Approach to abnormal uterine bleeding in reproductive-aged patients: Clinical sciences

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Introduction 0:00–1:26

Abnormal uterine bleeding or au is a common problem for reproductive aged patients. In general, normal menses has a duration of five days with a cycle length between 21 and 35 days with no bleeding in between cycles.
While the volume differs between individuals. AUB is defined as menstrual bleeding that deviates from normal duration, regularity, frequency or volume.
The International Federation of Gynecology and Obstetrics has established a classification system for AUB that defines it by bleeding pattern in etiology and has replaced historical terms for abnormal bleeding such as menorrhagia, metrorrhagia, and polymenorrhea.
The two bleeding patterns include heavy menstrual bleeding and intermenstrual bleeding. The etiologies can be remembered with the pneumonic palm coin.
Palm includes structural causes of au polyp adenomyosis, leiomyoma, and malignancy coin includes nonstructural causes, coagulopathy, ovulatory dysfunction, endometrial iatrogenic and not yet classified.
Keep in mind that palm coin refers only to gynecological causes of au not pregnancy related ones. The first step in evaluating a reproductive aged patient who presents with AUB is to perform a cab CDE assessment to determine if they are stable or unstable if the patient is unstable control life threatening hemorrhage, which may include IV hormonal therapy or surgical intervention also stabilize the airway breathing and circulation, obtain IV access and monitor vitals.

Unstable Patient 1:26–1:52

On the flip side. If the patient is stable.

Stable Patient 1:52–2:02

The first step is to obtain a focused history and physical exam as well as an HCG to assess for pregnancy. If the HCG test is positive, the patient is pregnant.

Pregnant2:02–2:17

Any vaginal bleeding during pregnancy is abnormal and potentially dangerous. So be sure to evaluate immediately for life threatening conditions such as an ectopic pregnancy.
On the other hand, if HCG is negative, assess for non pregnancy related causes of AU for this, you'll need to obtain a pelvic ultrasound to evaluate the uterus and adnexa.

Assess for structural causes of abnormal bleeding by anatomic site2:17–2:51

If ultrasound demonstrates abnormal uterine findings, assess for structural causes of abnormal bleeding. Keep in mind that pregnancy doesn't exclude these conditions, but they're unlikely to be a source of abnormal bleeding during pregnancy.
Let's start with polyps, which is the pea in palm coin. The history may include postcoital spotting or intermenstrual bleeding.

Endometrial or endocervical polyp2:51–4:21

Physical examination will reveal a normal uterine size and shape and there might be a soft polypoid mass at the cervical os.
As for the ultrasound, you'll see no myometrial pathology, but it may demonstrate a thickened asymmetric endometrial lining.
That's suggestive of an endometrial polyp. While endocervical polyps can be seen on physical examination.
Endometrial polyps can be delineated with sonohysterogram or hysteroscopy. Sonohysterogram involves injecting a small amount of saline into the uterine cavity during ultrasonography.
While hysteroscopy involves placing a hysteroscope into the uterus for direct visualization. If there's an echogenic mass or lesion within the endometrial cavity, that's endometrial polyp.
For both endocervical and endometrial polyps, you should perform a directed excisional biopsy or polypectomy. This will not only treat the patient's bleeding but histologic evaluation can provide definitive diagnosis with benign histology.
You can make the diagnosis of endocervical or endometrial polyp. Even though these polyps are frequently benign in reproductive aged patients.
Be sure to closely follow the results in case it comes back with hyperplasia or malignancy. Next, let's assess for adenomyosis.
The A and our pneumonic in this case, the patient may report heavy vaginal bleeding or dysmenorrhea. And physical exam will demonstrate a diffusely enlarged globular and tender uterus.

Adenomyosis 4:21–4:52

Ultrasound will show a heterogeneous myometrium, asymmetric myometrial thickness and myometrial cysts with these findings.
The presumptive diagnosis is adenomyosis. Let's move on to l leiomyomas.

Leiomyoma4:52–5:55

The patient's history may include heavy vaginal bleeding as well as pelvic pain and pressure. While the physical exam might reveal an enlarged uterus with an irregular contour.
If ultrasound findings demonstrate one or more myometrial masses, you can diagnose leiomyoma. Here's a high yield fact, leiomyomas arise from the myometrium leiomyomas that grow into the endometrium or endometrial cavity known as submucosal leiomyomas are very likely to cause abnormal bleeding.
On the other hand, intramural myomas which are confined to the myometrium or subserosal myomas which extend into the pelvic cavity are much less likely to cause au sometimes ultrasound doesn't clearly delineate between submucosal and intramural myomas.
So, a sonohysterogram or hysteroscopy can be performed to clarify. The location.
Next is endometrial malignancy. The M in our pneumonic.

Malignancy 5:55–8:30

When considering malignancy, it's important to obtain a history that addresses risk factors for endometrial hyperplasia or carcinoma.
These risk factors include age greater than 45 chronic anovulation, unopposed, estrogen and obesity. Physical examination is usually unremarkable while ultrasound will show an absence of myometrial abnormalities but may demonstrate a thickened heterogeneous endometrial lining.
Here's a clinical pearl, endometrial thickness varies significantly throughout the menstrual cycle and is most abundant just prior to menstruation.
So keep the patient's last known menstrual period in mind when interpreting the ultrasound, a thickened endometrium in a premenopausal patient is not necessarily abnormal.
But if you have concerns, consider a repeat scan in a different phase of their cycle. On the other hand, a thickened endometrium is definitely concerning for malignancy in postmenopausal patients who are symptomatic.
All right. If the patient has one or more risk factors for endometrial hyperplasia or carcinoma.
Endometrial sampling is indicated, this can be done with a blind endometrial biopsy which involves inserting a papilla catheter into the uterus and collecting an endometrial sample.
The other option is to perform a hysteroscopy and directed biopsies. The decision to perform one or the other is determined by factors like the availability of resources and the patient's medical comorbidities if the biopsy demonstrates crowding of the endometrial glands within the stroma and possibly shows nuclear atypia.
The diagnosis is endometrial intraepithelial neoplasia, previously known as endometrial hyperplasia with or without atypia.
However, if the biopsy demonstrates crowded endometrial glands without intervening stroma, nuclear atypia and significant glandular irregularity.
The diagnosis is endometrial carcinoma. Here's another clinical pearl, cervical pathology like dysplasia and malignancy may also cause au but is not part of M in palm coin when assessing a non adolescent patient for AU, be sure to obtain cervical cancer screening if they are not up to date with current guidelines.
Now that we're done with structural causes. Let's go back to our pelvic ultrasound and physical exam.

Assess for nonstructural causes of uterine bleeding 8:30–8:45

If they show normal uterine findings, assess for nonstructural causes of AU which is coin in our pneumonic. First, let's consider C which stands for coagulopathy.

Coagulopathy8:45–9:52

The patient's history will include easy bruising or gingival bleeding as well as heavy vaginal bleeding. Usually from the time of menarche.
It may include a history of intermenstrual bleeding, heavy bleeding with surgery or pregnancy or a family history of a bleeding disorder.
The physical exam may reveal bruises or petechia when considering coagulopathy, obtain a CBCP in R PTT and A Von Willebrand Factor screening.
These tests may show thrombocytopenia, a prolonged PTI NR or PTT or a positive screen for V WF. If so, the patient's bleeding is likely a result of coagulopathy time for a high yield fact, the most common inherited bleeding disorder in patients with AU is von Willebrand disease.
Other common bleeding disorders are platelet function defects, thrombocytopenia and clotting factor deficiencies. Next, let's consider ovulatory dysfunction.
The O and Palm coin, the history may include heavy irregular menstrual cycles and weight gain. The physical exam may be positive for obesity, acne and hirsutism.

Ovulatory dysfunction 9:52–10:23

Consider ovulatory dysfunction and obtain thyroid stimulating hormone or TSH total testosterone and dehydroepiandosterone sulfate or DHEAS.
If the TSH is abnormal and both the testosterone and D hea s are normal, then the diagnosis is a thyroid disorder. However, if labs reveal a normal TSH and possibly elevated total testosterone or DHEAS level, the likely diagnosis is Polycystic Ovary syndrome or PCO S.

Thyroid disorder 10:23–10:33

Polycystic ovary syndrome 10:33–10:50

And further evaluation would be needed to confirm the diagnosis. On the other hand, if all the labs are normal, assess the patients age.

Immature Hypothalamic Pituitary Ovarian Axis/Declining Ovarian Function 10:50–11:17

If your patient is within 18 months of menarche, then they may have abnormal bleeding due to an immature, hypothalamic pituitary ovarian axis.
On the flip side, if your patient is 40 years or older, consider the diagnosis of declining ovarian function which is associated with perimenopause.
Now, let's consider the e which is endometrial dysfunction. The diagnosis includes a history of regular predictable menses, heavy vaginal bleeding or intermenstrual bleeding cycles are regular because ovulatory function is normal.

Endometrial dysfunction11:17–12:11

So, the diagnosis of endometrial dysfunction can be made when no other cause for aub is identified, patients, symptoms will help guide you to the exact cause.
So if they are experiencing heavy menstrual bleeding it can be due to an issue with local endometrial hemostasis on the flip side.
If they report intermenstrual bleeding, it is often due to poor endometrial repair mechanisms. This could be related to inflammation, infection or endometrial vasculature itself.
One possible cause is an infection of the endometrium known as endometritis. Next, we can consider iatrogenic causes of abnormal bleeding.

Iatrogenic12:11–12:33

The key here is a history that may include hormonal contraception, IUD use or anticoagulation. With this information in the absence of other abnormalities, you can make a diagnosis of iatrogenic bleeding.
Finally, let's talk about causes that are not yet classified. The N in palm coin.

Not yet classified12:33–13:01

These conditions might contribute to abnormal bleeding but haven't been adequately studied or are poorly defined. These include cesarean scar defects, arteriovenous malformations and sarcoidosis even though they are not classified.
Now, they might be recategorise or given a new category in the future. All right, as a quick recap, abnormal uterine bleeding is a common problem in reproductive aged patients to remember the causes of au use the palm coin system.

Review 13:01–13:26

This includes polyps, adenomyosis, leiomyomas and malignancy, as well as coagulopathy, ovulatory dysfunction, endometrial dysfunction, iatrogenic and not yet classified.
Approach to abnormal uterine bleeding in reproductive-aged patients | Osmosis