A systematic approach to chronic abnormal uterine bleeding
The care you provide to women of childbearing age who are bleeding gets an assist from an established classification system of 9 causes and a range of therapies.
PRACTICE RECOMMENDATIONS
› Perform endometrial biopsy on all women who have abnormal uterine bleeding and risk factors for endometrial cancer and on all women ≥45 years, regardless of risk. C
› Initiate a workup for a coagulation disorder in women who are close to the onset of menarche and have a history of heavy menstrual bleeding. C
› Promote lifestyle changes and weight loss as primary treatments for polycystic ovary syndrome. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
NSAIDs can be effective because they reduce bleeding by causing vasoconstriction, but they provide the greatest benefit when started before menses, which can be difficult for a patient who has irregular cycles.
Endometrial causes of AUB should be suspected when a patient has heavy menstrual bleeding with regular menstrual cycles and no other causes can be identified. Endometrial dysfunction as the cause of AUB stems from aberrations in the biochemical pathways of endometrial hemostasis and repair, and therefore is difficult to confirm by laboratory analysis or histologic evaluation.3 Medical management focuses on alleviating heavy menstrual bleeding (TABLE 3).
Iatrogenic. The most common type of iatrogenic AUB is unscheduled bleeding, also known as breakthrough bleeding, that occurs during hormonal treatment with an OC or during the first few months after insertion of an LNG-IUD or contraceptive implant.3 In most cases, no specific treatment is required; bleeding resolves upon continued use of the contraceptive.
Not yet classified. This category is difficult to define; it was created for causes of AUB that have not yet been identified and remain unclear. For example, a condition known as chronic endometritis is under study as a possible cause of AUB, but has not been assigned to a PALM–COEIN category.3 As more data become available and understanding of pathophysiologic mechanisms lead to better definitions of disease, this and other poorly understood conditions will be moved to an appropriate category in the FIGO classification system.
CASE 2
Ms. G is given a diagnosis of PCOS, based on her history. You recommend weight loss and exercise; screen her for diabetes and dyslipidemia; and prescribe metformin.
ACKNOWLEDGMENT
Barry D. Weiss, MD, University of Arizona College of Medicine, Department of Family and Community Medicine, Tucson, assisted with the editing of this manuscript.
CORRESPONDENCE
Melody A. Jordahl-Iafrato, MD, Community Hospital East Family Medicine Residency, 10122 East 10th Street, Suite 100, Indianapolis, IN 46229; Mjordahl-iafrato@ecommunity.com.
