Approach

In the majority of women with AUB, the menstrual history alone can establish the diagnosis with sufficient confidence, and treatment can be started without any further laboratory evaluation or imaging.

History

  • Menstrual history: the nature and extent of uterine bleeding is crucial in determining the underlying cause, as well as the extent of the negative impact on the patient's quality of life. This includes:

    • Frequency

    • Regularity

    • Volume

    • Duration

    • Onset of abnormal menstrual loss (e.g., peri-menarcheal, sudden, gradual)

    • Temporal association (e.g., post-coital, postnatal, post-pill, weight gain, or weight loss).

  • Sexual and reproductive history: parity and mode of birth, need for fertility and or uterine preservation, need for contraception, history of STIs, cervical smear history, and exclusion of pregnancy.

  • Medicines: use of hormonal medications, drugs interfering with the hypothalamic-pituitary-ovarian axis (e.g., GnRH agonists and antagonists, SSRIs, tricyclic antidepressants), oral contraceptive pill, non-prescription supplements, and complementary medicines. Also note use of other medications such as warfarin, non-steroidal anti-inflammatory drugs (NSAIDs), gingko, ginseng, and motherwort.[11]

  • Associated symptoms: pelvic pain, pelvic pressure (constipation and urinary frequency), vaginal discharge, dysmenorrhoea, and inter-menstrual bleeding (IMB).

  • Medical history: bleeding disorders and other associated complaints are important to exclude, particularly in young, post-puberty patients.[19] Endocrine disorders, such as thyroid problems, may be a cause of AUB.[24] Breast milk secretion (galactorrhoea) is suggestive of hyperprolactinaemia.

  • Age of menarche.

  • Menopausal symptoms: these are important clues in women late in their reproductive life. AUB in these patients may be related to the peri-menopausal period.

  • Symptoms of anovulatory AUB: irregular menstrual cycle, absence of premenstrual molimina (e.g., breast fullness and tenderness, weight gain, and mild mood swings), features of polycystic ovary syndrome (PCOS) (e.g., hirsutism, acne, acanthosis nigricans), and obesity are clues for anovulation.

  • Impact on quality of life.

Physical examination

Examination should be directed towards determining the severity of uterine bleeding, identifying structural and histological abnormalities, and investigating the possibility of other pelvic disorders.

  • In patients who present with acute AUB, the assessment should focus on signs of acute blood loss, such as hypovolaemia and anaemia.[45] Excessive uterine bleeding or persistent bleeding for long periods can be associated with acute or chronic anaemia. Acute bleeding may present with unstable vital signs, and chronic bleeding may be associated with non-specific manifestations of chronic iron deficiency anaemia, such as fatigue, dyspnoea, and pallor on examination.

  • In adults, a vaginal speculum and bi-manual examination should be performed to examine the cervix and assess the size and shape of the uterus.[11] In acute AUB it is important to establish that the patient is not bleeding from other areas of the genital tract, and to determine the amount and intensity of bleeding.[45]

  • In the UK, the National Institute for Health and Care Excellence (NICE) guidance suggests that in women with heavy menstrual bleeding without other related symptoms (e.g., IMB, pelvic pain, pelvic pressure, symptoms suggestive of a histological or structural cause, including fibroids, adenomyosis), pharmacological treatment may be considered without a physical examination (unless the chosen treatment is the levonorgestrel-releasing intrauterine device).[3]

Laboratory evaluation

A pregnancy test should be carried out in all women of reproductive age who have any deviation from their normal pattern of menstrual bleeding. Following that, a full blood count (FBC), thyroid-stimulating hormone level, and cervical cancer screening should be considered in all patients. Carry out an FBC for all women with heavy menstrual bleeding (HMB).[3] Chlamydia screening should also be considered, particularly in patients at high risk of infection.[11]

In women with HMB, routine testing of ferritin or hormone profile is not routinely recommended, and in the UK, NICE guidance does not recommend thyroid hormone testing unless signs or symptoms of thyroid disease are present. The American College of Obstetricians and Gynecologists (ACOG) suggest that screening for thyroid disease is inexpensive and reasonable for women with AUB.[11] Coagulation profile is indicated if HMB started at menarche, or if there is family history of coagulation disorders.

In summary, the tests that are not routinely indicated are: serum ferritin, luteinizing hormone, follicle-stimulating hormone, estradiol, progesterone, thyroid profile (unless signs and symptoms of thyroid disorder are present), and a coagulation screen.

Further investigation

A transvaginal ultrasound scan (TVUS) is usually the initial imaging test to evaluate AUB, particularly if there is any abnormality detected on physical examination that could be suggestive of uterine pathology, such as an enlarged uterus due to fibroids or adenomyosis. In women with AUB, TVUS is recommended in the following scenarios:

  • History or examination suggestive of a structural abnormality (pelvic mass, fibroids, polyps)

  • History or examination suggestive of a histological abnormality

  • Physical examination is inconclusive

  • Suspected adenomyosis (dysmenorrhoea and/or bulky tender uterus on pelvic examination)

  • Pelvic pain and/or pressure symptoms

  • Inter-menstrual bleeding (IMB)

Carry out endometrial sampling with TVUS in patients at high risk of hyperplasia, atypia, or cancer.

If TVUS is unacceptable, trans-abdominal ultrasound or magnetic resonance image (MRI) may be offered.[3] The use of MRI will be limited by availability and resources.

Hysteroscopy is recommended in the following cases and should be coupled with endometrial sampling, if indicated:

  • Persistent IMB

  • Ultrasound suggests a structural cause within or distorting the uterine cavity (polyps, submucous fibroids)

  • Risk factors for endometrial pathology (endometrial hyperplasia, cancer)[3]​​

  • Age >45 years

  • Nulliparity

  • Persistent irregular bleeding

  • Obesity

  • PCOS

  • Hypertension

  • Diabetes

  • Family history of breast, colon, or endometrial cancer (e.g., Lynch syndrome)

  • History of tamoxifen use

  • Failure of medical management.

Endometrial sampling should only be performed in the context of a hysteroscopy, rather than a blind biopsy.[3]

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