Abnormal uterine bleeding

 Refers to uterine bleeding of abnormal quantity, duration, or schedule

If a patient came to you with abnormal uterine bleeding:

 Ask age:
 In a reproductive-age patient, single event, hemodynamically stable,
otherwise normal menstrual cycles: does not require evaluation. Just
ask the patient to keep a menstrual diary.
 In postmenopausal: even a single episode of bleeding is considered
abnormal and requires evaluation.
 Assess hemodynamic stability:
 Hemodynamically unstable patients (eg, tachycardic, hypotensive,
orthostatic) need to be stabilized in the emergency department
before evaluation.
 Hemodynamically stable patients can be evaluated in the outpatient
setting.
 Take history:
 Menstrual history: regularity, amount/ flow, bleeding pattern
 Sexual history:
 She might be pregnant
 She might have sexually transmitted infections (eg, Chlamydia
trachomatis, Neisseria gonorrhoeae, trichomonas, herpes
simplex), which can cause cervicitis and present with cervical
bleeding. Any lower abdominal pain, fever, and/or vaginal
discharge?
 Bleeding related to trauma or intercourse suggests a vaginal or
cervical source of bleeding (eg, cervical dysplasia, cervicitis,
vulvovaginal atrophy, cervical polyp)
 Contraceptive history:
 OCP may lead to unscheduled bleeding, decreased menstrual
flow, or amenorrhea.
 The copper IUD increases menstrual flow.
 levonorgestrel IUDs (eg, LNG 52; Mirena, Liletta) are associated
with decreased menstrual flow and amenorrhea.
 Ask endometrial cancer risk factors (prolonged estrogen exposure):
  older age, Unopposed estrogen therapy, Tamoxifen therapy
Early menarche, Late menopause (after age 55), nulliparity,
obesity, PCOS.
 Medications: anticoagulants
 Bleeding disorders: von Willebrand disease (chronic heavy uterine
bleeding).
 Endocrine disorders:
 Thyroid disease is often associated with oligomenorrhea or
amenorrhea.
 Hyperprolactinemia is also associated with amenorrhea.
 Changes in bladder or bowel function may suggest a mass effect from
an enlarged fibroid uterus or a neoplasm.

 Physical exam:
 General:
 look for signs of systemic illness such as fever or ecchymoses.
 Check for enlarged thyroid gland.
 look for hyperandrogenism (eg, hirsutism, acne, clitoromegaly,
male pattern balding).
 Acanthosis nigricans may be seen in patients with polycystic
ovary syndrome (PCOS).
 Galactorrhea suggests the presence of hyperprolactinemia.
 pelvic examination
 Any active bleeding? From where?
 Any mass, laceration, ulceration, friable area, vaginal or cervical
discharge, foreign body, urethral caruncle, hemorrhoid.
 Size and contour of the uterus:
 Enlarged uterus may be due to pregnancy, uterine
leiomyomas, adenomyosis, or uterine malignancy.
 Limited uterine mobility suggests pelvic adhesions (from
prior infection, surgery, or endometriosis) or a pelvic
mass is present.
 A boggy, globular, tender uterus may be noted in
patients with adenomyosis.
 Uterine tenderness is often present in patients with PID.
 Presence of an adnexal mass or tenderness:
 Tubo-ovarian abscess associated with endometritis.

Ovarian neoplasm (eg, granulosa cell tumor) may be

hormonally active and cause endometrial neoplasia.
 Do PREGNANCY TEST: if positive, patients should be evaluated for
pregnancy-related causes of bleeding.

 Investigations:
 In general investigations for this condition might include labs,
transvaginal ultrasound, pelvic ultrasound, abdominal ultrasound,
endometrial sampling, Saline infusion sonography, hysteroscopy, or
MRI. CT has no role.
 If patient has IUD no need for further investigations because it is
most likely iatrogenic.
 In case of heavy or prolonged regular cyclic bleeding (ovulatory
menses):
 Imaging: to look for submucosal fibroids, Adenomyosis,
endometrial polyps, uterine arteriovenous malformation.
 Labs: CBC (anemia), ferritin level (depleted iron stores), WBC
(PID, endometritis), TSH (thyroid disease), coagulation
parameters (bleeding disorders), INR (warfarin)
 Endometrial sampling for patients with risk factors for uterine
malignancy.
 In case of Intermenstrual bleeding:
 Imaging: for endometrial polyps and cesarean scar defect.
 Endometrial sampling: if there are risk factors for uterine
malignancy or chronic endometritis is supected.
 Laboratory tests are generally not required for patients with
intermenstrual bleeding.
 In case of Irregular bleeding (think ovulatory dysfunction due to
extremes of reproductive age postmenarchal or perimenopausal):
 Further evaluation is not generally required.
 Can order some Labs: TSH (to r/o thyroid disease), prolactin
level (if there is glactorrhea), androgen levels (if there are signs
of androgen excess), FSH/ LH (to r/o premature ovarian
insufficiency), Estrogen (to r/o hypothalamic dysfunction due to
 poor nutrition or intense exercise and to r/o estrogen-secreting
ovarian tumor if there is adnexal mass)
 Endometrial sampling: if irregular bleeding for six months or
more with increased risk of endometrial malignancy.
 Imaging: generally not required for patients with irregular
bleeding but can be done to r/o PCOS
 In case of decreased volume: consider hysteroscopy for Asherman
syndrome.
 Regular menses with increased frequency can happen normally
during perimenopause.
 Who is at higher risk of endometrial malignancy for endometrial
sampling?:
 Age 45 years to menopause: Bleeding that is frequent (interval
between the onset of bleeding episodes is <21 days), heavy,
prolonged (>8 days), or occurs between cycles.
 Age <45 years: Bleeding that is persistent (usually defined as six
months or more) and occurs in the setting of one of the
following: a history of unopposed estrogen exposure (eg,
obesity, chronic ovulatory dysfunction), failed medical
management of the bleeding, or in patients at high risk of
endometrial cancer (eg, tamoxifen therapy, Lynch or Cowden
syndrome).
 Saline infusion sonography Vs. Hysteroscopy?
 ACOG prefers to start with Saline infusion sonography.
 NICE prefers starting directly with Hysteroscopy.
 Management of acute uterine bleeding with hemodynamic instability:
 Fluid resuscitation and blood product: two large bore (14 gauge or
larger) peripheral intravenous (IV) lines and type and cross-matching.
 Intrauterine tamponade: balloon or gauze packing to decrease
bleeding.
 30 mL Foley catheter is used as a balloon. Bakri balloon can be
used for up to 300 mL.
 Kerlix gauze is used after being impregnated with 5000 units
thrombin in 5 mL sterile saline to enhance clotting
 Uterine curettage: is the treatment of choice with cessation or
significant decrease in bleeding in less than one hour
  High-dose IV estrogen is beneficial in combination with other
measures. Estrogen promotes rapid regrowth of endometrium over
the bleeding epithelial surface. takes three or more hours.
 Uterine artery embolization: first line therapy in case the etiology was
uterine arteriovenous malformation. Alternative to hysterectomy in
women who wish to preserve their uterus.
 Hysterectomy: In the rare cases in which the above measures fail,
hysterectomy is a last resort.
 Management of acute uterine bleeding in hemodynamically stable women:
 High-dose oral estrogen: first-line therapy for hemodynamically stable
women is high-dose oral estrogen. Give antiemetics with it.
 High dose oral contraceptives can be used: less effective because they
inhibit the synthesis of estrogen receptors, thereby impeding the
rapid proliferation of endometrium induced by estrogen.
 High dose progestins-only: In women with a thickened endometrium.
 GnRH analogs: second or third line if previous failed.
 Tranexamic acid: antifibrinolytic effect. only when other options have
been unsuccessful and only in women who are not at a high risk of
thrombosis.
 Endometrial ablation: used in stable women in whom medical therapy
is contraindicated or unsuccessful. This procedure provide long-term
improvement but precludes subsequent pregnancy.
 FIGO System 1 terminology and symptoms
Parameter Normal Abnormal
Frequency ≥24 and ≤38 days Absent (no bleeding):
amenorrhea
Infrequent (>38 days)
Duration ≤8 days Prolonged (>8 days)
Regularity Regular: shortest to longest cycle Irregular: shortest to longest
variation: ≤7 to 9 days* cycle variation: ≥10 days
Flow volume (patient Patient considers normal Patient considers light
determined) Patient considers heavy
Intermenstrual bleeding None Random
(bleeding between cyclically Cyclic (predictable):
regular onset of menses)  Early cycle
 Mid cycle
 Late cycle
Unscheduled bleeding on Not applicable for patients not on Present
progestin±estrogen gonadal gonadal steroid medication
steroids (contraceptive pills, None (for patients on gonadal
 steroid medication)
rings, patches, IUDs, or injections)
 FIGO System 2 PALM-COEIN etiology classification

This document has the most important point from these uptodate articles:

1. Abnormal uterine bleeding in nonpregnant reproductive-age patients:

Evaluation and approach to diagnosis
2. Managing an episode of severe or prolonged uterine bleeding