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.
Ms. R undergoes a sonogram that reveals a 4-cm fibroid in the uterine fundus that has not distorted the uterine cavity. Although she has completed childbearing, Ms. R is not interested in a surgical procedure at this time. You recommend insertion of an LNG-IUD; she accepts your advice.
CASE 2
Claire G, 27 years old, with a body mass index of 41,* complains of irregular menses for several months. Her menstrual cycle is irregular, as is the duration of menses and amount of bleeding. She has some mild fatigue without dizziness.
Endometrial biopsy should be part of the initial evaluation of abnormal uterine bleeding in all women >45 years and in younger women who have risk factors for endometrial cancer.
The physical exam is notable for mild hirsutism, without abnormalities on pelvic examination. Lab testing reveals iron-deficiency anemia; a pregnancy test is negative.
The questions that were raised by Ms. R’s case challenge you here, too: What is the appropriate workup of Ms. G’s bleeding? Once the cause is confirmed, how should you treat her?
Nonstructural AUB: The “COEIN” mnemonic
In the absence of abnormalities on a pelvic exam, and after excluding endometrial malignancy/hyperplasia in patients with the aforementioned risk factors, a nonstructural cause of AUB should be considered (TABLE 1).3 In women 20 to 40 years of age, the primary common cause of nonstructural uterine bleeding is ovulatory dysfunction, most often caused by PCOS or anovulatory bleeding.
