Obgyno Wino Podcast Episode 73 - Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women
“I am all in favour of science and reason if they are scientific and reasonable. But I am against granting scientists and the materialist worldview an exemption from critical thinking and skeptical investigation. We need an enlightenment of the Enlightenment” ― Rupert Sheldrake
PB#128 - Published July 2012 (Reaffirmed 2016)
"Normal menstruation" is classified by ACOG as: 5 days of bleeding with cycle length of 21-35 days
PALM-COIEN is a classification system for abnormal uterine bleeding.
Get good at SIS and hysteroscopy! A meta-analysis found intrauterine cavitary anomalies in roughly 50% of women with AUB
Fibroids tend to present as heavy periods. Polyps tend to present as intermenstrual bleeding. Adenomyosis presents with painful and heavy periods.
Accuracy of blind endometrial biopsy is great if (a) an adequate sample is collected and (b) the endometrial process is global. A blind EMB can miss cancer if less than 50% of the endometrium is involved.
What's a normal bleeding pattern?
- 5 days of bleeding is considered typical
- cycle length: from day 1 of bleed until day 1 of next bleed
- cycle length is typically 21-35 days
- oligomenorrhea: bleeding less frequently than every 35 days
- polymenorrhea: bleeding more frequently than every 21 days
- heavy menstrual bleeding: >80 cc of blood while menstruating, but this is value is only useful in research; the current definition is based on patient's perception of "too much"
Note: "Menorrhagia" has been replaced by "heavy menstrual bleeding" and "metrorrhagia" has been replaced by "intermenstrual bleeding".
Causes of bleeding
- look no further than the PALM-COEINE classification system:
- the first five categories are pretty self-explanatory
- AUB-O generally refers to endocrinopathies like PCOS or the irregular hormonal fluctuations at the extremes of reproductive age (large category that is a common culprit)
- AUB-E generally refers to deficiency in local production of prostaglandins or endothelin-1 or an excess of plasminogen activator
- AUB-I generally refers to the use of systemic hormonal agents, intrauterine contraceptive devices, or other contraceptive devices (e.g. implantable devices like Nexplanon)
- multiple factors may be present
- clinical history and physical exam will be most important to identifying the cause of AUB
- ask about medications: anticoagulants, NSAIDs, gingko, ginseng, and motherwort can cause AUB
Note: Fibroids tend to present as heavy periods. Polyps tend to present as intermenstrual bleeding. Adenomyosis presents with painful and heavy periods.
- see Box 2
- here is my step-by-step guide to the gyn physical exam:
Clothes on. Start with complex history, especially related to menstruation
Perform general physical assessment (keep an eye out for hirsutism, acne, goiter, akanthosis nigricans, petechiae, ecchymoses, skin pallor)
Ask that they undress from the waist down and then give them some privacy
Before you get started, review her recent PAP results and obtain consent for recollection if appropriate BEFORE she gets undressed
Place her feet in stirrups and perform a consensual external exam of the vulva and perianal region.
Now obtain consent for an interval exam. Insert a lubricated speculum into the vagina to reveal the cervix. Move as slowly or gently as necessary to optimize her comfort. Collect PAP if needed (and she consented). Inspect the vaginal walls and cervix.
At this time, if an endometrial biopsy (EMB) is indicated, consent her and collect your specimen.
Remove the speculum, then consent her for a bimanual exam. Insert one finger into the vagina and place the opposite hand above the pubic symphysis to gauge the size and shape of the uterus and to detected fullness or masses in the adnexa. Note any tenderness.
Allow the patient get dressed before you present your findings and management options
**The goal for the next few steps is to gather sufficient info but to minimize the time that she has to spend half naked in front of a stranger
- lab work can be helpful to evaluate for anemia, bleeding disorders (e.g. vWD, pregnancy, thyroid disorders (TSH), or chlamydial infection)
- while in the clinic, you can also perform saline-infusion sonohysterography (SIS) and ultrasound
- outpatient follow-up will likely be required for hysteroscopy or MRI
The most likely causes for AUB differ by age group
- most likely due to immaturity within the hypothalamic-pituitary-ovarian axis (AUB-O)
- could also be due to hormonal contraceptives (AUB-I), pregnancy, pelvic infection (AUB-N), or coagulopathies (AUB-C)
- most likely pregnancy, anovulatory cycles as seen in PCOS (AUB-O), structural lesions (AUB-L or AUB-P), use of hormonal contraception (AUB-I)
- could also be hyperplasia (AUB-M), but malignancy is uncommon in this age group
- dysregulated ovulatory cycles more likely as a woman approach menopause (AUB-O)
- endometrial hyperplasia or malignancy should always be considered, especially if cycles seems to be off (AUB-M)
- fibroids are super common in this age group (AUB-L)
- endometrial atrophy can be a cause in postmenopausal bleeding, but you should rule out malignancy
What's the role of imaging in the AUB work-up process?
- standard ultrasound: helpful to evaluate for fibroids; measuring endometrial echo complex (the EEC, or "stripe") isn't helpful in women of reproductive age; features of adenomyosis can also be seen on ultrasound such a a globular shape to the uterus versus the typical papaya shape; you can also look for polycystic-appearing ovaries; 56% sensitive for fibroids and 73% for polyps
- SIS or hysteroscopy: helpful to evaluate for intracavitary lesions like fibroids or polyps; also helpful in identifying focal thickening of EEC versus uniform; hysteroscopy is especially helpful for visualizing and biopsying cancer
Note: Get good at SIS and hysteroscopy! A meta-analysis found intrauterine cavitary anomalies in roughly 50% of women with AUB
- MRI: helpful in mapping fibroids (aka myomas) to determine any interfacing with the endometrium; not recommended as a routine practice, but could be useful if planning for myomectomy, or UAE. Also, the best method for visualizing adenomyosis (T2)
When is EMB appropriate?
- if <45 years, reasonable if patient is exposed to unopposed estrogen (e.g. obesity, PCOS) or in the case of medical management failure
- if >45 years, reasonable as a baseline screen in any AUB where hyperplasia/malignancy is suspected
How is it done?
- biopsy curette, uterine aspirator, hysteroscopy, or dilation and curettage (D&C)
- EMB accuracy is great if (a) an adequate sample is collected and (b) the endometrial process is global
- a blind EMB will miss cancer if less than 50% of the endometrium is involved
- 82% chance of cancer if EMB is positive for atypia/carcinoma (therefore workup stops there when result is positive)
- if result is negative, but suspicion remains high (e.g. persistent bleeding in presence of risk factors), further workup is recommended (see Figure 2 above)