Diagnosis of abnormal uterine bleeding

A structured approach should be used for evaluation of women with abnormal uterine bleeding:

A detailed history

• menstrual history
  • menarche
  • last menstrual period
  • duration, frequency and regularity of flow, intermenstrual or postcoital bleeding
• symptoms of anaemia
  • light-headedness
  • shortness of breath with activity
• sexual and reproductive history
  • previous pregnancies and mode of deliveries
  • future fertility desires
  • sub-fertlity
  • current contraceptive requirement
  • previous sexually transmitted infections
• associated symptoms
  • pelvic pain and/or pressure effects
  • discharge
• systemic
  • weight change
  • coagulopathy screening e.g. - features of a bleeding disorder - bleeding during dental work, history of very easy bruising, excessive bleeding since menarche
  • PCOS, liver, renal, thyroid, pituitary and adrenal disease
  • drug history – anti-platelet, anti-coagulant, tamoxifen, hormones, HRT, dopamine agonist
• family history
  • malignancy e.g. - endometrial or colon cancer
  • inherited coagulation disorders
• social
  • impact of symptoms
  • smoking (1,2)

Physical examination

• general assessment
  • vital signs
  • weight/BMI
  • thyroid exam
  • skin exam – pallor, bruising, striae, hirsutism, petichiae
  • abdominal exam – to detect an enlarged uterus, hepatosplenomegaly
• gynaecological assessment
  • inspection for any gross pathology – vulva, vagina, cervix, anus and urethra
  • speculum examination of the cervix is important
  • a bimanual pelvic examination can be used to assess the uterine size and mobility, pelvic tenderness and adnexal masses
  • rectal examination – if bleeding is suspected or risk of concomitant pathology (1,2)

investigations

• pregnancy test
• a complete blood count - to detect anaemia and thrombocytopaenia
• if history or physical examination indicates, the following tests should be carried out
  • thyroid function test
  • coagulation screen
  • prolactin, liver function test
• imaging - is indicated when examination suggests structural causes for bleeding, conservative management has failed, or there is a risk of malignancy
  • ultrasound
    • first-line diagnostic tool for identifying structural abnormalities,
    • transabdominal or transvaginal probes can be used
  • endometrial biopsy carried out in women with ultrasonic abnormalities
    • should be considered in all women with persistent menorrhagia
  • hysteroscopy
    • can be performed in the outpatient setting
    • should be used in cases where ultrasound results were inconclusive
    • can be therapeutic as well e.g. - removal of endometrial polyps, submucous fibroids or the endometrium
  • MRI
    • may be used when ultrasound provides indeterminate results or cannot be performed (1,2)

Reference:

1. Whitaker L, Critchley HOD. Abnormal uterine bleeding. Best Practice & Research Clinical Obstetrics & Gynaecology. 2016;34:54-65.
2. Singh S et al. Abnormal uterine bleeding in pre-menopausal women. J Obstet Gynaecol Can. 2013;35(5):473-475.