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A. Patient History

  1. Age
  2. Parity
  3. Last Menstrual Period
  4. Previous Menstrual Period
  5. Sexual Activity / Contraceptive Use

B. Differential Diagnosis

  1. Dysfunctional Uterine Bleeding
    1. Non-pregnant - wrong part of the menstrual cycle
    2. Pregnant - abnormal implantation, other abnormalities
  2. Infection
  3. Neoplasm (uterine cancer)
  4. Endometriosis
  5. Uterine Fibroids
  6. Uterine Hyperplasia / Polyps
  7. Normal Menstruation / Menorrhagia
  8. Vaginal Bleeding or Vaginal Atrophy
    1. Pregnancy associated - abnormal implantation, Rh Disease (Rh test performed)
    2. Non-pregnancy - premenopausal (concern for cancer) and post-menopausal
  9. Post-Menopausal Bleeding [2]
    1. Bleeding after withdrawal of replacement progestins (may be cyclical)
    2. Uterine Fibroids
    3. Complex endometrial hyperplasia (with atypia) and endometrial carcinoma (<2-5%)
    4. Over 95% of causes are benign in this group of patients
  10. Other
    1. Trauma
    2. Abuse
    3. Coagulopathy - including thrombocytopenia, von Willebrand Disease

C. Evaluation

  1. History and Physical Examination
  2. Pelvic Examination
  3. Complete Blood Count, electrolytes, promthrombin and partial thromboplastin times
  4. Pregnancy Test (nearly always performed)
    1. Qualitative: Urine Chorionic Gonadotropic (UCG)
    2. Quantitative HCG (chorionic gonadotropins) for all positive UCG
    3. Ultrasound should be considered
    4. Obstetrics consultation - any concerning pregnancies
  5. Ultrasound
    1. Pelvic Ultrasound - best for leiomyomas (fibroids), other uterine anomalies, ovaries
    2. Endovaginal Ultrasound
    3. For evaluation of pregnancy
  6. Endovaginal Ultrasound [3]
    1. To assess for thickened endometrium
    2. In 92% of abnormal endometrial biopsies, ultrasound showed >5mm endometrium
    3. In 96% of endometrial cancer by biopsy result, ultrasound showed >5mm endometrium
    4. Therefore, ultrasound measured endometrium <5mm is likely benign uterine condition
    5. Thickened endometrium may represent polyps, hyperplasia, or cancer
  7. Hysteroscopy [4]
    1. Direct endoscopic visualization of endometrial cavity
    2. Evaluation of polyps, endometrial cavity, suspicious areas (hyperplasia, neoplasia)
    3. High diagnostic accuracy for endometrial cancer
    4. Moderate diagnostic accuracy for hyperplasia (biopsy therefore required)
  8. Endometrial Biopsy
    1. Mainstay of diagnosis, required with any radiographic abnormality
    2. Usually office based procedure, though it is uncomfortable
    3. Poor sensitivity for polyps
    4. Good sensitivity for neoplasia, hyperplasia
    5. Important for women on unopposed estrogen or tamoxifen therapy
  9. Rh test on all vaginal bleeding in first trimester of pregnancy

D. Treatment

  1. Related to underlying cause
  2. Endometrial Resection
    1. Standard surgery effective in ~80% of patients with menorrhagia [1]
    2. Transcervical resection effective in 90% of patients 2 years after procedure [5]
  3. Menorrhagia [6,7]
    1. Levonorgestrel releasing intrauterine device (LNG-IUS) is alternative to hysterectomy
    2. LNG-IUS is an intrauterine system releases 20µg levonorgestrel in 24 hours over 5 years
    3. Over 5 years, ~50% of women with LNG-IUS underwent hysterectomy
    4. Costs overall (even with delayed histerectomy) substantially less with LNG-IUS
    5. Quality of life similar between hysterectomy and LNG-IUS
  4. Hysterectomy
    1. Often required in cases of severe uterine bleeding
    2. Subtotal hysterectomy results in more rapid recovery and fewer short term complications than total hysterectomy (but may have increased cyclical bleeding) [8]
  5. Early detection of endometrial cancer leads to excellent 5 year survival (Stage 1, 98%)
  6. Rh (D) immune globulin if Rh negative for bleeding in first trimester of pregnancy

References

  1. O'Connor H. and Magos A. 1996. NEJM. 335(3):151 abstract
  2. Good AE. 1997. Mayo Clin Proc. 72(4):345 abstract
  3. Smith-Bindman R, Kerlikowske K, Feldstein VA, et al. 1998. JAMA. 280(17):1510 abstract
  4. Clark TJ, Voit D, Gupta JK, et al. 2002. JAMA. 288(13):1611
  5. Cooper KG, Parkin DE, Garratt AM, Grant AM. 1999. Brit J Obstet Gynaecol. 106:258 abstract
  6. Hurskainen R, Teperi J, Rissanen P, et al. 2001. Lancet. 357(9252):273 abstract
  7. Hurskainen R, Teperi J, Rissanen P, et al. 2004. JAMA. 291(12):1456 abstract
  8. Thakar R, Ayers S, Clarkson P, et al. 2002. NEJM. 347(17):1318 abstract