What is the workup for an anovulatory cause of abnormal uterine bleeding (AUB)?

From the Guidelines

The workup for anovulatory abnormal uterine bleeding (AUB) should begin with a thorough history and physical examination, followed by laboratory testing and imaging studies, as recommended by the American College of Radiology Appropriateness Criteria 1. The initial step in evaluating anovulatory AUB involves assessing the patient's medical history, physical examination, and selected laboratory and imaging tests, including a pregnancy test, thyroid-stimulating hormone and prolactin levels, and endometrial biopsy, as suggested by the American College of Obstetricians and Gynecologists (ACOG) 1. Key considerations in the workup include:

• Initial laboratory tests: pregnancy test, complete blood count, thyroid function tests (TSH, free T4), and prolactin levels
• Additional hormonal testing: follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol to evaluate ovarian function
• Imaging studies: combined transabdominal and transvaginal ultrasound of the pelvis with Doppler as the most appropriate initial imaging study 1
• Further testing: MRI of the pelvis without and with contrast, sonohysterography, or endometrial biopsy if the initial ultrasound is inconclusive or if the patient has risk factors for endometrial hyperplasia or cancer This comprehensive approach helps identify the underlying cause of anovulation, allowing for targeted treatment of the specific etiology, which may include polycystic ovary syndrome (PCOS), hypothalamic dysfunction, premature ovarian insufficiency, hyperprolactinemia, or thyroid disorders, as outlined in the ACOG guidelines 1.

From the Research

Workup for Anovulatory Cause of Abnormal Uterine Bleeding

The workup for anovulatory cause of abnormal uterine bleeding (AUB) involves a comprehensive approach to determine the underlying cause of the bleeding. The following steps are involved in the workup:

• Eliciting a focused menstrual history to identify patterns of bleeding and potential causes
• Performing a pelvic examination, including a vaginal speculum examination, to differentiate anovulatory bleeding from other causes of bleeding 2
• Using the PALM-COEIN classification system to categorize the cause of AUB, which includes:
  • Polyp
  • Adenomyosis
  • Leiomyoma
  • Malignancy and hyperplasia
  • Coagulopathy
  • Ovulatory dysfunction
  • Endometrial
  • Iatrogenic
  • Not yet classified 3, 4
• Conducting laboratory tests, such as a pregnancy test and complete blood count (CBC) with platelets, to rule out other potential causes of bleeding 4
• Considering the patient's medical history, family history, and sexual history to identify potential risk factors for anovulatory bleeding

Additional Considerations

In cases where anovulatory bleeding is suspected, additional considerations may include:

• Evaluating for polycystic ovary syndrome (PCOS), which is a common cause of anovulatory bleeding 5
• Considering the use of hormonal contraceptives, such as levonorgestrel-releasing intrauterine devices, to regulate menstrual cycles and reduce the risk of endometrial hyperplasia and cancer 5, 6
• Monitoring for potential complications of anovulatory bleeding, such as endometrial hyperplasia and cancer, and taking steps to prevent these complications 5