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Abnormal Uterine Bleeding May Be Best Evaluated by Menopausal Status

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http://www.medscape.com/viewarticle/555284

 

Abnormal Uterine Bleeding May Be Best Evaluated by Menopausal Status CME

 

News Author: Laurie Barclay, MD

CME Author: D?sir?e Lie, MD, MSEd

Disclosures

 

Release Date: April 17, 2007; Valid for credit through April 17, 2008 Credits Available spacer.gifspacer.gifdots480.gif

Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)? for physicians;

Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians spacer.gif

 

April 17, 2007 ? The best approach to evaluating and treating abnormal uterine bleeding is to stratify women by premenopausal, perimenopausal, or postmenopausal status, according to a review published in the April issue of the Southern Medicine Journal. This review describes the differential diagnosis and diagnostic workup of abnormal uterine bleeding, defines an approach to etiology, and discusses treatment options.

 

"Disorders of the menstrual cycle are a common problem in ambulatory medicine, accounting for up to 30% of outpatient visits to gynecologists," write Sara B. Fazio, MD, and Amy N. Ship, MD, from the Harvard Medical School in Boston, Massachusetts. "Abnormal uterine bleeding describes bleeding that is excessive or outside the normal menstrual cycle. In the premenopausal woman, the differential diagnosis is broad, and pregnancy must always be considered."

 

In premenopausal women, after pregnancy has been excluded, the most important branch point is determining whether the bleeding is ovulatory or anovulatory. One of the most common causes of abnormal uterine bleeding is anovulation. In patients with anovulatory bleeding, treatment goals are to regulate cycles, minimize blood loss, and prevent iatrogenic complications from chronic unopposed estrogen treatment.

 

After determining the etiology of oligomenorrhea or amenorrhea, management should include maintenance of adequate estrogen to support bone health. The increasing incidence of endometrial hyperplasia and malignancy in the perimenopausal and postmenopausal population mandates a low threshold for endometrial assessment and referral to a gynecological specialist.

 

"Abnormal uterine bleeding is a common condition, and evaluation is best approached by stratifying into pre-, peri-, and postmenopausal status," the authors conclude. "Utilizing a systematic approach to the differential diagnosis will help to avoid a misdiagnosis. Much of the evaluation and treatment can be done in the office of the internist."

 

The authors have disclosed no relevant financial relationships.

 

South Med J. 2007;100:376-382.

 

 

Clinical Context

According to the authors of the current study, abnormal uterine bleeding accounts for up to 30% of outpatient visits to gynecologists and is described as bleeding that is excessive or outside of normal cyclic menstruation. A typical cycle interval is 21 to 35 days with an average flow duration of 2 to 8 days and estimated blood loss between 30 and 80 mL. Predictors of heavy bleeding include passage of clots, iron deficiency anemia, and volume depletion. While estrogen increases thickness and vascularity of the endometrium, progesterone increases the glandular secretions and vessel tortuosity, and withdrawal of sex steroids results in endometrial sloughing and bleeding.

 

This is a review of the differential diagnosis of abnormal uterine bleeding and treatment in premenopausal, perimenopausal, and postmenopausal women.

 

 

Study Highlights

  • A thorough history including sexual history and domestic violence screening is recommended.
  • Physical examination should include pelvic examination and identifying alternate sources of bleeding such as rectal or urethral.
  • For the premenopausal woman, the bleeding should be characterized as ovulatory or anovulatory.
  • In the perimenopausal and postmenopausal woman, malignancy becomes of greater concern.
  • Women with abnormal uterine bleeding should have a pregnancy test (if premenopausal), complete blood count, and a Papanicolaou test if not recently performed.
  • Cervical cultures may be indicated.
  • Ovulatory status may be determined using the basal body temperature method or serum progesterone levels.
  • If anovulatory cycles are suspected, thyroid function and prolactin level should be obtained.
  • Adolescents require a screening for hypothalamic causes and coagulopathy.
  • Luteinizing hormone/follicle-stimulating hormone and dehydroepiandrosterone sulfate levels can help in diagnosis of polycystic ovary syndrome (PCOS).

  • Premenopausal Women
    • Pregnancy must be considered and can present as amenorrhea or light spotting; early pregnancy, spontaneous abortion, and ectopic pregnancy are possibilities.
    • Anovulation can lead to episodic menstruation at short intervals and may occur in adolescence or near menopause.
    • Chronic anovulation may be caused by PCOS.
    • PCOS diagnosis is made when at least 2 of the following are present: oligomenorrhea or anovulation, clinical or laboratory evidence of androgen excess, and polycystic ovaries on ultrasound.
    • Ultrasound evidence is neither necessary nor sufficient to make a diagnosis of PCOS.
    • Anovulation also may occur in hypothalamic dysfunction (secondary to stress, systemic illness, and sudden weight loss) or with prolactinemia (caused by pituitary prolactinoma or neuroleptics).
    • Menorrhagia is reported in women with subclinical or overt hypothyroidism and Cushing's syndrome.
    • Uterine causes for abnormal uterine bleeding include fibroids (20% of women 35 years or older), adenomyosis, endometrial polyps, endometriosis, and endometrial hyperplasia.
    • Intrauterine devices can produce abnormal bleeding as can endometritis after delivery or spontaneous or therapeutic abortion.
    • Cervical disease including sexually transmitted infections, cervical polyps, and carcinoma should be considered.
    • Vaginal and vulvar disease, trauma, and injury are other possible causes of abnormal uterine bleeding.
    • Among drugs, low-estrogen contraceptives, medroxyprogesterone injection, and hormone replacement may produce intermenstrual bleeding, whereas phenothiazines can induce anovulatory cycles.
    • Smokers may have breakthrough bleeding associated with increased metabolism of estrogen.
    • The goal of treatment of anovulatory bleeding is to regulate cycles, minimize blood loss, and prevent complications.

    [*]Perimenopausal and Postmenopausal Women

    • Because chronic anovulation can lead to prolonged periods of unopposed estrogen, a low threshold for endometrial assessment is recommended in this population.
    • Irregular bleeding of more than 6 months and cycle length of less than 17 to 19 days are considered indications for endometrial assessment.
    • The risk for endometrial cancer in a postmenopausal woman not receiving hormone replacement therapy is approximately 10%.
    • Office-based endometrial biopsy has a false-negative rate of up to 5% to 15% while transvaginal ultrasound has a sensitivity of 90% and negative predictive value of 99%.
    • The most common sources of bleeding in postmenopausal women are atrophic vaginitis, endometrial atrophy, and endometrial polyps.

Pearls for Practice

  • Abnormal uterine bleeding should be classified as premenopausal, perimenopausal, or postmenopausal and characterized as ovulatory vs anovulatory for further workup.
  • Some of the causes of abnormal uterine bleeding in premenopausal women are related to hormonal (anovulation, hypothalamic, exogenous hormones), local (vaginal, cervical or vulvar) or systemic (coagulopathy, smoking) sources, whereas some of the causes in premenopausal and postmenopausal women focus on uterine (endometrial hyperplasia and carcinoma) and local (atrophic vaginitis, cervicitis) sources.

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