Abnormal uterine bleeding: Avoid the rush to hysterectomy

What else do you observe? When evaluating patients with abnormal uterine bleeding, don’t let the obvious focus on the gynecologic organs cause you to overlook other possibly significant findings. Look for acanthosis nigrican and an elevated body mass index (BMI), signs of PCOS, and also check for evidence of hyperthyroidism or galactorrhea. The bimanual exam should determine if the patient has an enlarged uterus, suggesting fibroids or adenomyosis.

TABLE 1
Abnormal uterine bleeding: 4 categories, many causes

Refer for a look inside the uterus

Patients with a pelvic exam that is inconclusive or suggests an enlarged uterus will likely benefit from referral for transvaginal sonography. This procedure is considered by many to be the test of choice for abnormal uterine bleeding.⁶ Saline infusion vaginal sonography, however, is considered a more sensitive test by some authorities.⁷ In saline infusion sonography, the clinician infuses a small amount of sterile saline into the uterus via a small catheter, which distends the normally compressed uterine walls and allows visualization of any endometrial cavity abnormalities, such as polyps or fibroids (FIGURE).

Office or outpatient hysteroscopy can also help visualize the endometrial cavity to diagnose cavity defects. Although hysteroscopy is an excellent and usually well-tolerated technique for visualizing the endometrial cavity, it cannot visualize the myometrium or ovaries as saline infusion sonography can. (TABLE 2) details the pros and cons of these diagnostic procedures.

FIGURE
What a difference saline can make

TABLE 2
Diagnostic studies: The pros, the cons

What’s to be done?

In many cases clinicians can direct a plan of care on the basis of an accurate diagnosis. For example, patients with endometrial polyps or submucous uterine fibroids will benefit from referral to a gynecologist for outpatient surgical intervention. Otherwise, a variety of medical or minimally invasive surgical options are available.

Patients unaware of other options may come in asking about a hysterectomy, the second most common surgical procedure in the United States.⁸ Although this procedure is the definitive treatment for abnormal uterine bleeding, it carries the risk of surgical bleeding, ureteral or intestinal damage, incision breakdown, venous thromboembolism, and other intra- and postoperative problems.

While it is certainly appropriate to counsel the patient that hysterectomy is an option, there are many other options to consider. We now have a number of randomized trials that provide evidence-based guidance for the management of chronic abnormal uterine bleeding without hysterectomy (TABLE 3). These options can allow the patient to avoid the risks of major surgery and return to work and normal activities more rapidly.

TABLE 3
Beyond hysterectomy: Other treatment options to consider