Clinical evaluation of abnormal uterine bleeding

Many conditions may be responsible for abnormal uterine bleeding (AUB).

In the pre menarchal period

• potential causes of AUB include - malignancy, trauma, and sexual abuse or assault
• it is important to carry out a physical examination (possibly under anesthesia) since 54% of cases are reported to be associated with focal lesions of the genital tract and 21% of these lesions may be malignant (1)

During the childbearing years, patients with AUB may present with any change in menstrual frequency or duration, quantity of blood flow or intermenstrual bleeding (1)
General assessment

• determine whether the bleeding is
  • related to pregnancy
  • first cause to consider in this group of patients
  • enquire about cycle patterns, contraception, and sexual activity and about symptoms related to pregnancy e.g. - nausea, weight gain, urinary frequency
  • if patients complain of pelvic pain think about pregnancy-related bleeding causes like miscarriage, ectopic pregnancy etc.
  • eminating from the cervical canal rather than another location
• evaluate for anaemia

Once the bleeding has been confirmed or suspected to be of uterine origin (and if any other source cannot be identified), evaluation should be carried out in a systemic fashion (to address each component of the "PALM-COEIN" classification system)

• disorders of ovulation
  • associated menstrual abnormalities may range from amenorrhoea, through extremely light and infrequent bleeding to episodes unpredictable and extreme bleeding requiring medical or surgical intervention
  • many ovulatory disorders can be traced to endocrinopathies e.g. -
    • polycystic ovary syndrome - hirsutism, acne, acanthosis nigricans, obesity
    • pituitary conditions - galactorrhea, headache, visual-field disturbance
  • in some cases it might be due to iatrogenic causes e.g. –
    • gonadal steroids
    • drugs that impact dopamine metabolism – phenothiazines, tricyclic antidepressants
  • ovulatory disorders may also occur at the extremes of reproductive age – adolescence and during menopause transition
  • if ovulatory status is uncertain, mid luteal serum progesterone or endometrial biopsy may provide evidence supporting (or refuting) the presence of ovulation in a given cycle
• screening for systemic disorders of hemostasis
  • a structured history can be used as an initial screening tool to detect an underlying disorder of hemostasis in a patient with excessive bleeding e.g. -
    • heavy menstrual bleeding since menarche
    • one of the following:
      • postpartum hemorrhage
      • surgical-related bleeding
      • bleeding associated with dental work
    • two or more of the following symptoms:
      • bruising 1–2 times per month
      • epistaxis 1–2 times per month
      • frequent gum bleeding
      • family history of bleeding symptoms
• evaluation of the endometrium
  • endometrial sampling is indicated in persistent AUB that is unexplained or inadequately treated
• evaluation of the structure of the endometrium
  • to identify abnormalities such as endometrial/endocervical polyps, submucosal leiomyomas
  • transvaginal ultrasound is an appropriate screening tool
• myometrial assessment
  • check for leiomyomas or adenomyosis
  • transvaginal ultrasound, transabdominal ultrasound, hysteroscopy (1,2,3)

Reference:

• (1) Munro MG et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011;113(1):3-13
• (2) Whitaker L, Critchley HOD. Abnormal uterine bleeding. Best Practice & Research Clinical Obstetrics & Gynaecology. 2016;34:54-65.
• (3) Albers JR, Hull SK, Wesley RM. Abnormal uterine bleeding. Am Fam Physician. 2004;69(8):1915-26.