Abnormal uterine bleeding

Abnormal uterine bleeding in women of reproductive age is experienced by approximately 1/3 of all women throughout their lifetime.

A common condition that leads to increased healthcare costs and decreased quality-of-life.

It is effectively managed medically in most cases.

Describes any variation from normal bleeding pattern in non-pregnant, reproductive aged women beyond menarche lasting for at least six months.

Terminology of menorrhagia, metrorrhagia, re, and oligomenorrhea are replaced with heavy menstrual bleeding, intermenstrual bleeding, and unscheduled bleeding or breakthrough bleeding on a hormone medication.

Classifications based on structural and non-structural entities include polyps, copper, adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory dysfunction, endometrial disorders, and iatrogenic.

Not all abnormal bleeding has a uterine source, and the cervix, vagina, vulva, urinary and G.I. tracts need to be considered.

Classification is facilitated by patient history, imaging, histopathologic analysis of laboratory evaluation to immature accurate diagnosis and treatment approaches.

A general medical, surgical and GYN history is required for evaluation of abnormal uterine bleeding and includes assessment of the bleeding pattern.

Causes:complications of pregnancy, reproductive tract abnormalities, systemic disease, iatrogenic factors or dysfunctional uterine bleeding.

An unpredictable heavy menstrual bleeding pattern suggests abnormal urine bleeding with ovulatory dysfunction.

Most commonly unpredictable pattern of uterine bleeding is caused by polycystic ovarian syndrome, associated with menarche or perimenopause, or results from the use of hormonal contraceptives.

Intermenstrual bleeding may be caused by an individual polyp, endometritis, or an IUD.

Postcoital bleeding suggest the presence of cervical disease.

The initial step in evaluating a patient with abnormal uterine bleeding is to evaluate for pregnancy, and to determine whether a woman is premenopausal and post menarche.

Bleeding before menarche, after menopause, and during pregnancy requires different evaluations.

Am adequate history will help distinguish gynecologic causes of bleeding from those with urinary or gastrointestinal etiologies.

Heavy menstrual bleeding in a women of reproductive age is often caused by uterine fibroids or adenomyosis but may be also caused by an IUD or a coagulation disorder.

A CBC and serum ferritin level should be obtained from women with heavy menstrual bleeding because of the risk for iron depletion and iron deficiency anemia.

Leukocytosis suggests PID or postpartum endometritis in women with abnormal uterine bleeding.

Von Willebrand disease is usually accompanied by heavy bleeding at menarche.

All women of reproductive age should have a urine or serum pregnancy test.

Dysfunctional uterine bleeding refers to bleeding that occurs without an identifiable anatomic process.

Dysfunctional uterine bleeding occurs in 33-50% of women with abnormal bleeding.

Any estrogen or progesterone hormonal imbalance may lead to dysfunctional uterine bleeding.

Evaluation and management encourage high health costs especially when including the common use of hysterectomy.

Hormonal contraceptives remain the most common medical therapy, and the 52 mg levonorgestrel intrauterine system is increasingly used to manage troublesome bleeding is for a surgical approach.

The etiology in reproductive age women is almost always benign.

Inter-menstrual bleeding or abnormal uterine bleeding may occur and up to 67% of premenopausal women with endometrial polyps.

Endometrial biopsy is performed after excluding pregnancy in reproductive age women with AUB, an increased risk for endometrial malignancy including ages 45 years or older, those who are obese, women with unopposed estrogen exposure, and women were persistent AUB with failed medical management theory

A pelvic examination can aid in the diagnosis by revealing cervical infection or lesions, the presence of fresh or old blood clots at the cervical os, the sizing and contour of the uterus can be determined, as well as adnexal tenderness.

Pregnancy testing is appropriate for women younger than age 55 who are experiencing abnormal uterine bleeding.

For women younger than 55 years with AUB should have cervical cytology, HPV testing, or both in women who have not had recent cervical cancer screening and testing for Chlamydia trachomatis, Neisseria gonorrhea, and Trichomonas vaginalis, using nucleic acid amplification testing on vaginal swabs for patients younger than 25 years or when there is vaginal discharge, pelvic pain, new with multiple sexual partners, cervical motion, or adnexal tenderness.

Imaging, which most often is transvaginal ultrasound, may be useful in evaluating patients with AUB.

Ultrasound may show an enlarged uterus, an adnexal mass, suspected polycystic ovarian syndrome, uterine polyps, and uterine leiomyoma.

CT and MRI are second line tests.

Heavy menstrual bleeding is treated when it impairs quality-of-life or causes anemia.

For most women with premenstrual heavy menstrual bleeding medical management is the initial therapy with combination estrogen-progestin contraceptives.

High dose oral progesterone therapy can also be used when combination contraceptives are contra indicated, and may be more effective than lower dose combination formulations.

Initiating hormonal management in women with the AUB may be associated with irregular or even continuous light bleeding or spotting which decreases over time in most patients.

Levonorgestrel 52 mg IUD Is highly effective and suppressing heavy menstrual bleeding, reducing bleeding rates as effectively as endometrial ablation.

Nonsteroidal anti-inflammatory drugs are not as effective as hormonal agents and tranexamic acid can also reduce heavy menstrual bleeding and are useful in patients who want to avoid or have contraindications to hormonal treatments.

Heavy menstrual bleeding often leads to iron depletion in iron supplementation is appropriate management.

In women with heavy menstrual bleeding who have completed childbearing, endometrial ablation results in a one-year patient satisfaction rate of approximately 88%, and is a minimally invasive treatment for patients.

In women with heavy menstrual bleeding associated with fibroids and have completed childbearing,

uterine arterial embolization can result in 10 year satisfactory rates of 78%.

Hysterectomy is a definitive therapy for heavy menstrual bleeding and is associated with high rates of patient satisfaction but with more adverse events and time off work than endometrial ablation.

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