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Countdown to Intern Year, Week 1: Abnormal Uterine Bleeding

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

Medical History

  • 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

Physical Examination

  • General physican
  • Pelvic examination
    • External
    • 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

Fig. 1. Basic PALM–COEIN classification system for the causes of abnormal uterine bleeding in nonpregnant women of reproductive age. This system, approved by the International Federation of Gynecology and Obstetrics, uses the term AUB paired with descriptive terms that describe associated bleeding patterns (HMB or IMB), or a qualifying letter (or letters), or both to indicate its etiology (or etiologies). Modified from Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO classification system (PALM–COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. FIGO Working Group on Menstrual Disorders. Int J Gynaecol Obstet 2011;113:3–13. [PubMed] [Full Text]


Most Frequent Differential Diagnoses by Age

13-18 Years 19-39 Years 40 Years to Menopause
  1. Anovulatory bleeding due to immaturity or dysregulation of the hypothalamic–pituitary–ovarian axis
  2. Hormonal contraceptive use
  3. Pregnancy
  4. Pelvic infection (STI)
  5. Coagulopathies 
  1. Pregnancy
  2. Structural lesions
  3. Anovulatory cycles 
  4. Use of hormonal contraception
  5. Pelvic Infection (STI)
  6. Endometrial hyperplasia

**Endometrial cancer is less common but may occur in this age group.**

  1. Anovulatory bleeding due to declining ovarian function
  2. Endometrial hyperplasia 
  3. Endometrial carcinoma
  4. Endometrial atrophy 
  5. Leiomyoma


The Low-Down on the Work-Up

Laboratory Tests

  • 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
  • Hysteroscopy

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.

Fig. 2. Uterine evaluation. The uterine evaluation is, in part, guided by the medial history and other elements of the clinical situation, such as patient age, presence of an apparent chronic ovulatory disorder, or presence of other risk factors for endometrial hyperplasia or malignancy. For those at increased risk, endometrial biopsy is probably warranted. If there is a risk of structural anomaly, particularly if previous medical therapy has been unsuccessful, evaluation of the uterus should include imaging, at least with a screening transvaginal ultrasonography. Unless the ultrasound image indicates a normal endometrial cavity, it will be necessary to use either or both hysteroscopy and sonohysterography to determine whether target lesions are present. Such an approach is also desirable if endometrial sampling has not provided an adequate specimen. Uncommonly, these measures are inconclusive or, in the instance of virginal girls and women, not feasible outside of an anesthetized environment. In these instances, magnetic resonance imaging may be of value, if available. Abbreviations: AUB, abnormal uterine bleeding; AUB-P, polyp; AUB-A, adenomyosis; AUB-L SM , leiomyoma submucosal; AUB-M, malignancy and hyperplasia; AUB-O, ovulatory dysfunction; AUB-E, endometrial; CA, carcinoma; MRI, magnetic resonance imaging; SIS, sonohysterography; TVUS, transvaginal ultrasonography. Reprinted from Munro MG. Abnormal Uterine Bleeding. Cambridge: Cambridge University Press; 2010.

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

Countdown to CREOG

Video Resources

Included in All Editions

If you have any feedback or requests for topics to be covered, please reach out to Samhita Nelamangala at [email protected]