From the Guidelines
The workup for atypical uterine bleeding should begin with a thorough history and physical examination, followed by laboratory tests including a complete blood count, pregnancy test, thyroid function tests, and coagulation studies, as recommended by the most recent guidelines 1. The initial evaluation aims to identify the underlying cause of the bleeding, which can be structural or non-structural.
- Structural causes include endometrial polyps, adenomyosis, leiomyoma, malignancy, and endometrial hyperplasia, which can be diagnosed with imaging studies 1.
- Non-structural causes, such as coagulopathies, ovulatory dysfunction, and iatrogenic etiologies, cannot be assessed with imaging and require a thorough history and physical examination 1. Transvaginal ultrasound is the first-line imaging study to evaluate the endometrium and identify structural abnormalities, as it is a non-invasive and effective method for assessing the uterus and ovaries 1. For women over 35 or those with risk factors for endometrial cancer, endometrial sampling is recommended, typically via endometrial biopsy in the office setting, to rule out malignancy and identify treatable causes 1. Additional imaging studies, such as saline infusion sonohysterography, can better characterize intracavitary lesions, while hysteroscopy allows direct visualization and targeted biopsy 1. Management depends on the underlying cause but may include hormonal therapies, such as combined hormonal contraceptives or oral progestins, or non-hormonal options like tranexamic acid 1. Surgical options, including endometrial ablation or hysterectomy, may be considered for women who have completed childbearing or have failed medical management 1.
From the Research
Atypical Bleeding Workup
- The workup for atypical bleeding typically begins with a clinical assessment, pertinent history, and family history to determine the cause of bleeding 2.
- Routine screening tests include a complete blood cell count, platelet count, and evaluation of a peripheral blood sample, a prothrombin time, and an activated partial thromboplastin time 2.
- Thrombocytopenia may result from various conditions, including idiopathic thrombocytopenic purpura, disseminated intravascular coagulation, or acute leukemia, and can be evaluated through a well-prepared peripheral blood smear 2.
- An isolated prolongation of the activated partial thromboplastin time may indicate low levels of factors VIII, IX, or XI, while a slightly prolonged activated partial thromboplastin time and moderate decrease in factor VIII may suggest von Willebrand disease or the "carrier" state for hemophilia A 2.
Laboratory Tests
- Specific laboratory tests for von Willebrand disease include assays of factor VIII, von Willebrand factor antigen, von Willebrand factor activity, and template bleeding time 2.
- Multimeric analysis of von Willebrand factor can be done using sodium dodecyl sulfate gels, radiolabeled antibody to von Willebrand's factor, and autoradiography to determine the type of von Willebrand disease 2.
- Coagulation screens, including prothrombin time and activated partial thromboplastin time, may not always be associated with clinically significant decreases in coagulation factors 3.
- The bleeding time test can be used to evaluate platelet function, but its use is limited due to variability in results 4, 5.
Interpretation and Management
- Abnormal results from coagulation tests, such as prolonged prothrombin time, activated partial thromboplastin time, and bleeding time, require a practical approach to evaluation and may necessitate subspecialty consultation 4.
- Identification and basic management of bleeding disorders in adults involve a thorough history and physical examination, as well as knowledge of the pathophysiologic processes contributing to impaired hemostasis 6.
- Management of bleeding disorders is determined by bleeding phenotype and, for invasive procedures, the anticipated risk for bleeding, and may require consultation with a hematologist 6.