Who Should Evaluate Abnormal Uterine Bleeding
Primary care physicians (family medicine or internal medicine) should perform the initial evaluation of abnormal uterine bleeding, with referral to a gynecologist indicated for specific high-risk findings or failed medical management. 1
Initial Evaluation by Primary Care
Primary care providers are equipped to conduct the comprehensive initial workup for abnormal uterine bleeding, which includes:
- Pregnancy testing (β-hCG) in all reproductive-age women as the first mandatory step 1, 2
- Assessment of hemodynamic stability, with urgent evaluation needed if bleeding saturates a large pad or tampon hourly for at least 4 hours 1
- Physical examination including abdominal palpation for enlarged uterus or masses, speculum examination to visualize cervix and vagina, and bimanual examination to assess uterine size and adnexal masses 1
- Laboratory workup including thyroid-stimulating hormone, prolactin levels, and complete blood count with platelets 1, 3
- First-line imaging with combined transabdominal and transvaginal ultrasound with Doppler to identify structural causes such as polyps, adenomyosis, leiomyomas, and endometrial pathology 1
Primary care physicians can also initiate medical management with options like the levonorgestrel-releasing IUD, combined hormonal contraceptives, or oral progestins for appropriate cases 3.
Mandatory Referral to Gynecology
Specific clinical scenarios require gynecologic consultation 1:
- Failed medical management after appropriate trial of first-line therapies 1, 2
- Endometrial sampling showing hyperplasia or malignancy 1, 2
- Postmenopausal bleeding with endometrial thickness ≥4 mm on ultrasound 1, 2
- Age >45 years or younger patients with risk factors for endometrial cancer (obesity, diabetes, hypertension, unopposed estrogen exposure, tamoxifen use, Lynch syndrome) requiring endometrial biopsy 2
- Structural pathology requiring surgical intervention such as large fibroids, polyps, or adenomyosis not responsive to medical therapy 2
Referral to Gynecologic Oncology
Patients with endometrial biopsy showing hyperplasia with atypia or adenocarcinoma should be referred directly to a gynecologic oncologist rather than general gynecology 4. This ensures specialized management of potential malignancy with appropriate staging and treatment protocols.
Common Pitfalls to Avoid
- Do not skip pregnancy testing in reproductive-age women, even if the patient reports contraceptive use or believes pregnancy is unlikely 1, 2
- Do not rely on endometrial biopsy alone to rule out focal lesions such as polyps or submucosal fibroids, as it has variable sensitivity; saline infusion sonohysterography has 96-100% sensitivity for intracavitary pathology 3, 2
- Do not delay endometrial sampling in high-risk patients (age >45, obesity, diabetes, unopposed estrogen exposure) as this can miss endometrial hyperplasia or cancer 2
- Perimenopausal women require a lower threshold for endometrial sampling due to higher risk of endometrial hyperplasia and cancer 2