What is the workup for abnormal uterine bleeding (AUB)?

From the Guidelines

The workup for abnormal uterine bleeding should begin with a thorough history and physical examination, followed by laboratory tests including complete blood count, pregnancy test, thyroid function tests, and coagulation studies, as recommended by the most recent guidelines 1. Initial imaging should include a pelvic ultrasound to evaluate for structural abnormalities, such as polyps, adenomyosis, leiomyomas, or malignancy, which are common causes of abnormal uterine bleeding in premenopausal women 1. For postmenopausal women, endometrial sampling is recommended to rule out endometrial cancer, particularly if the endometrial thickness is greater than 4mm on ultrasound, due to the increased risk of endometrial cancer in this population 1. Some key points to consider in the workup and management of abnormal uterine bleeding include:

• The PALM-COEIN classification system, which helps categorize causes as structural (polyps, adenomyosis, leiomyomas, malignancy) or non-structural (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified) 1.
• The use of hormonal therapy, such as combined oral contraceptives, progestins, or levonorgestrel IUD, for the management of abnormal uterine bleeding due to ovulatory dysfunction or other non-structural causes 1.
• The consideration of surgical interventions, such as endometrial ablation or hysterectomy, for refractory cases of abnormal uterine bleeding, particularly in patients with significant intracavitary lesions or other structural abnormalities 1.
• The importance of iron supplementation, such as ferrous sulfate 325mg daily, for patients with anemia due to heavy menstrual bleeding, to improve quality of life and reduce morbidity 1. Overall, the management of abnormal uterine bleeding depends on the underlying cause, and a thorough workup and individualized treatment approach are necessary to improve outcomes and quality of life for patients with this condition.

From the Research

Abnormal Bleeding Workup

• The workup and management of bleeding in the emergency room can be a daunting task, requiring accurate diagnosis of the bleeding cause, appropriate investigations and interpretation of the results, and timely management of bleeding symptoms to prevent limb- or life-threatening complications 2.
• A thorough yet focused history exploring bleeding symptoms, medications/drugs, mechanism of trauma/injury, personal and family history of diagnosed bleeding disorders or bleeding symptoms is crucial in the management of a bleeding patient 2.
• Physical examination should focus on signs of mucocutaneous versus deep tissue or joint bleeding and assessing for structural lesions that may contribute to bleeding symptoms in patients with known bleeding diathesis 2.
• Key laboratory tests must be quickly ordered and interpreted to determine whether the hemorrhagic disorder is congenital or acquired, severe or mild, and progressive or stable 3.
• Hemostasis may fail owing to deficiencies of platelets, the plasma coagulation protein system, or endothelial disturbances, and a precise diagnosis and appreciation of the tempo of the disorder will guide specific therapy 3.

Role of Tranexamic Acid

• Tranexamic acid (TXA) is an antifibrinolytic agent commonly used for the treatment or prevention of bleeding, with indications including heavy menstrual bleeding, trauma, postpartum hemorrhage, traumatic brain injury, and surgical site bleeding 4, 5, 6.
• The utility of TXA goes beyond common indications, with accumulating data suggesting its ability to reduce bleeding and improve clinical outcomes in the face of many different hemostatic challenges, without a clear increase in thrombotic risk 4.
• However, results from existing studies are confounded by methodological and statistical ambiguities and are open to varied interpretations, and substantial knowledge gaps remain on dosing, pharmacokinetics, mechanism of action, and clinical applications for TXA 5.
• A more selective and individualized use of TXA, guided by extended and functional coagulation assays, is advocated in the context of the evolving concept of precision medicine 5.