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The evaluation of abnormal uterine bleeding.

Introduction Abnormal uterine bleeding (AUB) can arise from a bewildering number of sources (Table 1). Prior to menopause, 20% of gynecology visits and approximately one fourth of gynecologic procedures are done for AUB. The primary goal of the clinical evaluation of AUB is to establish a specific diagnosis in the most efficient and least invasive manner possible. History and physical examination provide the foundation and direction on which the course of the evaluation begins. However, a contemporary, safe, and comprehensive evaluation most often also relies on diagnostic procedures, which will be the focus of this chapter. Abnormal uterine bleeding will be considered to arise from 1 of 4 broad etiologic categories. First are pregnancy-related etiologies (such as abortion, ectopic, and trophoblastic disease as well as puerperal complications such as retained products of conception and endomyometritis). Second is AUB arising from the endocrine-mediated sequelae of anovulation. Third is AUB resulting from disorders of coagulation. Finally, the fourth category of AUB involves a direct anatomic (structural) source of uterine pathology (including benign and cancerous or precancerous lesions). This chapter will review current information to guide the selection and use of the prevailing diagnostic procedures aimed at establishing or excluding structural sources of AUB during the reproductive years. Although thoughtful selective use of these diagnostic techniques may be critical to establish a diagnosis efficiently, comprehensive evaluation for nonstructural sources of AUB is a necessary prerequisite. It is not uncommon to encounter more than 1 source of AUB concomitantly. A systematic approach toward evaluating AUB will be presented followed by an analysis of the use of diagnostic procedures for differentiating anatomic causes.