Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women

Question 1

PALM-COEIN

Answer 1

PALM (Structural):

• Polyp
• Adenomyosis
• Leiomyosis
• Malignancy/hyperplasia

COEIN (Non-structural):

• Coagulopathy
• Ovulatory dysfunction
• Endometrial
• Iatrogenic
• Not yet classified

Question 2

Laboratory tests to order for abnormal uterine bleeding

Answer 2

pregnancy test, CBC, TSH (usually hypo, but can be subclinical hyper as well), cervical cancer screening, and Chlamydia test in high-risk women

Question 3

Length of normal menstrual cycle

Answer 3

between 21 and 35 days

Question 4

Average length of menses

Answer 4

5 days

Question 5

Ovulatory dysfunction

Answer 5

eg. endocrinopathy (PCOS), abnormal prostaglandin synthesis and receptor upregulation, increased local fibrinolytic activity, increased tissue plasminogen activator activity; etiologies related to unopposed estrogen
- the hypothalamic-pituitary axis is intact and steroid profiles are normal

Question 6

What to ask in the medical history

Answer 6

Menarche (menopause if applicable), menstrual bleeding patterns, pain and severity, family history of AUB, medication usage (warfarin, heparin, hormonal contraceptives, NSAIDS, ginko, ginseng, and motherwort)

Question 7

What to look for on the physical exam

Answer 7

signs of PCOS (overweight, hirsutism, acne), thyroid nodule, signs of insulin resistance (acanthosis nigracans), skin exam (bruising, pallor, swollen joints),
pelvic exam (speculum exam for cervical or vaginal lesions and a bimanual exam for size and contour of the uterus)

Question 8

Clinical screen for disorders of hemostasis in pts with AUB (based on medical history)

Answer 8

Heavy menstrual bleeding since menarche

One of the following:

• Postpartum hemorrhage
• Surgery-related bleeding
• Dental work bleeding

Two of the following:

• bruising one to two times per month
• Epistaxsis one to two times per month
• Frequent gum bleeding
• family history of frequent bleeding

Question 9

Initial lab tests for bleeding disorder

Answer 9

CBC with platelets, PT and PTT

Question 10

Tests for von Willebrand disease

Answer 10

von Willebrand-ristocetin cofactor activity, von Willebrand factor antigen, and factor VIII

Question 11

Imaging options

Answer 11

Primarily transvaginal ultrasound, but sonohysterography and hysteroscopy are better for intracavitary lesions, MRI is only special cases (pre-menarche)