gynecology and obstetrics
Abnormal Uterine Bleeding
Diagnosis of AUB
Menstrual history Pregnancy test, complete blood count (CBC,) and hormone measurement (eg, thyroid-stimulating hormone [TSH], prolactin) Pelvic imaging studies, usually transvaginal ultrasonography Sometimes procedures (endometrial sampling or hysteroscopy) Women should be evaluated to identify the cause of abnormal uterine bleeding when the amount or timing of vaginal bleeding is inconsistent with normal menses. Pregnancy should be excluded, even in young adolescents and perimenopausal women. The pattern of abnormal uterine bleeding often suggests possible causes (eg, regular cycles with prolonged or excessive bleeding suggest structural abnormalities; irregular bleeding or amenorrhea is often due to ovulatory dysfunction) and helps guide the choice of laboratory or imaging tests. Coagulation disorders should be considered in adolescents who have anemia or require hospitalization for bleeding and in patients with a family history or other risk factors for coagulation disorders. Several tests are typically done: A urine or blood pregnancy test Complete blood count (CBC) Thyroid-stimulating hormone (TSH), prolactin, and sometimesprogesteronelevels or urine luteinizing hormone (LH) All women of reproductive age with AUB should have a pregnancy test. CBC is routinely done. Anemia may be severe in women who regularly have heavy periods. If Iron Deficiency Anemia is suspected in women who have chronic, heavy bleeding, the serum ferritin level, which reflects body iron stores, is measured. TSH levels are usually measured, and prolactin levels are measured, even when galactorrhea is absent, because thyroid disorders and hyperprolactinemia are common causes of AUB. To determine whether a patient is anovulatory or ovulatory, some clinicians measure serumprogesteronelevels during the luteal phase (after day 14 of a normal menstrual cycle or after basal body temperature increases, as occurs during this phase). A level of≥3 ng/mL (≥9.75 nmol/L) suggests that ovulation has occurred. Another option is for patients to use a home test kit for urine LH levels, which are measured daily for several days beginning at or after cycle day 9. Other tests are done depending on results of the history and physical examination and include the following: and dehydroepiandrosterone sulfate (DHEAS) levels if Diagnosis is suspected Serum glucose and lipid levels, blood pressure, and body mass index if polycystic ovary syndrome is suspected Follicle-stimulating hormone (FSH) andestradiollevels if primary ovarian insufficiency is possible Coagulation tests if women have risk factors for Overview of Coagulation Disorders , bruising, or hemorrhage Tests done to exclude other causes of vaginal bleeding include A cervical cancer screening test (eg, Papanicolaou [Pap] test, human papillomavirus [HPV] test) if the patient is due for routine screening or a biopsy when a suspicious cervical lesion is seen during a pelvic examination species if Pelvic Inflammatory Disease (PID) or Transvaginal ultrasonographyis done as part of the evaluation for AUB in most patients. Specifically, it is done if women have any of the following: Bleeding pattern, other symptoms, or a pelvic examination suggesting a structural lesion or pelvic organs cannot be examined adequately Risk factors for endometrial cancer (eg, obesity, diabetes, hypertension, polycystic ovary syndrome, chronic eugonadal anovulation, other conditions associated with prolonged unopposedestrogenexposure) Age≥45 (earlier if women have risk factors) Bleeding that continues despite use of empiric hormone therapy Transvaginal ultrasonography can detect structural abnormalities, including most polyps, fibroids, other masses, ovarian abnormalities, adenomyosis, and endometrial thickening. If focal thickening is detected, further testing may be needed to identify smaller intrauterine masses (eg, small endometrial polyps, submucous myomas). Sonohysterography (ultrasonography after saline is infused into the uterus) is useful in evaluating such abnormalities; it can be used to determine whether hysteroscopy, a more invasive test, is indicated and to plan resection of intrauterine masses. Or hysteroscopy may be done without sonohysterography. Both can be done in the office. For some patients with postmenopausal bleeding, measurement of endometrial thickness (endometrial stripe) during transvaginal ultrasonography may be used as a first-line test to evaluate for endometrial neoplasia (hyperplasia or cancer). Endometrial sampling is required if patients have Risk factors for endometrial cancer (eg, current or recenttamoxifentherapy) Persistent or recurrent bleeding Endometrial thickness>4 to 5 mm determined during ultrasonography (as a follow-up test) used for evaluation for endometrial neoplasia because it varies across the menstrual cycle ( Evaluation reference ): During menstruation: 2 to 4 mm Early proliferative phase (cycle days 6 to 14): 5 to 7 mm Late proliferative phase: ≤ 11 mm Secretory phase: 7 to 16 mm MRI provides detailed images that are useful in planning surgery but is expensive and is not the first-line imaging test for patients with AUB. Endometrial sampling is usually recommended to rule out hyperplasia or cancer in women with any of the following: Age ≥ 45 years Age < 45 years with one or more risk factors for endometrial cancer (see above) Abnormal bleeding that is persistent or recurs after a normal initial evaluation and despite treatment Postmenopausal patients with abnormal endometrial findings detected during transvaginal ultrasonography (endometrial thickness>4 to 5 mm or with focal or irregular endometrial thickening) Inconclusive ultrasonography findings in a patient with suspected endometrial neoplasia Inendometrial sampling(which may be done as an office endometrial biopsy or a dilation and curettage procedure), only about 25% of the endometrium is analyzed, but sensitivity for detecting abnormal cells is approximately 97%. Most endometrial biopsy specimens contain proliferative or dyssynchronous endometrium, which confirms anovulation because no secretory endometrium is found. Directed biopsy(with hysteroscopy) may be done to visualize the endometrial cavity directly and do targeted biopsies of focal endometrial abnormalities. 1.Weerakkody Y, Fahrenhorst-Jones T, Sharma R, et al: Endometrial thickness. Radiopaedia.org. https://doi.org/10.53347/rID-8106 Accessed 1/3/23. 