Community Hospital East Family Medicine Residency, Indianapolis, Ind (Dr. Jordahl-Iafrato); University of Arizona College of Medicine, Department of Obstetrics and Gynecology, Tucson (Dr. Reed); COPE Community Services, Inc., Tucson, Ariz (Dr. Hadley); University of Arizona College of Medicine, Department of Family and Community Medicine, Tucson (Dr. Kolman) Mjordahl-iafrato@ecommunity.com
The authors reported no potential conflict of interest relevant to this article.
Recently, Ms. R reports, she has been bleeding continuously for 14 days, with episodes of lighter bleeding followed by heavier bleeding. She also complains of fatigue.
Bimanual examination is notable for an enlarged uterus.
How would you proceed with the workup of this patient, to determine the cause of her bleeding and tailor management accordingly?
Structural AUB: The “PALM” mnemonic
A structural cause of AUB must be considered when you encounter an abnormality on physical exam (TABLE 1).3 In obese women or other patients in whom the physical exam is difficult, historical clues—including postcoital bleeding, intermenstrual bleeding, or pelvic pain or pressure—also suggest a structural abnormality.4
Transvaginal ultrasonography (TVUS) is the initial method of evaluation when a structural abnormality is suspected.1,4 However, although TVUS is excellent at visualizing the myometrium, lesions within the uterine cavity can be missed. If intracavitary pathology, such as submucosal fibroids or endometrial polyps, is suspected, additional imaging with saline infusion sonohysterography (SIS) should be performed. If a cavitary abnormality is confirmed, hysteroscopy is indicated.1 Magnetic resonance imaging (MRI) is reserved for cases in which a uterine cavity abnormality is found on TVUS but cannot be further characterized by SIS or hysteroscopy.1
