As you get closer to your orientation this summer, your ACOG Junior Fellow Advisory Council wants to make sure you have the resources you need to succeed! Over the next four weeks, we will be sending out compiled resources on four high yield topics that you will see during intern year. In addition to clinical resources, we’ll also be sending along sage advice from our seasoned JFAC Junior Fellows as well as links to additional ACOG resources.
We wish you the best of luck as you get started this summer. And remember, your JFAC has got your back!
What’s my differential and work up?
Content adapted from relevant ACOG Practice Bulletins and Committee Opinions.
Key HPI and Physical Exam Points
Diagnostic Evaluation of Abnormal Uterine Bleeding
- Age of menarche and menopause
- Menstrual bleeding patterns
- Severity of bleeding (clots or flooding)
- Pain (severity and treatment)
- Medical conditions
- Surgical history
- Use of medications
- Symptoms and signs of possible hemostatic disorder
- General physican
- Pelvic examination
- Speculum with Pap test, if needed*
*for non-adolescent patients only
Don’t forget to ask about history of bleeding issues! Up to 20% of women (at any age) presenting with heavy menstrual bleeding will have an underlying bleeding disorder.
Common Causes: Remember PALM-COEIN
Most Frequent Differential Diagnoses by Age
|13-18 Years||19-39 Years||40 Years to Menopause|
**Endometrial cancer is less common but may occur in this age group.**
The Low-Down on the Work-Up
- Pregnancy test (blood or urine)
- Complete blood count
- Targeted screening for bleeding disorders (when indicated)†
- Thyroid-stimulating hormone level
- Chamydia trachomatis
Available Diagnostic or Imaging Tests (when indicated)
- Saline infusion sonohysterography
- Transvaginal ultrasonography
- Magnetic resonance imaging
A Quick Bit About Imaging
When is imaging indicated?
- The literature is unclear, but a good rule of thumb: when symptoms persist despite treatment in the setting of a normal pelvic exam, further evaluation is indicated with transvaginal ultrasonography, or biopsy, or both.
How do all of these imaging modalities compare?
- Transvaginal ultrasonography (TV-US): great screening test to assess the endometrial cavity for fibroids and polyps. Sensitivity and specificity for evaluating intracavitary pathology are only 56% and 73%, respectively.
- Sonohysterography: better than TV-US in the detection of intracavitary lesions. Provides better information on size and location of lesions.
- MRI: Routine use not recommended for AUB, but it may be useful to guide the treatment of complex myomas and uterine anomalies. Consider $$ vs. benefits.
For more information on acute abnormal uterine bleeding and management check out the resources below. We’ll be back next week with a brief review of Pre-Term Labor!
Relevant ACOG Practice Bulletins
- Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women
- Management of Abnormal Uterine Bleeding Associated With Ovulatory Dysfunction
- Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women
Countdown to CREOG
Included in All Editions
- Your Junior Fellow Advisory Council recently chimed in with their advice for surviving and succeeding during intern year. Check out their responses.
- Stay up to date on all Ob-Gyn virtual happenings.
- ACOG Wellness Resources: Wellness resource bank with helpful links and opportunities available to you to get you through this difficult period.
If you have any feedback or requests for topics to be covered, please reach out to Samhita Nelamangala at [email protected]