What is the workup and treatment for a 27-year-old female with abnormal uterine bleeding (AUB) for 2 months, normal urinalysis, and a negative pregnancy test?

Workup and Treatment for Abnormal Uterine Bleeding in a 27-Year-Old Female

For a 27-year-old female with abnormal uterine bleeding (AUB) for 2 months, the initial workup should include pregnancy and structural cause exclusion, followed by treatment with combined hormonal contraception or progestin-only methods as first-line therapy. 1

Diagnostic Workup

Laboratory Tests

• Pregnancy test (already negative in this case)
• Complete blood count to assess for anemia
• TSH and prolactin levels to rule out thyroid disease and hyperprolactinemia 1, 2
• Coagulation studies if heavy bleeding is present
• Beta-hCG quantitative test (even with negative urine test) to definitively rule out pregnancy and gestational trophoblastic disease 3
• Hormonal measurements (days 3-6 of cycle): LH, FSH, testosterone, androstenedione, DHEAS 2

Imaging

• Transvaginal ultrasound (TVUS) is the most appropriate initial imaging study 1
  • Evaluates endometrial thickness
  • Identifies structural abnormalities (polyps, fibroids, adenomyosis)
  • Assesses ovaries for PCOS features
• If TVUS is inconclusive or structural abnormality is suspected:
  • Saline infusion sonohysterography (sensitivity 96-100%) for better visualization of intracavitary lesions 1
  • MRI if ultrasound cannot adequately visualize the endometrium due to patient factors 1

Additional Testing

• Endometrial biopsy if:
  • Patient has risk factors for endometrial hyperplasia/cancer
  • Bleeding persists despite medical therapy
  • Structural abnormality is identified on imaging 1

Classification Using PALM-COEIN System

Evaluate for both structural and non-structural causes 1:

Structural Causes (PALM)

• Polyps
• Adenomyosis
• Leiomyoma (fibroids)
• Malignancy and hyperplasia

Non-structural Causes (COEIN)

• Coagulopathy
• Ovulatory dysfunction (most common in this age group)
• Endometrial disorders
• Iatrogenic
• Not yet classified

Treatment Algorithm

First-Line Treatment for Ovulatory Dysfunction

1. Combined hormonal contraceptives (COCs) 1, 2, 4

   • Reduces menstrual blood loss by up to 50%
   • Regulates cycles and provides contraception
   • Contraindicated in women with history of thromboembolism, uncontrolled hypertension, migraine with aura, liver disease, or smokers >35 years

2. Progestin-only methods 1, 2

   • Options include oral progestins, medroxyprogesterone acetate injections, or levonorgestrel IUD
   • Levonorgestrel IUD is highly effective for heavy bleeding
   • Suitable for women with contraindications to estrogen

For Acute Heavy Bleeding

• Multidose COC regimen (3 pills daily for 7 days, then 1 daily) 5
• Tranexamic acid during days of bleeding 2, 5
• NSAIDs during bleeding episodes (reduces blood loss by ~20%) 2, 5

If Initial Treatment Fails

• Change to a COC with higher estrogen content (if using low-dose) 6, 4
• Switch to a different progestin formulation 4
• Add supplemental estrogen if using progestin-only methods 4
• Consider levonorgestrel IUD if not already tried 5

Surgical Options (if medical management fails)

• Endometrial ablation (if family complete)
• Hysteroscopic removal of structural abnormalities if present
• Hysterectomy as last resort 1

Management Pitfalls to Avoid

1. Failing to rule out pregnancy complications

   • False negative pregnancy tests can occur with very high hCG levels (hook effect) as seen in molar pregnancies 3
   • Consider quantitative serum hCG if clinical suspicion remains

2. Missing structural causes

   • Standard TVUS may miss focal lesions; saline infusion sonohysterography improves detection 1

3. Inadequate follow-up

   • Assess response after 3 months of therapy
   • If bleeding persists beyond 3 months on hormonal therapy, further investigation is warranted 1, 2

4. Inappropriate treatment discontinuation

   • Breakthrough bleeding is common in first 3 months of hormonal contraceptive use
   • Counseling and reassurance are important during this period 4

5. Overlooking non-gynecologic causes

   • Thyroid disorders, coagulopathies, and liver disease can present with abnormal bleeding
   • Complete the recommended laboratory workup before attributing to ovulatory dysfunction 1, 2

By following this systematic approach to diagnosis and treatment, most cases of AUB in young women can be effectively managed with medical therapy, avoiding the need for surgical intervention.