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) SUMMARY 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 Etiology Causes include structural abnormalities e.g., adenomyosis, uterine fibroids, malignancy, and polyps bleeding disorders and coagulopathies medications anovulation genital infection mnemonic PALM-COEIN login to view 9 more bullets Pathogenesis mechanism of AUB due to anovulation corpus luteum does not form absence of progesterone unapposed estrogen continues to proliferate the endometrium login to view 2 more bullets Presentation Symptoms variation of normal menstrual cycle symptoms of anemia light-headedness shortness of breath Physical exam dependent on etiology obesity, hirsutism, and acanthosis nigricans can suggests polycystic ovarian syndrome (PCOS) an enlarged pelvic mass may suggest leiomyoma Imaging studies transvaginal ultrasound first-line in adult patients when assessing for structural abnormalities STUDIES 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 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 login to view 2 more bullets NSAIDs or tranexamic acid can be used in patients who do not want to be treated with hormone therapy, or have contraindications login to view 4 more bullets in cases of menstrual bleeding due to ovulatory dysfunction reassurance in pediatric patients login to view 1 more bullet hormone therapy login to view 3 more bullets 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 Complications May be at increased risk for endometrial cancer or hyperplasia in AUB secondary to anovulation Prognosis Treatment may improve quality of life