QUICK RECERTIFICATION SERIES
Abnormal uterine bleeding
Elyse Watkins, DHSc, PA-C, DFAAPA
GENERAL FEATURES
• Defined as bleeding from the uterus that is irregular in fre-
quency, volume, and/or duration in the absence of pregnancy.
• Excessive uterine bleeding describes a bleeding volume
that interferes with a woman’s quality of life.
• The terms menometrorrhagia and menorrhagia have
fallen out of favor.
• The average age of menarche is 12 years.
• The average age of menopause is 51 years.
• The average length of menses is 5 days.
• The average frequency of menses is 24 to 35 days.
• The average volume of blood loss per day in women of
reproductive age ranges from less than 4 mL to more
than 14 mL.
• Acute abnormal uterine bleeding refers to an episode of
heavy bleeding that requires urgent intervention to pre-
vent hemodynamic compromise.
CLINICAL ASSESSMENT
• Determine that patient is of reproductive age, as the dif-
ferential diagnosis is different for women who are meno-
pausal and girls who are premenarchal.
• The most common causes of abnormal uterine bleeding
in women of reproductive age can be classified using the
PALM-COEIN system.
° PALM (structural)
t Polyp
t Adenomyosis
t Leiomyoma
t Malignancy or hyperplasia
° COEIN (other)
t Coagulopathy
t Ovulatory dysfunction
t Endometrial
t Iatrogenic
t Not yet classified
• History should focus on gravida and para status, men-
strual history, previous obstetric or gynecologic surger-
ies, sexual history, evidence of blood dyscrasias, and
risk factors for endometrial dysplasia and carcinoma.
At the time this article was written, Elyse Watkins was an assistant
professor in the PA program at High Point (N.C.) University. The
author has disclosed no potential conflicts of interest, financial or
otherwise.
Dawn Colomb-Lippa, MHS, PA-C, department editor
DOI:10.1097/01.JAA.0000544302.46201.43
Copyright © 2018 American Academy of Physician Assistants
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2018 American Academy of Physician Assistants
• Review of medications should include use of contracep-
tives, unopposed estrogen, levothyroxine, and antico-
agulants.
• Patients with endometrial cancer generally have painless
bleeding.
• Patients with leiomyomata can complain of dyspareunia
and abdominal or pelvic fullness.
DIAGNOSIS
• Rule out other sources of bleeding such as cervical,
vaginal, urinary, or gastrointestinal.
• Rule out pregnancy.
• Obtain a thorough history and physical examination.
• Up to 20% of patients with abnormal uterine bleeding
have a bleeding disorder; von Willebrand disease is the
most common.
• Pelvic examination should focus on ruling out bleeding
from other areas and identify evidence of trauma.
QUESTIONS
1. A 28-year-old woman who has had two pregnancies and
two children born vaginally presents to the office with
a 3-month history of heavy bleeding. She states her
menses will last 5 to 7 days, and describes the bleeding
as heavy enough to have to change tampons every hour
during the first 2 to 3 days of her cycle. She denies
postcoital bleeding, dyspareunia, or pelvic pain. She
does not use contraception and takes no medication on a
regular basis. Her past medical history is noncontributory
and physical examination is unremarkable. A serum
pregnancy test is negative, and transvaginal ultrasound
shows no structural abnormalities and a normal
endometrial thickness. Which of the following is the best
choice for initial management?
a. endometrial ablation
b. intrauterine tamponade
c. levonorgestrel-containing intrauterine system
d. conjugated equine estrogen
2. Which test should always be included in the initial
evaluation of a reproductive-age patient with a history
of abnormal uterine bleeding?
a. endometrial sampling
b. pelvic ultrasound
c. thyroid-stimulating hormone
d. human chorionic gonadotropin
www.JAAPA.com 47
QUICK RECERTIFICATION SERIES
• Bimanual examination may reveal an enlarged and/or
irregularly shaped uterus that could indicate leiomyoma.
• Initial laboratory testing should include a complete blood
cell count and serum pregnancy test.
• If the patient is experiencing acute abnormal uterine
bleeding that may require blood product replacement,
order a blood type and crossmatch.
• If a bleeding disorder is suspected, check a partial throm-
boplastin time, prothrombin time, activated partial
thromboplastin time, and fibrinogen.
• Initial laboratory testing for von Willebrand disease
includes von Willebrand factor antigen, factor VIII, and
ristocetin cofactor assay.
• Consider checking liver enzymes and a thyroid panel if
clinically indicated.
• Transvaginal and pelvic ultrasound can reveal structural
anomalies and endometrial hyperplasia.
• Endometrial sampling via dilation and curettage, com-
bined with hysteroscopy, must be considered in women
with exposure to unopposed estrogen, possible Lynch
syndrome, failed medical management of previous abnor-
mal uterine bleeding episodes, and women for whom
endometrial pathology is suspected.
TREATMENT
• Treatment depends on the cause and the patient’s desire
for future fertility.
• Medical:
° Hormonal options include combination progestin and
estrogen contraceptive pills, and progestin-only pills
and injections.
° Tranexamic acid, an antifibrinolytic, can be used for
chronic and acute abnormal uterine bleeding, unless
the patient has a history of thrombotic or thrombo-
embolic events.
48 www.JAAPA.com
Copyright © 2018 American Academy of Physician Assistants
° A levonorgestrel-containing intrauterine system can
offer women 3 to 5 years of bleeding control.
° The treatment of acute abnormal uterine bleeding is
IV conjugated equine estrogens, unless the patient has
contraindications to estrogen.
• Surgical:
° Endometrial ablation is reserved for women who do
not wish to pursue future pregnancies. Pretesting with
endometrial sampling and imaging is required to rule
out hyperplasia, malignancy, or structural abnormali-
ties.
° Acute abnormal uterine bleeding also can be treated
with uterine artery embolization.
° Hysterectomy is considered the definitive treatment if
other options fail. JAAPA
component of the initial evaluation.
pelvic ultrasound is helpful, it is not always a necessary
factors for hyperplasia or endometrial cancer. Although a
sampling is generally reserved for women with risk
reproductive age with irregular bleeding. Endometrial
2. D. Pregnancy must be ruled out in a woman of
cancer.
increases a woman’s risk for endometrial hyperplasia and
Conjugated equine estrogen, if used without a progestin,
for acute bleeding when medications do not work.
pregnancies. Intrauterine tamponade is a treatment
is reserved for patients who do not desire future
endometrial sampling and imaging and generally
control. Endometrial ablation requires pretesting with
safe and effective and provides 3 to 5 years of bleeding
1. C. The levonorgestrel-containing intrauterine system is
Answers
Volume 31 • Number 9 • September 2018