What is the step-wise evaluation and management of dysfunctional uterine bleeding?

Step-wise Evaluation and Management of Dysfunctional Uterine Bleeding

The evaluation of dysfunctional uterine bleeding should begin with ruling out structural causes through transvaginal ultrasound, followed by appropriate laboratory testing and possibly endometrial sampling, before proceeding to medical or surgical management based on the PALM-COEIN classification system. 1

Initial Assessment

History and Physical Examination Focus Points

• Bleeding pattern: regularity, volume, frequency, duration
• Age-related considerations: adolescence, reproductive age, perimenopause
• Risk factors for endometrial cancer
• Medication use (hormonal contraceptives, anticoagulants)
• Symptoms of thyroid dysfunction, hyperprolactinemia, PCOS
• Physical examination to assess for structural abnormalities

Laboratory Testing

1. Pregnancy test (β-hCG)
2. Complete blood count
3. Thyroid-stimulating hormone
4. Prolactin level
5. Coagulation studies (especially if heavy menstrual bleeding)

Imaging Evaluation

First-Line Imaging

• Transvaginal ultrasound (TVUS) - Usually Appropriate as first imaging study 1
  • Evaluates endometrial thickness
  • Identifies structural abnormalities (polyps, fibroids, adenomyosis)
  • Limitations: body habitus, uterine position, presence of leiomyomas

Second-Line Imaging (if TVUS is inconclusive)

• Saline infusion sonohysterography - High sensitivity (96-100%) for endometrial pathology 1

  • Better visualization of intracavitary lesions
  • Can confirm whether intracavitary lesions are present

• MRI with diffusion-weighted imaging 1

  • When TVUS cannot adequately visualize the endometrium
  • Superior for evaluating adenomyosis and leiomyomas
  • Excellent tissue contrast resolution
  • Can visualize endometrium even with leiomyomas present

Endometrial Sampling

• Indications for endometrial biopsy:
  • Women ≥35 years with recurrent anovulation
  • Women <35 years with risk factors for endometrial cancer
  • Excessive bleeding unresponsive to medical therapy
  • Postmenopausal bleeding

Classification Using PALM-COEIN System

The PALM-COEIN classification system helps categorize abnormal uterine bleeding: 1

• Structural causes (PALM):

  • Polyp
  • Adenomyosis
  • Leiomyoma (submucosal or other)
  • Malignancy and hyperplasia

• Non-structural causes (COEIN):

  • Coagulopathy
  • Ovulatory dysfunction
  • Endometrial
  • Iatrogenic
  • Not yet classified

Management Algorithm

1. Acute Heavy Bleeding Management

• High-dose estrogen therapy for acute control
• Consider dilation and curettage if bleeding results in hypovolemia 2

2. Anovulatory Bleeding Management

• Adolescents:

  • Medroxyprogesterone acetate 10 mg daily for 10 days each month for ≥3 months 2

• Reproductive-age women:

  • Combined hormonal contraceptives if contraception is desired
  • Medroxyprogesterone acetate 5-10 mg daily for 5-10 days beginning on day 16-21 of cycle 3
  • Clomiphene citrate if pregnancy is desired 2

• Perimenopausal women:

  • Cyclic progestin therapy
  • Low-dose combined oral contraceptives (if non-smoker without vascular disease)
  • Conjugated estrogens with medroxyprogesterone acetate 2

3. Ovulatory Bleeding (Menorrhagia) Management

• First-line options:

  • Levonorgestrel-releasing intrauterine system - most effective non-surgical option 4, 5
  • Nonsteroidal anti-inflammatory drugs 4
  • Tranexamic acid (antifibrinolytic) - FDA approved but expensive 4

• Second-line options:

  • Oral progestins for 21 days per month 4
  • Danazol
  • GnRH agonists (last resort due to side effects) 2

4. Surgical Management (when medical therapy fails)

• Uterus-sparing procedures:

  • Polypectomy or fibroidectomy for structural causes
  • Endometrial ablation techniques
  • Uterine artery embolization for fibroids

• Definitive treatment:

  • Hysterectomy - most definitive but has higher complication rate 4, 5

Special Considerations

Endometrial Hyperplasia

• Hyperplasia without atypia: Cyclic or continuous progestin therapy
• Hyperplasia with atypia: Refer to gynecologist
• Adenocarcinoma: Refer to gynecologic oncologist 4

Common Pitfalls to Avoid

1. Failing to rule out pregnancy before initiating treatment
2. Missing coagulopathies (especially von Willebrand disease) - present in approximately 1% of population 2
3. Inadequate evaluation of the endometrium in women at risk for endometrial cancer
4. Treating without proper diagnosis of the underlying cause
5. Failing to recognize when TVUS is inadequate and additional imaging is needed 1

By following this step-wise approach to evaluation and management, clinicians can effectively diagnose and treat dysfunctional uterine bleeding while minimizing risks and optimizing outcomes for patients.