A systematic approach to chronic abnormal uterine bleeding

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Applied Evidence

A systematic approach to chronic abnormal uterine bleeding

J Fam Pract. 2019 March;68(2):82-84,86-92

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References

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4. National Institute for Health and Care Excellence (NICE). Heavy menstrual bleeding: assessment and management [NG88]. www.nice.org.uk/guidance/ng88. Accessed February 28, 2019.

5. Committee on Practice Bulletins—Gynecology. American College of Obstetricians and Gynecologists Practice Bulletin Number 136, July 2013: Management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol. 2013;122:176-185.

6. Hassa H, Tekin B, Senses T, et al. Are the site, diameter, and number of endometrial polyps related with symptomatology? Am J Obstet Gynecol. 2006;194:718-721.

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Ovulatory dysfunction. Abnormal uterine bleeding caused by ovulatory dysfunction is generally due to PCOS or anovulatory bleeding. Other causes, beyond the scope of this discussion, include hypothyroidism, hyperandrogenism, female athlete triad, stress, and hyperprolactinemia.

› Polycystic ovary syndrome. A diagnosis of PCOS is made using any of several recognized criteria. The commonly used Rotterdam 2003 criteria²⁷ require that at least 2 of the following be present to make a diagnosis of PCOS:

oligo-ovulation or anovulation
hyperandrogenism

polycystic ovaries seen on ultrasonography.

In addition, women with PCOS are frequently obese, show signs of insulin resistance (diabetes, prediabetes, acanthosis nigricans), or hyperandrogenism (hirsutism, acne). Even if these latter findings are not present at diagnosis, women with PCOS are at risk for a metabolic disorder. Once a diagnosis of PCOS has been established, therefore, screening tests for diabetes and cardiac risk factors (eg, dyslipidemia) should be performed.^28.29

Hysterectomy is the definitive treatment for uterine fibroids, but is reserved for women who have completed childbearing and failed (or have a contraindication to) other options.

To evaluate for hyperandrogenism, free testosterone should be measured using a high-sensitivity immunoassay in all women in whom PCOS is suspected. Because of a higher prevalence of nonclassical (ie, late-onset) congenital adrenal hyperplasia (CAH) in women of Ashkenazi Jewish (estimated prevalence, 3.7%), Hispanic (1.9%), Slavic (1.6%), and Italian (0.3%) descent, screening for CAH as a possible cause of hyperandrogenism is also recommended, by a test of a morning 17-hydroxyprogesterone level.^23,29,30 (Note: The general Caucasian population has an estimated prevalence of nonclassical CAH of 0.1%.³⁰)

Treatment of PCOS should be individualized, based on a patient’s symptoms and comorbidities. For overweight and obese women, weight loss, exercise, and metformin (1500-2000 mg/d) are the mainstays of therapy, and might reduce AUB.^29,31 If these measures do not reduce AUB, other options include an OC, an LNG-IUD, and NSAIDs.

Continue to: Information on treating other PCOS-related symptoms...