Diagnosis
Definition: Abnormal uterine bleeding (AUB) refers to menstrual bleeding of abnormal quantity, duration, or schedule (i.e. it’s irregular, lasts too long, or too heavy)
H&P
Distinguish b/n uterine vs. non-uterine bleeding with the H&P.
Ovulatory (regular menses) vs. anovulatory (irregular menses) AUB
Ddx(PALM-COEIN).
Diagnostic studies
-R/o pregnancy.
Treatment
-Based on type – Ovulatory vs. non-ovulatory.
Background
Normal menstrual cycle: Interval: 24 – 35 days; Menses last: 4 – 7 days; Blood loss: 30 – 45 mL
Median age at menarche is between 12 years and 13 years in well-nourished populations in developed countries.
Menarche must start before the criteria for primary amenorrhea are met.
A normal menstrual cycle requires a normal functioning hypothalamus-pituitary-ovarian (HPO) axis. If the HPO axis is functioning, you get regular menses. If it’s not functioning well, you get irregular periods. That’s it.
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The predominant hormone that works in preventing ovulation is progesterone. Estrogen allows you to use less progestin.
The progesterone surge
If no ovulation, no progesterone (the ovary is the source of progesterone in women). Continuous exposure to estrogen alone leads to a proliferation of the endometrium. This endometrium is unstable without progesterone. Estrogen = Bricks. Progesterone = Mortar. Without mortar, the wall continues to grow and then falls apart.
Low estrogen states = Light menses; irregular but light menses (need to check)
High estrogen states = irregular but heavy menses (need to check)
Cancer isn’t so organized. Bleeding from cancer is usually erratic/irregular vs. regular during menses.
CIN 3 is used as the surrogate for cervical cancer.
***The terms “dysfunctional uterine bleeding (DUB)” and “menorrhagia” are no longer used. They recommended term is Abnormal Uterine Bleeding.
“A 47-year-old female is concerned about a change in her menstrual pattern. Her monthly periods continue, but for the past several months they have been heavier than usual and have been lasting a few days longer. Last month she also noted some spotting for several days prior to the onset of her menses. Her pelvic examination is normal. Which one of the following would be most appropriate at this time?
Observation only, and reexamination in 3 months
A serum FSH level
Transvaginal ultrasonography
Progestin-only therapy to normalize bleeding
Cyclic estrogen-progestin therapy to normalize bleeding
Rationale:
Abnormal uterine bleeding can be a sign of endometrial cancer in premenopausal women, who account for 20% of cases of endometrial cancer. The American College of Obstetricians and Gynecologists recommends that women with abnormal uterine bleeding should be evaluated for endometrial cancer if they are older than 45 years or if they have a history of unopposed estrogen exposure (SOR C). Most guidelines recommend either transvaginal ultrasonography or endometrial biopsy as the initial study in the evaluation of endometrial cancer. Transvaginal ultrasonography is often preferred as the initial study because of its availability, cost-effectiveness, and high sensitivity. If bleeding persists despite normal transvaginal ultrasonography a tissue biopsy should be performed. The listed hormonal treatment options may be appropriate once cancer is ruled out. An FSH level can help determine whether someone is menopausal or approaching menopause, in which case they will likely be missing periods. Continued observation would only delay the diagnosis.” ABFM
References / Further Reading
Diagnosis and management of endometrial cancer. Am Fam Physician 2016;93(6):468-474.
Am Fam Physician. 2012 Jan 1;85(1):35-43. http://www.aafp.org/afp/2012/0101/p35.html
https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Menstruation-in-Girls-and-Adolescents-Using-the-Menstrual-Cycle-as-a-Vital-Sign
Int J Gynaecol Obstet. 2011 Apr;113(1):3-13. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. https://www.ncbi.nlm.nih.gov/pubmed/21345435.
FIGO 2011 article: http://sogc.com.ar/PALN-COEIN.pdf, Last Accessed 3/27/2018
http://obgyn.ucla.edu/fibroids, Last Accessed 3/27/2018
https://www.uptodate.com/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women