Chapter 76 Abnormal Uterine Bleeding
Clinical Case Problem 1 A 35-Year-Old Woman with Heavy Menses
Select the best answer to the following questions
1. The patient’s bleeding pattern is best described as
2. Which of the following should initially be considered in the differential diagnosis of this patient’s problem?
3. Which of the following is not appropriate for the initial workup of this patient?
4. The most likely diagnosis in this patient is
5. What is the most likely underlying mechanism for this patient’s abnormal bleeding?
6. Your patient returns to discuss test results. They are all normal except her hemoglobin level is 10.8 g/dL. She does not desire future fertility and has no method of birth control at this time. Which of the following therapies would not be an appropriate medical management option for this patient?
Clinical Case Problem 2: A 25-Year-Old Woman with Amenorrhea
7. Which of the following best describes this patient’s bleeding pattern?
8. Which of the following would be the least likely cause for this patient’s bleeding pattern?
9. You perform a urine pregnancy test, and the result is negative. Which of the following laboratory studies should be done as initial workup for this patient?
10. What is the most appropriate initial step in the evaluation of this patient’s condition?
11. The patient’s laboratory studies come back normal. She had a positive response to a progestin challenge. At this time, what would be the most beneficial medical therapy for this patient?
Clinical Case Problem 3 A 55-Year-Old Woman with Postmenopausal Bleeding
12. You perform a Pap smear and a gonorrhea/ chlamydia screen. You also check a CBC and TSH. What else do you recommend to the patient at this time?
13. A transvaginal ultrasound examination is performed and is read as “no structural abnormalities, normal-sized uterus and ovaries, 9 mm endometrial stripe noted.” What should be the next step in this patient’s management?
Clinical Case Problem 4 A 27-Year-Old Woman with Oligomenorrhea
14. What condition do you suspect in this patient?
15. All of the following laboratory studies are appropriate for initial evaluation except
16. The patient returns after 2 weeks to discuss her blood test results. Her pregnancy test result is negative, and her prolactin, TSH, and 17-hydroxyprogesterone levels are normal. Her LH/FSH ratio is 4:1, and her testosterone level is mildly elevated. Which of the following treatment options has (have) been found to be beneficial in the treatment of her condition?
Answers
1. a. This patient has menometrorrhagia, which is defined as excessive menstrual bleeding (>80 mL/cycle) that occurs at irregular intervals. Metrorrhagia is defined as irregular, frequent bleeding of varying amounts, but not excessive. Menorrhagia is excessive bleeding (>80 mL/cycle) that occurs at regular intervals. Polymenorrhea is regular bleeding at intervals of less than 21 days. Oligomenorrhea is bleeding at intervals longer than every 35 days.
2. e. All of the listed answers could be causes of the patient’s bleeding. DUB refers to uterine bleeding for which no specific genital tract lesion or systemic cause is found. If there is a secondary cause, it should be corrected if possible. The secondary causes that should be considered include the following: (1) uterine (especially submucous) fibroids, (2) endometriosis, (3) adenomyosis, (4) chronic PID, (5) endometrial or endocervical polyps, (6) coagulation defects, (7) morbid obesity, (8) ovarian abnormalities, (9) severe hypothyroidism, (10) adenomatous hyperplasia, and (11) endometrial carcinoma.
3. c. The first and most important condition to rule out is pregnancy. A urine pregnancy test is quick and inexpensive to perform and should be done as part of initial evaluation. Once pregnancy has been ruled out, one can proceed with a further workup. A pelvic examination should be performed to assess for structural lesions such as a cervical polyp or uterine fibroid. A CBC should be done to assess for anemia. Other laboratory studies, such as chemistry panel and liver function tests, can be done if there is suspicion of systemic hepatic or renal disease. Routine performance of these studies in otherwise healthy patients generally does not reveal useful information. TSH and serum prolactin should be considered in women deemed anovulatory. A thorough history should be sought for bleeding dyscrasia (history of easy bruising, epistaxis, bleeding gums, and family history), particularly in adolescents presenting with menorrhagia. Bleeding disorders have been demonstrated in up to 10.7% of women presenting with menorrhagia, the most common being von Willebrand disease. Laboratory assessment for an inherited coagulation disorder should be done if indicated by history. Transvaginal ultrasonography is not necessary in the initial evaluation unless pelvic examination reveals abnormalities or an adequate pelvic examination was unable to be performed (because of body habitus or patient discomfort). Testosterone and DHEAS levels should be considered if there is evidence of androgen excess (hirsutism or acne) or virilization (male pattern baldness, deepening voice, and clitoromegaly), but these are not routinely indicated in the evaluation of irregular bleeding.
4. a. The most likely cause for bleeding in this patient is DUB. Her history of normal Pap smears and low-risk sexual history make PID and cervical carcinoma unlikely. Given her age (younger than 35 years), endometrial carcinoma is unlikely but should always be considered in the differential diagnosis. There should be a low threshold to perform endometrial biopsy if her bleeding is not responsive to medical therapy.
5. b. The most common cause of DUB is anovulatory bleeding. Ovulatory DUB accounts for less than 10% of all DUB. When the uterine lining is sequentially proliferated by estrogen and then ripened with progesterone (secretory phase), the endometrium is structurally stable. Sloughing of the endometrium does not occur unless progesterone withdrawal takes place. When progesterone is withdrawn, the tissue breakdown is orderly and progressive. Bleeding is limited in both amount and duration by spiral arteriolar vasoconstriction. Menstrual shedding is simultaneous in all endometrial segments. This is why ovulatory cycles are regular and predictable from month to month. In anovulatory states, the uterine lining is proliferated by estrogen alone without progesterone to stabilize it, and the endometrium continues to thicken. When the endometrial proliferation reaches a given thickness, it outgrows its blood supply and starts to shed, but this bleeding is not accompanied by spiral arteriolar vasoconstriction. Therefore, it is not limited in either amount or duration and can occur at any time. Endometrial shedding occurs at random times from random sites within the uterus. This is why anovulatory bleeding is irregular and unpredictable.
In the evaluation of abnormal uterine bleeding, it is often helpful to consider the patient’s reproductive status:
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