From the Guidelines
The initial evaluation of a young female with abnormal vaginal bleeding should begin with a thorough history and physical examination, followed by laboratory testing including a complete blood count, pregnancy test, and coagulation studies, as recommended by the most recent guidelines 1. The evaluation process is crucial in determining the underlying cause of the abnormal bleeding, which can be due to structural or non-structural causes.
- Structural causes include endometrial polyps, adenomyosis, leiomyoma, malignancy, and endometrial hyperplasia, which can be diagnosed with imaging studies 1.
- Non-structural causes include coagulopathies, ovulatory dysfunction, primary endometrial disorders, iatrogenic etiologies, and other causes not otherwise classified 1.
Initial Management
For acute heavy bleeding, hormonal therapy is often first-line, with combined oral contraceptives (such as ethinyl estradiol 35 mcg/norethindrone 1 mg) given 3 times daily for 7 days, then daily for 3 weeks, as supported by recent studies 1. Alternatively, medroxyprogesterone acetate 10 mg daily for 10-14 days can be used.
- For hemodynamically unstable patients, IV conjugated estrogens 25 mg every 4-6 hours may be necessary.
- Iron supplementation (ferrous sulfate 325 mg three times daily) should be initiated if anemia is present.
- NSAIDs like ibuprofen 600-800 mg three times daily can help reduce blood loss.
- Tranexamic acid 1300 mg three times daily during menses is effective for reducing heavy bleeding.
Long-term Management
Long-term management should address the underlying cause, which may include structural abnormalities, endocrine disorders, coagulopathies, or medication effects.
- If an underlying gynecologic problem is identified, treat the condition or refer for care.
- If an underlying gynecologic problem is not found and the woman wants treatment, consider hormonal treatment (if medically eligible) with low-dose COCs or estrogen for short-term treatment (10–20 days) 1.
- If irregular bleeding persists and the woman finds it unacceptable, counsel her on alternative methods, and offer another method if it is desired.
From the Research
Initial Evaluation
The initial evaluation of a young female presenting with abnormal vaginal bleeding should include:
- A prompt assessment for signs of hypovolemia and potential hemodynamic instability 2
- A sensitive pregnancy test to exclude pregnancy as a cause of bleeding 3
- Laboratory tests such as hemoglobin and hematocrit determinations, platelet count, and occasionally coagulation studies 3
Classification and Diagnosis
The etiologies of acute abnormal uterine bleeding should be classified using the PALM-COEIN system 2
- Imaging modalities such as transvaginal ultrasound (TVUS) may be used to screen for structural abnormalities and direct patient care 4
- Endometrial biopsy or dilation and curettage may be necessary to rule out endometrial hyperplasia or other pathology 3
- Hysteroscopy with selected biopsy or curettage may be superior to routine dilation and curettage in evaluating abnormal ovulatory bleeding 3
Management
Medical management should be the initial treatment for most patients, if clinically appropriate 2
- Options include:
- Intravenous conjugated equine estrogen
- Multi-dose regimens of combined oral contraceptives or oral progestins
- Tranexamic acid
- Surgical management should be considered for patients who are not clinically stable, are not suitable for medical management, or have failed to respond appropriately to medical management 2
- Treatment options for patients having ovulatory cycles include an oral contraceptive, an oral progestin, danazol (Danocrine), a gonadotropin-releasing hormone agonist, mefenamic acid (Ponstel), and surgery 3
Special Considerations
Cancer of the cervix is a serious cause of abnormal vaginal bleeding and should not be missed 5
- Endometrial carcinoma is a worrisome cause of abnormal bleeding, but benign etiologies such as fibroids, polyps, and endometrial atrophy are more prevalent 6