINGBASEDONRISKFORENDOMETRIALCAN
CER
!BNORMAL 5TERINE "LEEDING
BEFORE DIAGNOSING
ABNORMAL UTERINE BLEEDING
.ORMAL 0ATHOLOGY
"LEEDING CONTINUES
"LEEDING CONTINUES
'YNECOLOGIC REFERRAL
0OSTMENOPAUSAL WOMEN WHO ARE POOR CANDIDATES FOR GENERAL ANESTHESIA OR WHO DECLINE DILATATION AND CURET
TAGE MAY BE OFFERED TRANSVAGINAL ULTRASONOGRAPHY OR SALINE
INFUSION SONOHYSTEROGRAPHY WITH ENDOMETRIAL BIOPSY
/65,!4/29 $93&5.#4)/.!, 54%2).% ",%%$).' MEFENAMIC ACID 0ONSTEL AN .3!)$ FOR THE
TREATMENT FOR MENORRHAGIA THIS AGENT IS WELL
-EDICAL THERAPY FOR MENORRHAGIA PRIMARILY TOLERATED ;3/2 ! META
ANALYSIS= 4HE LEVO
INCLUDESNONSTEROIDALANTI
INFLAMMATORYDRUGS NORGESTRELCONTRACEPTIVEDEVICEHASBEENSHOWN
.3!)$S AND THE LEVONORGESTREL
RELEASING TO DECREASE MENSTRUAL BLOOD LOSS SIGNIFICANTLY
INTRAUTERINESYSTEM-IRENA 4HE53&OODAND AND TO BE SUPERIOR TO CYCLIC PROGESTINS FOR THIS
$RUG !DMINISTRATION HAS APPROVED THE USE OF PURPOSE ;3/2 ! META
ANALYSIS=
#OMBINATION /#0
TO MCG OF ETHINYL ESTRADIOL PLUS A #YCLE REGULATION
PROGESTIN MONOPHASIC OR TRIPHASIC PILL TAKEN #ONTRACEPTION
DAILY TRANSDERMAL FORMS ALSO ARE AVAILABLE 0REVENTION OF ENDOMETRIAL
HYPERPLASIA
MCG PILL FROM TWICE DAILY TO EVERY SIX HOURS -ANAGEMENT OF
FOR FIVE TO SEVEN DAYS UNTIL MENSES IS STOPPED NONEMERGENCY HEAVY
FOLLOWED BY TAPER TO ONE PILL DAILY FOR BLEEDING
COMPLETION OF
DAY PACK THEN ONE /#0
PACKET PER MONTH FOR THREE TO SIX MONTHS
#ONJUGATED ESTROGENS MG )6 EVERY TO HOURS UNTIL BLEEDING -ANAGEMENT OF ACUTE
)6 0REMARIN CEASES OR FOR HOURS THEN /#0 AS ABOVE EMERGENCY BLEEDING
0ROGESTINS
-EDROXYPROGESTERONE OR MG PER DAY FOR TO DAYS PER MONTH #YCLE REGULATION
ACETATE 0ROVERA
.ORETHINDRONE TO MG PER DAY FOR TO DAYS PER 0REVENTION OF ENDOMETRIAL
ACETATE !YGESTIN MONTH HYPERPLASIA
-ICRONIZED PROGESTERONE MG PER DAY FOR DAYS PER MONTH
0ROMETRIUM
OLOGY
!PGAR "3 'REENBERG ' 5SING PROGESTINS IN CLINICAL
#LARK 4* 6OIT $ 'UPTA *+ (YDE # 3ONG & +HAN PRACTICE!M&AM0HYSICIAN
+3 !CCURACY OF HYSTEROSCOPY IN THE DIAGNOSIS OF
ENDOMETRIAL CANCER AND HYPERPLASIA A SYSTEMATIC $E6ORE '2 /WENS / +ASE . 5SE OF INTRAVENOUS
QUANTITATIVE REVIEW *!-!
0REMARIN IN THE TREATMENT OF DYSFUNCTIONAL UTER
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SONOGRAPHY SALINE INFUSION SONOGRAPHY AND HYS
,ETHABY ! !UGOOD # $UCKITT + .ONSTEROIDAL ANTI
TEROSCOPY IN PREMENOPAUSAL WOMEN WITH ABNORMAL INFLAMMATORY DRUGS FOR HEAVY MENSTRUAL BLEEDING
UTERINE BLEEDING * #LIN 5LTRASOUND
#OCHRANE $ATABASE 3YST 2EV #$
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4RANSVAGINAL ULTRASONOGRAPHY SONOHYSTEROGRAPHY GESTOGEN RELEASING INTRAUTERINE SYSTEMS VERSUS
AND OPERATIVE HYSTEROSCOPY FOR THE EVALUATION OF EITHER PLACEBO OR ANY OTHER MEDICATION FOR HEAVY
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#$
7IDRICH 4 "RADLEY ,$ -ITCHINSON !2 #OLLINS 2, &RASER )3 -C#ARRON ' 2ANDOMIZED TRIAL OF HOR
#OMPARISON OF SALINE INFUSION SONOGRAPHY WITH MONAL AND PROSTAGLANDIN
INHIBITING AGENTS IN
OFFICE HYSTEROSCOPY FOR THE EVALUATION OF THE ENDO
WOMEN WITH A COMPLAINT OF MENORRHAGIA !UST . : *
METRIUM !M * /BSTET 'YNECOL
/BSTET 'YNAECOL
/#ONNELL ,0 &RIES -( :ERINGUE % "REHM 7 4RIAGE OF 3OWTER -# ,ETHABY ! 3INGLA !! 0RE
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ABNORMAL POSTMENOPAUSAL BLEEDING A COMPARISON ENDOMETRIAL THINNING AGENTS BEFORE ENDOMETRIAL
OF ENDOMETRIAL BIOPSY AND TRANSVAGINAL SONOHYS
DESTRUCTION FOR HEAVY MENSTRUAL BLEEDING #OCHRANE
TEROGRAPHY VERSUS FRACTIONAL CURETTAGE WITH HYSTEROS
$ATABASE 3YST 2EV #$
COPY !M * /BSTET 'YNECOL
,ETHABY ! &ARQUHAR # #OOKE ) !NTIFIBRINOLYTICS FOR
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AND SALINE SONOHYSTEROGRAPHY IN THE DETERMINATION
OF THE CAUSE OF ABNORMAL UTERINE BLEEDING !M *
/BSTET 'YNECOL
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IN POSTMENOPAUSAL WOMEN WITHOUT SYMPTOMS !M
* /BSTET 'YNECOL