Abnormal Uterine Bleeding in Reproductive-Aged Women
Journal of Clinical Outcomes Management. 2015 February;22(2)
References
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What are key elements of the physical examination?
The physical examination should include visual inspection and palpation of the thyroid gland as well as an abdominal exam to evaluate for hepatosplenomegaly or lower abdominal tenderness or masses. Signs of anemia such as pallor should also be noted. The gynecologic exam should include visual inspection of the external genitalia, a bimanual exam, and a speculum exam. Cervical and endometrial polyps may be visible as masses at the cervical os or extending into the vaginal canal. An enlarged mobile uterus with irregular contours is consistent with leiomyomas [8].Endometriosis may manifest as tenderness, thickening, or nodularity of the uterine corpus, the vaginal canal, the uterosacral ligaments, or the adnexa. Endometriosis may also cause an asymmetric, fixed position of the uterus, the cervix, or the adnexa [9].Adenomyosis may cause diffuse moderate uterine enlargement with or without tenderness [10].Endometrial carcinoma may also cause uterine enlargement and/or immobility.
What laboratory testing should be performed?
Laboratory testing should include a pregnancy test and complete blood count (CBC). The CBC is important to assess the severity of the bleeding, which may not be apparent by history and physical examination alone. A screening thyroid-stimulating hormone test is commonly obtained, though only 7% of hypothyroid women report heavy menstrual bleeding [11].A prolactin level should be obtained. Von Willebrand factor deficiency is an underdiagnosed cause of heavy menstrual bleeding, and further testing is recommended if the history is suggestive, especially for women with a history of heavy bleeding since menarche [12].This testing should include prothrombin time, partial thromboplastin time, von Willebrand factor antigen, von Willebrand factor activity (ristocetin cofactor activity), and factor VIII activity. Creatinine and liver function testing should be obtained if indicated based on the history and physical exam (Table 4).
What additional testing would be useful in narrowing the differential diagnosis?
If the physical examination and initial laboratory testing is nondiagnostic, the decision to initiate a trial of symptom management or proceed with further testing (imaging and/or tissue sampling) is based on risk of endometrial cancer, severity of symptoms, and patient preference. In many women, body habitus makes a confirmatory pelvic examination difficult, which may lower the threshold for obtaining a pelvic ultrasound.
Women with risk factors for endometrial cancer should undergo office-based endometrial biopsy as the first step in evaluation of heavy menstrual bleeding [7].Risk factors include older age (45 years and older), obesity (BMI > 30), diabetes mellitus, nulliparity, and history of chronic anovulation (eg, polycystic ovary syndrome). Pelvic ultrasound is the first step in the evaluation of women with an abnormal physical exam suggesting a structural lesion [7].If the physical exam is abnormal and the pelvic ultrasound is nondiagnostic, a hysteroscopy or saline-infusion sonohysterogram should be performed, as these tests are more sensitive for the detection of intracavitary lesions and submucosal fibroids [13].Most endometrial polyps will appear as a thickened or irregular endometrium on pelvic ultrasound, but be clearly delineated on sonohysterogram. Women who have a negative initial evaluation but then go on to have persistent bleeding despite a trial of therapy also require further evaluation.
