Abnormal uterine bleeding: A Quick Guide To Evaluation And Treatment

TABLE 1

Causes of menstrual dysfunction

Special populations

Adolescents. Teens with irregular heavy menses should be evaluated for coagulopathies, since 20% to 30% have a major bleeding diathesis.³ This is especially true if the patient presents with a hemoglobin level of less than 10 g/dL or if hospitalization is required. Specifically, adolescents should be evaluated for von Willebrand’s disease with the ristocetin cofactor assay, the single best screening test for the disease. This prevents false-negative results. Other laboratory tests should include:

• Serum human chorionic gonadotropin (hCG)
• Bleeding time
• Partial time (PT) and partial thromboplastin time (PTT)
• Complete blood count (CBC) with platelets

Successful medical therapies for von Willebrand’s disease include oral contraceptives (OCs), which have an 88% success rate; desmopressin acetate; antifibrinolytic agents; and plasma-derived concentrates rich in the high-molecular-weight multimers of von Willebrand factor (vWf).⁴

Perimenopausal women. Women entering perimenopause may have recurrent bouts of DUB and associated physical complaints due to changes in the hypothalamic-pituitaryovarian axis. The hormonal milieu is associated with decreased inhibin, variable estradiol, normal FSH, and menstrual cycles that can be episodically ovulatory.⁵ Many menstrual complaints occur in perimenopausal women, including menometrorrhagia, amenorrhea, and oligomenorrheic cycles. Decreased mental clarity and concentration, vaginal dryness, hot flushes, and night sweats are classic symptoms of perimenopause.

Oral contraceptive (OC) therapy is quite useful in these women and should be the first line of intervention, rather than conventional hormone replacement therapy (HRT).⁶ The usual postmenopausal doses of HRT do not suppress ovulation or prevent pregnancy, while OCs do. In healthy, nonsmoking women over 35 years of age, OCs regulate menstrual cycles, decrease vasomotor symptoms, improve bone mineral density (BMD), and reduce the need for surgical intervention for DUB. They also reduce endometrial and ovarian cancer rates.

Postmenopausal patients. Bleeding that occurs with HRT or tamoxifen use more than 1 year after the cessation of menses requires thorough evaluation. While the most common cause of postmenopausal bleeding is atrophy, it is important to rule out intracavitary pathology, endometrial hyperplasia, and cancer. Approximately 10% of women with postmenopausal bleeding have endometrial cancer. Because the risk of this cancer increases with each decade of life, its exclusion is critical.

Focal intracavitary lesions, including polyps, submucosal fibroids, and endometrial hyperplasia, account for 20% to 40% of cases of abnormal uterine bleeding in this population.⁷

Organic diseases. Women with renal or liver disease also may have abnormal uterine bleeding. Patients with liver disease may have higher circulating levels of estrogen due to hepatic dysfunction and an inability to metabolize estrogen. Coagulopathies also may occur with liver disease, while renal failure is associated with hypothalamic-pituitaryovarian axis irregularities due to gonadal resistance to hormones, platelet dysfunction, and abnormal factor VIII activity.

Medical therapy

Once the likely cause of abnormal bleeding is identified, appropriate treatment should be instituted. For anovulatory cycles, medical therapy with OCs or progesterone is the standard. Patients with ovulatory abnormal bleeding should be evaluated for intracavitary uterine pathology, since hormonal dysfunction is probably not the cause. Patients whose abnormal bleeding is anatomic in origin usually are managed surgically.

Medical therapy should be tailored to the individual after reviewing her risks, benefits, contraindications, and individual concerns. It is important to determine which facet of the menstrual cycle the patient wants improved, e.g., length, duration, clotting, pain, quantity, in order to target treatment appropriately.

Objective measurements (alkaline hematin assay) of menstrual blood loss are impractical in an office setting.

Oral contraceptives. OCs have many roles in the treatment of menorrhagia and other forms of DUB. Short-term, high-dose therapy is valuable when excessive bleeding occurs in an emergency situation or when heavy menstrual bleeding occurs in adolescent and perimenopausal women. Any low-dose (30 to 35 mcg) ethinyl estradiol product can be given at 6-hour intervals for 5 days to stabilize bleeding. This should be followed by a tapering regimen of 1 low-dose OC pill at 8-hour intervals for 5 days, 12-hour intervals for 5 more days, and then daily for 5 days. This regimen quickly halts heavy menses and controls bleeding. It also prepares the patient for a withdrawal menses.

After the withdrawal bleed, the patient should continue on a maintenance dose (1 pill daily) to ensure regular menstrual cycles and contraception. Low-dose OCs are safe and effective for women over 35 who do not smoke and lack a history of thromboembolic disease.

Progesterone therapy. Women with anovulatory menstrual cycles also may benefit from progesterone therapy, which stabilizes the proliferative endometrium and establishes regular sloughing. Cyclical progesterone is useful in women with contraindications to estrogen therapy, e.g., women over 35 who smoke or have a history of deep venous thrombosis (DVT) or cardiovascular risk factors. Generally, 10 mg of medroxyprogesterone acetate for 10 to 14 days each month will induce a regular withdrawal bleed, although it does not provide contraception.