David L. Maness, DO, How best to manage MSS; Avinash Reddy, MD; Carolyn L. Harraway-Smith, MD; dysfunctional uterine bleeding Gregg Mitchell, MD; Vanessa Givens, MD Department of Family Medicine, Irregular or unusually heavy periods are a common University of Tennessee Health Science Center, complaint. Most often, the condition is benign and can Memphis by managed conservatively. [email protected] The authors reported no potential confl icts of interest relevant to this article. Test your skills: PRACTICE How would you treat these 3 patients? RECOMMENDATIONS CASE 1 Casey is a 14-year-old with a normal body mass index › Assess postmenopausal who has had heavy vaginal bleeding for 10 days. For the last women for cancer by endo- 3 days, the bleeding has been so heavy she has been soaking metrial biopsy, transvaginal more than 15 pads a day. She feels tired and is light-headed ultrasound, or saline infusion and dizzy when she stands up. Casey had her fi rst period 13 sonohysterogram. A months ago. Since then, her periods have varied in length › Treat mild dysfunctional from 18 to 40 days, with heavy bleeding for 7 to 14 days. She uterine bleeding (DUB) with tells you she is not taking any prescription or herbal medica- nonsteroidal anti-infl am- tions or over-the-counter supplements, and does not have any matory drugs, levonorgestrel other medical problems. She is not sexually active. Her physi- intrauterine device (IUD), or danazol. A cal examination was remarkable only for pale skin and a posi- tive tilt test. She feels frustrated and wants something done › Treat moderate DUB with immediately. oral contraceptive pills C , levonorgestrel IUD, danazol, CASE 2 Sarah is a 35-year-old obese woman whose chief or tranexamic acid. A complaint is irregular periods. For the past 3 years, she has › Treat severe DUB with the had only 3 to 6 periods per year, each period lasting for 3 to same agents used for moder- 10 days. Her most recent period was 4 months ago. Sarah has ate DUB, or with IV estrogen a moderate amount of acne and facial hair. followed by oral contraceptive pills. C CASE 3 Joan is a 53-year-old postmenopausal woman who Strength of recommendation (SOR) has never been pregnant. She has a history of type 2 diabetes A Good-quality patient-oriented mellitus, hypertension, and obesity. She has come to your of- evidence fi ce for a routine physical examination. She tells you that her B Inconsistent or limited-quality patient-oriented evidence periods were regular until she stopped menstruating 4 years C Consensus, usual practice, ago. But for the past 6 to 8 months she says she’s had irregular opinion, disease-oriented evidence, case series bleeding every 30 to 45 days, each period of bleeding lasting for 3 to 7 days. Her previous Pap smears and mammograms were normal. She has no family history of breast, gastrointes- tinal, or genital tract cancer. Her physical examination, includ- ing her pelvic examination, is negative. CONTINUED JFPONLINE.COM VOL 59, NO 8 | AUGUST 2010 | THE JOURNAL OF FAMILY PRACTICE 449 hese 3 women are fairly typical pa- TABLE 1 tients in a family medicine practice. Abnormal uterine bleeding: Most women experience episodes T 3,5,17,18,22-24,30 of abnormal uterine bleeding (AUB) at A typology some point in their reproductive lives. Genital tract pathology Th e condition occurs in approximately Vulva 1 in every 3 women of reproductive age and Cancer 1 in 10 postmenopausal women, and the Lichen sclerosis impact on quality of life is often substan- Sexually transmitted diseases (STDs) 1,2 Vagina tial. Abnormal bleeding can be divided STDs into 4 major categories: genital tract pathol- Trauma ogy, systemic disease, exposure to medica- Foreign body Cancer tion or radiation, and dysfunctional uterine Cervix bleeding (DUB). Specifi c conditions within STDs each category are listed in TABLE 1. Th e focus Cervicitis Cancer of this article will be on DUB, the category Uterus that remains after the other possibilities are Endometritis excluded. Hyperplasia Cancer Polyps To quantify First, fi nd out what your patient Leiomyomas blood loss, fi nd means by “abnormal” Systemic disease out how many A normal menstrual cycle varies in length between 24 and 35 days, with menstrual fl ow Crohn’s disease pads or tampons Von Willebrand’s disease the patient uses lasting 2 to 7 days. Blood loss of 30 to 80 cc Thrombocytopenia and how often per cycle is considered normal.3-5 To quantify Acute leukemia blood loss, ask the patient how many pads or Advanced liver disease she changes Hyper/hypothyroidism them, the size tampons she uses each period (<21 would be Chronic renal disease of clots, and normal), how often she has to change pads Pituitary disease whether she (every 3 hours is usual), the size of clots (less Emotional or physical stress has to get up at than 1 cm is normal), and whether she has Medication/iatrogenic cause 6 night to change to get up at night to change pads. If blood Tamoxifen pads. loss is suffi cient to cause anemia, the con- Corticosteroids dition is always considered abnormal and Chemotherapy Anticoagulants requires further evaluation. When your pa- Warfarin tient’s description leaves you in doubt about Aspirin whether her bleeding is abnormal, base your Clopidogrel Antipsychotics evaluation and treatment on her perception Hormonal therapy of a change in her menstrual cycle. Oral contraceptives Medroxyprogesterone acetate Intrauterine devices Stages of the reproductive life cycle Herbal supplement Th e meaning of abnormal bleeding varies Black cohosh with your patient’s stage in her reproductive Soy supplements Radiation life cycle. Uterine bleeding in a premenarchal child or a postmenopausal woman is always Dysfunctional uterine bleeding abnormal and must be evaluated.7-9 Anovulatory (90%) ❚ Premenarchal children with vaginal Hypothalamic suppression Pituitary adenoma bleeding should be evaluated for trauma, Eating disorders sexual or physical abuse, foreign bodies, signs Thyroid disorders of precocious puberty, and possible infec- Adrenal disorders Primary ovarian disorders (such as polycystic 7 tious etiologies. If the cause of the bleeding is ovarian syndrome) not obvious, these patients should be imme- Ovulatory (10%) diately referred to a pediatric gynecologist. Structural anomalies 450 THE JOURNAL OF FAMILY PRACTICE | AUGUST 2010 | VOL 59, NO 8 DYSFUNCTIONAL UTERINE BLEEDING ❚ Postmenopausal bleeding is defi ned genital tract pathology, including infection, as any bleeding that occurs more than 1 year polyps, uterine fi broids, and signs of cancer; after the last menstrual period.8 Cancer is the iatrogenic causes such as medications or ra- primary concern in these women and must diation; and systemic illnesses. In teenagers, always be excluded. (More on that, in a bit.) look for inherited clotting disorders such as Von Willebrand’s disorder. If cervical cancer screening is not up to date, do a Pap smear.16 History may reveal Cervical dysplasia generally does not cause underlying pathology heavy vaginal bleeding, but can cause post- Th e initial approach to evaluating abnormal coital bleeding.17 A complete blood count and bleeding is a thorough history and physical. a thyroid-stimulating hormone (TSH) level Ask about stress, dietary habits, exercise, will allow you to rule out anemia, leukemia, medications, radiation exposure, visual dis- thrombocytopenia, and thyroid disorders.11 turbances, headache, weight loss or gain, galactorrhea, palpitations, abdominal symp- toms, jaundice, or excessive hair growth. Your Dysfunctional uterine bleeding patient’s answers to these questions may (DUB): A diagnosis of exclusion point to pathologies that underlie the abnor- Once you have ruled out genital tract pathol- mal bleeding, as listed in TABLE 1. ogy, systemic disease, and iatrogenic causes, you are left with a diagnosis of dysfunctional Uterine In postmenopausal women, uterine bleeding. DUB occurs most common- bleeding in a rule out cancer ly at the onset of regular menstrual cycles or premenarchal Th e initial work-up for a postmenopausal pa- when menstruation is coming to an end dur- child or tient should begin with a pelvic examination, ing menopause. postmenopausal followed by an assessment of her endometri- Th e menstrual cycle in a woman with woman is al cavity by transvaginal ultrasound (TVUS), DUB may be ovulatory or anovulatory. Wom- always saline infusion sonohysterogram (SIS), or bi- en who have ovulatory cycles usually know abnormal opsy. An SIS, in particular, is often superior to the characteristics of their menses and are and must be TVUS in screening for anatomic anomalies.10 often aware of minor variations in the timing evaluated. If a sonogram shows an endometrial thick- or fl ow. A patient with an anatomic problem ness greater than 5 mm or the patient has risk who has ovulatory cycles will usually present factors for endometrial neoplasia, an endo- with complaints of menorrhagia. metrial biopsy for histologic diagnosis will be Anovulatory cycles are more typical, needed.11 Risk factors for endometrial cancer occurring in 90% of patients with DUB.18 In include age older than 40, infertility, diabetes anovulatory cycles, the corpus luteum is not mellitus, hypertension, obesity, and estrogen produced and the ovaries do not secrete pro- medication. Repeat the sampling if the biopsy gesterone. In the absence of progesterone, is inadequate. If the patient continues to have constant estrogen stimulation produces a uterine bleeding, further evaluation with hys- proliferative endometrium that is not sus- teroscopy by a gynecologist should be con- tainable. As 1 area of bleeding heals, another sidered.12-14 site begins to slough, and the result is an ir- regular and prolonged bleeding pattern that Evaluating bleeding in women is unpredictable. Th e clinical result in this of child-bearing age scenario is varying cycle lengths and diff ering Bleeding in this age group is most often re- amounts of menstrual blood loss.