Abnormal uterine bleeding

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A negative pregnancy test (urine or blood beta-hCG level) is a mandatory first step in the evaluation of AUB when pregnancy is a possibility. Pregnancy should be excluded in all sexually active women, even if using a method of contraception.[11]American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Jul 2012 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2012/07/diagnosis-of-abnormal-uterine-bleeding-in-reproductive-aged-women

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Diagnosis of anemia is important in determining the severity of AUB.[11]American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Jul 2012 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2012/07/diagnosis-of-abnormal-uterine-bleeding-in-reproductive-aged-women

Blood dyscrasias, such as leukemia and thrombocytopenia, can also be detected.[11]American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Jul 2012 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2012/07/diagnosis-of-abnormal-uterine-bleeding-in-reproductive-aged-women

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Diagnosis of underlying bleeding disorders is important, particularly in younger patients presenting with excessive uterine bleeding during their first menstrual cycles or those with a family history of bleeding disorders.[3]National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication]. https://www.nice.org.uk/guidance/ng88 [11]American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Jul 2012 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2012/07/diagnosis-of-abnormal-uterine-bleeding-in-reproductive-aged-women [46]James AH, Kouides PA, Abdul-Kadir R, et al. Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel. Am J Obstet Gynecol. 2009 Jul;201(1):12.e1-8. https://www.ajog.org/article/S0002-9378(09)00410-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/19481722?tool=bestpractice.com [47]American College of Obstetricians and Gynecologists. Committee opinion no. 785: screening and management of bleeding disorders in adolescents with heavy menstrual bleeding. Sep 2019 [internet publication]. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/09/screening-and-management-of-bleeding-disorders-in-adolescents-with-heavy-menstrual-bleeding

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Only indicated if clinical evaluation suggests either hypo- or hyperthyroidism. In the US, thyroid testing is routinely recommended.[3]National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication]. https://www.nice.org.uk/guidance/ng88 [11]American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Jul 2012 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2012/07/diagnosis-of-abnormal-uterine-bleeding-in-reproductive-aged-women

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A transvaginal ultrasound scan (TVUS) is the preferred method to rule out structural abnormalities (e.g., fibroids, adenomyosis). If unacceptable, organize a transabdominal ultrasound or magnetic resonance imaging (MRI) scan.[3]National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication]. https://www.nice.org.uk/guidance/ng88 [11]American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Jul 2012 [internet publication]. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2012/07/diagnosis-of-abnormal-uterine-bleeding-in-reproductive-aged-women

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Hysteroscopy is recommended when endometrial cavity pathology (e.g., endometrial polyps, submucous leiomyomas) or endometrial pathology (e.g., endometrial hyperplasia, cancer) is suspected.[3]National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication]. https://www.nice.org.uk/guidance/ng88

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Consider endometrial biopsy in women at high risk of endometrial pathology (e.g., hyperplasia, cancer).[3]National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication]. https://www.nice.org.uk/guidance/ng88 ​ Risk factors include: age >45 years; nulliparity; persistent irregular bleeding; obesity; polycystic ovary syndrome (PCOS); hypertension; diabetes; family history of breast, colon, or endometrial cancer (e.g., Lynch syndrome); history of tamoxifen use; and failure of medical management.  

Endometrial sampling should only be performed in the context of a hysteroscopy, rather than a blind biopsy.[3]National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication]. https://www.nice.org.uk/guidance/ng88

Women with a raised BMI, diabetes, hypertension, PCOS, age >45 years, nulliparity, late menopause, unopposed estrogen exposure, tamoxifen use, and those with a family history of breast, colon, or endometrial cancer (e.g., Lynch syndrome), are at a high risk of AUB caused by malignancy. Consider endometrial sampling in these populations, irrespective of age.