Updated: 12/11/2019

Abnormal Uterine Bleeding (AUB)

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Snapshot
  • A 39-year-old woman presents with abnormal heavy menstrual bleeding along with increased pelvic pressure. She denies pain and is not using any hormonal contraception. She uses multiple sanitary pads per day. On pelvic examination, there is an enlarged uterus with asymmetric contours. The uterus is non-tender to palpation. (Uterine leiomyomas)
Introduction
  • Also known as dysfunctional uterine bleeding (DUB)
  • Abnormal menstrual bleeding with regards to
    • quantity, duration, or schedule
  • The patient must not be pregnant
    • therefore, pregnancy must be ruled out
  • Causes include
    • structural abnormalities
      • e.g., adenomyosis, uterine fibroids, malignancy, and polyps
    • bleeding disorders and coagulopathies
    • medications
    • anovulation
    • genital infection
    • mnemonic
      • PALM-COEIN
        • Polyps
        • Adenomyosis
        • Leiomyomas
        • Malignancy & hyperplasia
        • Coagulopathy
        • Ovulatory dysfunction
        • Endometrial
        • Iatrogenic (e.g., medications)
        • Not yet classified (e.g., arteriovenous malformations, and chronic endometritis)
  • Pathogenesis
    • mechanism of AUB due to anovulation
      • corpus luteum does not form
      • absence of progesterone
      • unapposed estrogen continues to proliferate the endometrium
        • the endometrium becomes unstable and outgrows its blood supply
          • endometrial sloughing and breakthrough bleeding results
Presentation
  • Symptoms
    • variation of normal menstrual cycle
    • symptoms of anemia
      • light-headedness
      • shortness of breath
  • Physical symptoms
    • dependent on etiology
      • obesity, hirsutism, and acanthosis nigricans can suggests polycystic ovarian syndrome (PCOS)
      • an enlarged pelvic mass may suggest leiomyoma
Evaluation
  • Evaluation is dependent on likely cause of AUB
  • β-hCG
    • to rule out pregnancy
    • can be serum and urine
  • Blood testing
    • complete blood count (CBC)
    • coagulation studies
      • consider in patients with a history of bleeding disorder
    • thyroid-stimulating hormone (TSH)
      • in those with a history concerning for thyroid disease
  • Imaging studies
    • transvaginal ultrasound
      • first-line in adult patients when assessing for structural abnormalities
  • Endometrial biopsy
    • can be considered when
      • > 45 years of age
      • when refractory to treatment
      • < 45 years of age with high risk of endometrial cancer
Differential
  • Refer to introduction (PALM-COEIN)
Treatment
  • Treat the underlying cause of AUB
  • Treatment
    • in cases of heavy menstrual bleeding (most commonly due to leiomyomas or adenomyosis)
      • hormone therapy
        • estrogen-progestin contraception or levonorgestrel-releasing intrauterine devices are first-line
        • progestin-only treatment is reasonable
      • NSAIDs or tranexamic acid can be used in patients who do not want to be treated with hormone therapy, or have contraindications
        • NSAIDs decrease endometrial prostaglandin synthesis
          • results in decreased blood loss
        • tranexamic acid prevents plasminogen from being converted to plasmin
          • this in turn decreases fibrinolysis
    • in cases of menstrual bleeding due to ovulatory dysfunction
      • reassurance in pediatric patients
        • in a pediatric patient it is a normal finding secondary to an immature hypothalmic-pituitary-ovarian axis
      • hormone therapy
        • estrogen-progestin contraceptives, oral progestin therapy, or levonorgestrel-releasing intrauterine device are first-line

  • Surgical treatment
    • used in cases that are refractory to medical therapy or patient preference
      • heavy menstrual bleeding due to leiomyomas or adenomyomas is an indication for surgery
    • must assess whether patient wants to become pregnant or has completed childbearing
    • myomectomy
      • can be an option in patients who desire future pregnancy
    • endometrial ablation
    • uterine artery embolization
    • hysterectomy
      • definitive therapy
Prognosis, Prevention, and Complications
  • Prognosis
    • treatment may improve quality of life
  • Complications
    • may be at increased risk for endometrial cancer or hyperplasia in AUB secondary to anovulation
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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