This grand rounds presentation and discussion focused on abnormal uterine bleeding (AUB).
Abnormal Uterine Bleeding
Abnormal uterine bleeding occurs in 9 to 14 percent of women between menarche and menopause,
significantly impacting quality of life and imposing financial burden. The etiologies and treatments for
abnormal uterine bleeding over the reproductive years are best understood in the context of normal
menstrual physiology. A normal cycle starts when pituitary follicle-stimulating hormone induces ovarian
follicles to produce estrogen. Estrogen stimulates proliferation of the endometrium. A luteinizing hormone
surge prompts ovulation; the resultant corpus luteum produces progesterone, inducing a secretory
endometrium. In the absence of pregnancy, estrogen and progesterone levels decline, and withdrawal
bleeding occurs 13 to 15 days postovulation [Swe12].
Abnormal uterine bleeding (AUB) is best defined as irregular menstrual bleeding that is usually heavy,
prolonged or frequent. It is often a diagnosis of exclusion after establishing normal anatomy and absence of
other medical conditions. AUB is typically divided into two categories; anovulatory and ovulatory. Anovulatory
bleeding is characterized by irregular or infrequent periods, with flow ranging from light to excessively heavy.
Terms commonly associated with anovulatory bleeding include amenorrhea (absence of periods for more
m
than three cycles), oligomenorrhea (menses occurring at intervals of more than 35 days), metrorrhagia
er as
(menses at irregular intervals with excessive bleeding or lasting more than seven days), and dysfunctional
co
uterine bleeding (anovulatory bleeding in which underlying etiologies have been ruled out). Ovulatory
eH w
abnormal uterine bleeding (menorrhagia) occurs at regular intervals (every 24 to 35 days), but with excessive
volume or duration of more than seven days.
o.
rs e Clinical Assessment
ou urc
The clinical assessment for the patient with uterine bleeding begins with a basic assessment. The clinician
should review the body mass index (BMI) to evaluate for obesity, pallor and vital to evaluate for anemia.
Other evaluations will include visual field defects for a pituitary lesion; hirsutism or acne for
o
hyperandrogenism; a goiter for thyroid dysfunction, galactorrhea for hyperprolactinemia, purpura or
aC s
ecchymosis for a bleeding disorder.
vi y re
During the physical exam it is important to note the size and contour of the uterus and if there is any current
bleeding including the color, amount and odor of the fluid. It is also important to note any adnexal mass or
tenderness.
ed d
Diagnostics
ar stu
The first test on any women of reproductive age should always be a human chorionic gonadotropin or
pregnancy test. Additional blood work may include a complete blood count, thyroid levels, liver functions,
coagulopathies, prolactin levels, androgen levels, follicle stimulating hormone or luteinizing hormone and
is
estrogen levels [Kot13]. A pap smear should also be performed to rule out cervical cancer.
Th
Imaging may also be utilized. A transvaginal ultrasound (TVS) is an inexpensive, non-invasive and a convenient
way to indirectly visualize the endometrial cavity. It is recommended as a 1st line diagnostic tool for assessing
uterine pathology in reproductive age women presenting with AUB [Kot13]. Saline infusion
sonohysterography (SIS) is a technique in which a catheter is placed into the endometrial cavity and sterile
sh
saline is instilled to separate the walls of the endometrium.
A hysteroscopic (HYS) evaluation of the endometrial cavity and visually directed biopsy for histo-pathological
evaluation is considered the gold standard for assessing the endometrium and detecting or ruling out
endometrial cancer in current GYN practice. The major problem with a regular HYS was the need for general
anesthesia.
This study source was downloaded by 100000820363976 from CourseHero.com on 07-07-2021 03:50:32 GMT -05:00
https://www.coursehero.com/file/29047727/NR602-GR-Summary-W6docx/
Abnormal Uterine Bleeding
Abnormal uterine bleeding occurs in 9 to 14 percent of women between menarche and menopause,
significantly impacting quality of life and imposing financial burden. The etiologies and treatments for
abnormal uterine bleeding over the reproductive years are best understood in the context of normal
menstrual physiology. A normal cycle starts when pituitary follicle-stimulating hormone induces ovarian
follicles to produce estrogen. Estrogen stimulates proliferation of the endometrium. A luteinizing hormone
surge prompts ovulation; the resultant corpus luteum produces progesterone, inducing a secretory
endometrium. In the absence of pregnancy, estrogen and progesterone levels decline, and withdrawal
bleeding occurs 13 to 15 days postovulation [Swe12].
Abnormal uterine bleeding (AUB) is best defined as irregular menstrual bleeding that is usually heavy,
prolonged or frequent. It is often a diagnosis of exclusion after establishing normal anatomy and absence of
other medical conditions. AUB is typically divided into two categories; anovulatory and ovulatory. Anovulatory
bleeding is characterized by irregular or infrequent periods, with flow ranging from light to excessively heavy.
Terms commonly associated with anovulatory bleeding include amenorrhea (absence of periods for more
m
than three cycles), oligomenorrhea (menses occurring at intervals of more than 35 days), metrorrhagia
er as
(menses at irregular intervals with excessive bleeding or lasting more than seven days), and dysfunctional
co
uterine bleeding (anovulatory bleeding in which underlying etiologies have been ruled out). Ovulatory
eH w
abnormal uterine bleeding (menorrhagia) occurs at regular intervals (every 24 to 35 days), but with excessive
volume or duration of more than seven days.
o.
rs e Clinical Assessment
ou urc
The clinical assessment for the patient with uterine bleeding begins with a basic assessment. The clinician
should review the body mass index (BMI) to evaluate for obesity, pallor and vital to evaluate for anemia.
Other evaluations will include visual field defects for a pituitary lesion; hirsutism or acne for
o
hyperandrogenism; a goiter for thyroid dysfunction, galactorrhea for hyperprolactinemia, purpura or
aC s
ecchymosis for a bleeding disorder.
vi y re
During the physical exam it is important to note the size and contour of the uterus and if there is any current
bleeding including the color, amount and odor of the fluid. It is also important to note any adnexal mass or
tenderness.
ed d
Diagnostics
ar stu
The first test on any women of reproductive age should always be a human chorionic gonadotropin or
pregnancy test. Additional blood work may include a complete blood count, thyroid levels, liver functions,
coagulopathies, prolactin levels, androgen levels, follicle stimulating hormone or luteinizing hormone and
is
estrogen levels [Kot13]. A pap smear should also be performed to rule out cervical cancer.
Th
Imaging may also be utilized. A transvaginal ultrasound (TVS) is an inexpensive, non-invasive and a convenient
way to indirectly visualize the endometrial cavity. It is recommended as a 1st line diagnostic tool for assessing
uterine pathology in reproductive age women presenting with AUB [Kot13]. Saline infusion
sonohysterography (SIS) is a technique in which a catheter is placed into the endometrial cavity and sterile
sh
saline is instilled to separate the walls of the endometrium.
A hysteroscopic (HYS) evaluation of the endometrial cavity and visually directed biopsy for histo-pathological
evaluation is considered the gold standard for assessing the endometrium and detecting or ruling out
endometrial cancer in current GYN practice. The major problem with a regular HYS was the need for general
anesthesia.
This study source was downloaded by 100000820363976 from CourseHero.com on 07-07-2021 03:50:32 GMT -05:00
https://www.coursehero.com/file/29047727/NR602-GR-Summary-W6docx/
