What is the workup for a perimenopausal patient with mittelschmerz (ovulation pain), abnormal uterine bleeding (AUB), and a history of ovarian cysts with rupture?

From the Guidelines

The workup for a perimenopausal patient with ovulation pain, abnormal uterine bleeding, and history of ovarian cysts with rupture should begin with a comprehensive history and physical examination, followed by transvaginal ultrasound and laboratory testing, as recommended by the most recent guidelines 1. The initial laboratory tests should include:

• A complete blood count to assess for anemia
• Thyroid function tests
• Hormone levels including FSH, LH, estradiol, and progesterone A pregnancy test should be performed to exclude pregnancy as a cause of bleeding. Transvaginal ultrasound is essential to evaluate the ovaries for current cysts, assess endometrial thickness, and rule out structural abnormalities like fibroids or polyps. If the endometrial thickness is greater than 4-5mm, an endometrial biopsy may be warranted to rule out hyperplasia or malignancy, as suggested by the American College of Radiology Appropriateness Criteria 1. Management options include hormonal therapy such as combined oral contraceptives to regulate bleeding and prevent ovulation, thus reducing ovulation pain and cyst formation, as well as cyclic progestins like medroxyprogesterone acetate to help regulate bleeding, based on the guidelines from the American College of Obstetricians and Gynecologists 1. For pain management, NSAIDs like ibuprofen can be effective, and if symptoms are severe or persistent despite medical management, referral to gynecology for consideration of surgical options such as laparoscopy or hysterectomy may be appropriate, as indicated by the most recent update on acute pelvic pain in the reproductive age group 1. This comprehensive approach addresses both the diagnostic evaluation and symptomatic management of this perimenopausal patient's complex presentation, prioritizing morbidity, mortality, and quality of life as the primary outcomes.

From the Research

Evaluation of Perimenopausal Abnormal Uterine Bleeding

• The initial step in evaluating perimenopausal abnormal uterine bleeding involves a speculum examination to exclude cervical and vaginal causes, as well as ruling out sexually transmitted diseases or pregnancy 2.
• Transvaginal ultrasound is recommended as the first step for evaluation, with saline or gel contrast sonohysterography improving diagnostic accuracy 2.
• Measurement of haemoglobin and iron levels, human chorion gonadotropin, and thyroid hormones may be relevant in selected cases 2.

Consideration of Ovulation Pain and Ovarian Cysts

• The presence of ovulation pain and a history of ovarian cysts with rupture should be considered in the evaluation, although the provided studies do not directly address these specific symptoms 2, 3, 4, 5.
• The PALM-COEIN acronym, introduced by the International Federation of Gynecology and Obstetrics (FIGO), may be useful in evaluating abnormal uterine bleeding, but its application to ovulation pain and ovarian cysts is not explicitly stated in the provided studies 4.

Management of Abnormal Uterine Bleeding

• Management of abnormal uterine bleeding may involve hormonal treatment, such as oral progestogens, combined oral contraceptives, or insertion of the levonorgestrel intrauterine system, if anovulatory bleeding is interfering with quality of life 2, 5.
• Antifibrinolytic and non-steroidal anti-inflammatory drugs, progestogens, and the levonorgestrel intrauterine system may be used to reduce the amount of bleeding 2, 5.
• Focal intrauterine lesions, such as endometrial polyps or submucous myomas, may require operative hysteroscopic procedures, while endometrial ablation or endometrial resection may be considered in selected cases 2, 5.