ABNORMAL UTERINE BLEEDING

IN REPRODUCTIVE AGED WOMEN

August 2015
Hoa Nguyen
Jodi Nagelberg
John Joseph
Kimberly Truong
Rola Khedraki
Sangeeta Kalsi
Definitions
 Menorrhagia: heavy menstrual bleeding (>80 mL)
 Metrorrhagia: bleeding between periods
 Polymenorrhea: bleeding that occurs more often
than every 21 days
 Oligomenorrhea: bleeding that occurs less
frequently than every 35 days
 Classification: PALM-COEIN1

International Federation of Gynecology and Obstetrics, 2011

Diagnosis: H&P
 History
 Menstrual bleeding hx (incl. severity and assoc pain)
 FHx: AUB/ bleeding disorders
 Meds: warfarin, heparin, NSAID, OCP, ginkgo, ginseng,
motherwort
 Physical
 PCOS: obesity, hirsutism, acne
 Thyroid dysfunction: cold/heat intolerance, dry skin, lethargy,
proptosis
 DM: acanthosis nigricans
 Bleeding disorder: petechiae, pallor, signs of hypovolemia
 Pelvic exam
Diagnosis: Labs and Imaging
 Labs
 Pregnancy test
 CBC
 Targeted screening for bleeding disorder (when indicated)
 TSH
 Gonorrhea/Chlamydia in high risk patients
 Imaging:
 TVUS
 Sonohysterography
 Hysteroscopy
 MRI
 Endometrial biopsy
Common Differential by Age
13-18 19-39 40-Menopause
Anovulation Pregnancy Anovulatory bleeding
OCP Structural Lesions Endometrial hyperplasia/
Pelvic infection (leiomyoma, polyp) carcinoma
Coagulopathy Anovulatory cycles (PCOS) Endometrial atrophy
Tumor OCP Leiomyoma
Endometrial hyperplasia
Endometrial cancer (less
common)
Uterine Evaluation1
Management
 Medical management should be initial treatment for
most patients
 Need for surgery is based on various factors
(stability of patient, severity of bleed,
contraindications to med management, underlying
cause)
 Type of surgery dependent on above + desire for
future fertility
 Long term maintenance therapy after acute bleed is
controlled
Management Continued
 Determine acute vs. chronic
 If acute, signs of hypovolemia/hemodynamic
instability?
 Ifyes, IV access with 1 to 2 large bore IV; prepare for
transfusion and clotting factor replacement
 Once stable, evaluate etiology (PALM-COEIN)
 Determine Treatment
Medical Management
 Conjugated Equine Estrogen
 Combined OCPs
 Medroxyprogesterone Acetate
 Tranexamic Acid
 Long term therapy: levonorgesterel IUD, OCPs,
progestin (PO or IM); unopposed estrogen should not be
used long term
 Treatments differ for pts with bleeding disorders
 Ex: desmopressin can help in vWF disease, etc
 Avoid NSAIDs
Surgical Management Options
 D&C
 Endometrial Ablation
 Uterine Artery Embolization
 Hysterectomy
 References
1. Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in
reproductive-aged women. Obstet Gynecol. 2012 Jul;120(1):197-206.
doi: 10.1097/AOG.0b013e318262e320.

2. Committee Opinion no 557: management of acute abnormal uterine

bleeding in nonpregnant reproductive-aged women. Obstet Gynecol.
2013 Apr;121(4):891-6. doi: 10.1097/01.AOG.0000428646.67925.9a.
 MKSAP Questions
1) A 35 year old female is evaluated for a 5 month history of heavy
menstrual bleeding. She has been menstruating for the last 8 days
and is still going through 10 pads or more daily with frequent clots.
She has fatigue but no dizziness. She and her husband would like to
conceive a 2nd child next year. She does not smoke.
Vitals: Afebrile, BP 138/71, HR 80. Neg orthostasis. Pelvic exam:
moderate amount of blood in vaginal vault.
Pelvic u/s shows a large submucosal fibroid. Hb 10.5. You consult
ob/gyn for a myomectomy, scheduled in 2 weeks.

Which of the following is the most appropriate next step in

management?
A. Levonorgestrel IUD (Mirena)
B. IV estrogen
C. Estrogen-progesterin oral contraceptive
D. Re-evaluate in 2 weeks
Question 1: Answer
 Correct Answer: C) Estrogen-progestin OCP
 Estrogen-progestin OCP and IUD are effective
treatments for heavy menstrual bleeding.
Estrogen/progestin OCP is the better choice as pt is
planning to conceive in the near future. Pt also does
not have any contraindications to estrogen.
 IV Estrogen (B) would be appropriate if pt was
orthostatic or dizzy from blood loss. PE and DVT
are complications of IV estrogen.
 Monitoring (D) is not appropriate given her
significant, ongoing blood loss.
 Question 2
49 year old women presents to your primary care clinic with a 3 day history of heavy
menstrual bleeding. She denies dysmenorrhea but reports that her menstruation cycle
have been increasingly irregular over the past couple years. She is not sexually active
and had a bilateral tubal ligation 10 years ago.

Her physical exam demonstrated normal vital signs, no signs of hypovolemia, no

bruises. Pelvic exam was unremarkable for tenderness, nodularities, or abnormal size
uterus. Cervix was normal with blood in the os. Pregnancy test is negative and pap
smear was performed.

Which of the following is the most appropriate next step in management of this
patient?

A. Endometrial biopsy
B. Measure serum LH and FSH
C. Pelvic U/S
D. Oral contraceptives
 Question 2: Answer

A. Endometrial biopsy—Need rule out endometrial

cancer in patients older than 35 with AUB
B. Measuring LH and FSH can confirm menopause,
but does not rule out endometrial cancer.
C. Pelvic ultrasound– good with uncertain findings on
pelvic exams
D. Oral contraceptives are appropriate for patients
with anovulatory bleedings. But endometrial
carcinoma needs to be ruled out first
 Question 3

26 year old female presents with 4 days of history of light vaginal bleeding after
intercourse. Prior to this incident, she reports regular menstruation cycle and no vaginal
discharge. She is in a monogamous relationship with her husband.

Her physical exam was unremarkable. Her pelvic exam was unremarkable except small
amount of blood in the cervical os.

What is the next best step in management?

A. Perform endometrial biopsy
B. Start oral contraceptive
C. Perform pelvic ultrasound
D. Check HCG levels
 Question 3: Answer
A. Endometrial biopsy is important to rule of endometrial cancer. In
this younger patient, need to rule out more common causes initially
B. Oral contraceptives are appropriate in anovulatory women.
However, need to rule out endocrine and pregnancy first
C. Pelvic ultrasound important for the identification of anatomical
abnormalities or staging of pregnancy. However, pelvic exam was
unremarkable and screening of pregnancy with serum markers has
not been performed yet
D. Serum HCG– Pregnancy is a common cause of abnormal
uterine bleeding and needs to be ruled out in all women who
have not gone through menopause
Question 4
A 44 year old woman presents to your office with a complaint of intermenstrual bleeding. Her last
menstrual period ended 10 days ago, however for the past 3 days she noticed bleeding requiring
3-4 pads/daily. She reports that prior to this her periods were regular, lasting 5 days with
occasional light intermenstrual bleeding over the last 6 months. She is sexually active only with her
husband and uses barrier contraception.

On physical exam she was afebrile, BP 134/86, HR 74, negative orthostasis. Pelvic exam
demonstrated slightly enlarged, globular uterus, with blood noted in cervical os. Pregnancy test is
negative.

Which of the following is the most appropriate next step in the evaluation of this patient?
A. Magnetic resonance imaging
B. Transvaginal ultrasound
C. Hysteroscopy
D. Reassurance and monitoring
 Question 4: Answer

A. MRI is not the primary imaging modality to evaluate

AUB, however may be used as a follow-up test after
ultrasonography
B. Transvaginal ultrasound is important in this patient with
AUB and exam findings suggestive of structural
abnormality
C. Hysteroscopy/SIS should be done in patients with
concerning uterine cavity findings on TVUS
D. Monitoring would not be appropriate in the setting of
abnormal bleeding and concerning physical exam
findings
Question 5
A 29 year old woman presents to your office with a complaint of heavy menstrual
bleeding. She has been menstruating for the last week with persistent heavy bleeding
and passage of clots. She denies being sexually active. She is a current smoker (1-2
pack/day) and her only medications are metformin and lisinopril.
On physical exam she was afebrile, BP 154/102, HR 62, negative orthostasis. BMI 31.
Pelvic exam demonstrated moderate amount of blood in vault. Pregnancy test negative.
Endometrial biopsy was performed and results are negative for malignant or
hyperplastic disease.

Which of the following is the most appropriate next step in the management of this
patient?
A. Estrogen-progestin oral contraceptive
B. Endometrial ablation
C. Levonorgestrel (Mirena) IUD
D. Hysterectomy
 Question 5: Answer
A. Estrogen-progestin OCPs are effective in the treatment of
heavy menstrual bleeding, however this patient has several
risk factors for thrombosis
B. Endometrial ablation is a minimally invasive option in
patients in which medical therapy has failed. Medical
therapy should be initiated, also it is unknown whether the
patient wants to maintain fertility
C. Levonorgestrel IUDs are effective in the treatment of
heavy menstrual bleeding and would be an appropriate
choice in this patient with contraindications to estrogen use
D. Hysterectomy is curative in the treatment of uterine
bleeding, however medical therapy and less invasive
treatments are preferred initially