THE JOURNAL OF FAMILY PRACTICE D. Ashley Hill, MD Department of Obstetrics Abnormal uterine bleeding: and Gynecology, Florida Hospital Graduate Avoid the rush to hysterectomy Medical Education, Orlando, Fla. d.ashley.hill.md@fl hosp.org Patients with heavy bleeding may think hysterectomy is their only recourse, but research supports other alternatives. Practice recommendations several occasions. She says she often feels • The levonorgestrel-IUS is the tired, and worries that she may be ane- most effective treatment for heavy mic. Preserving fertility is not a concern; menstrual bleeding, reducing blood her husband has had a vasectomy. loss by close to 100%® Dowden (A). HealthOn Media exam she is without orthostasis and appears well. Her uterus is top- • Endometrial ablation is an effective normal size, nontender, and there are Copyrighttreatment forFor women personal who want to use noonly adnexal masses or cervical or vaginal avoid major surgery and preserve abnormalities. You note a normal Pap at their uterus, but have no wish to your offi ce 5 months ago. Her offi ce he- become pregnant in the future (A). moglobin is 9.8 mg/dL. IN THIS ARTICLE She asks you to refer her to a gyne- ❚ What a difference • Endometrial biopsy should be part cologist for a hysterectomy because she of the evaluation of abnormal uterine “just can’t take it anymore.” Her heavy saline can make: bleeding in all women over age 35 (B). menses are disrupting her life. Since she 2 sonograms does not want any more children, she Page 139 Strength of recommendation (SOR) feels that if someone could “just take it A Good-quality patient-oriented evidence out,” her problem would be solved. But B Inconsistent or limited-quality patient-oriented evidence ❚ Diagnostic C Consensus, usual practice, opinion, disease-oriented she isn’t really enthusiastic about a hys- studies: The pros, evidence, case series terectomy because her life is too busy to the cons allow time for a lengthy recovery. You explain that there are a number Page 140 s. M, a 39-year-old mother of of options you’d like her to consider fi rst. 3, runs a busy day-care center, Then you review the options and some of Mcares for her sick mother, and the research behind them, having recently shuttles her children among their myriad read an article on evidence-based therapy activities. During today’s offi ce visit, she for abnormal uterine bleeding. seems anxious. She says her periods are regular, but have become increasingly heavy in recent years and may last as long ❚ A common complaint as 9 days. The bleeding is very heavy, with in primary care a lot of clots and some cramps during the Abnormal uterine bleeding is a common fi rst few days. In the past year, painful pe- reason for women to visit their primary riods have caused her to miss work on care clinician, accounting for about 20% 136 VOL 58, NO 3 / MARCH 2009 THE JOURNAL OF FAMILY PRACTICE For mass reproduction, content licensing and permissions contact Dowden Health Media. 136_JFP0309 136 2/17/09 12:09:27 PM of gynecologic primary care visits.1 Wom- en are understandably concerned about any disruption of their normal bleeding pattern. Many, however, are unaware of common causes of abnormal bleeding and available treatment options. Most cases of chronic abnormal bleeding can be classifi ed as either heavy and regular (menorrhagia) or heavy and irregular (menometrorrhagia). A rule of thumb to help guide diagnostic testing is that menorrhagia often results from ana- tomic problems of the uterus or endome- trium, such as polyps. Menometrorrhagia is more likely to result from hormonal abnormalities, such as polycystic ovar- ian syndrome (PCOS). This review will focus on medical and minimally invasive surgical therapy for chronic abnormal bleeding. ❚ First step: Pregnancy test Many conditions can cause abnormal with a regular men- uterine bleeding (TABLE 1). In women of strual cycle (ovulatory reproductive age, the fi rst step in the diag- bleeding) usually has a dif- nostic process should be a urine or serum ferent etiology. It most often occurs be- pregnancy test. Urine pregnancy tests cause of anatomic abnormalities such have a sensitivity of 90% one day after as endometrial polyps, fi broids, and FAST TRACK a missed period and approximately 97% adenomyosis (pockets of endometrium All patients 2 after one week. In addition to a pregnan- found within the uterine myometrium). >35 years who cy test, consider testing for thyroid dys- Heavy menstrual bleeding that occurs function and obtaining serum prolactin at the onset of or shortly after men- have abnormal levels for women presenting with anovu- arche may be due to a coagulopathy, uterine bleeding latory bleeding.3 If anemia is suspected, a such as von Willebrand disease. There- should have an hematocrit or hemogram is indicated. All fore, consider platelet function analysis endometrial biopsy patients over the age of 35 who present for adolescents who present with heavy to rule out cancer. with abnormal uterine bleeding should menses, particularly if they require have an offi ce endometrial biopsy to rule blood transfusion. out endometrial hyperplasia or cancer.4 What else do you observe? When Is she ovulating? Most cases of heavy evaluating patients with abnormal uter- bleeding with irregular periods are the ine bleeding, don’t let the obvious focus result of anovulation, which is common on the gynecologic organs cause you to soon after menarche and at the approach overlook other possibly signifi cant fi nd- of menopause. Other causes of anovula- ings. Look for acanthosis nigrican and an tory bleeding include PCOS, hypothy- elevated body mass index (BMI), signs of roidism, and elevated prolactin levels. PCOS, and also check for evidence of Chronic, irregular bleeding without a hyperthyroidism or galactorrhea. The known anatomic cause is termed “dys- bimanual exam should determine if the functional uterine bleeding,” or DUB.5 patient has an enlarged uterus, suggest- IMAGE © MOLLY BORMAN IMAGE © MOLLY Are periods regular? Heavy bleeding ing fi broids or adenomyosis. CONTINUED www.jfponline.com VOL 58, NO 3 / MARCH 2009 137 137_JFP0309 137 2/17/09 12:09:32 PM THE JOURNAL OF FAMILY PRACTICE TABLE 1 Abnormal uterine bleeding: 4 categories, many causes MOST COMMON TYPE CATEGORY OF BLEEDING SELECTED CAUSES Bleeding associated Heavy bleeding, regular Endometrial polyps with uterine pathology cycle (menorrhagia) Adenomyosis Uterine fi broids Endometrial hyperplasia Uterine cancer Dysfunctional uterine Heavy bleeding, irregular Polycystic ovarian syndrome bleeding (DUB) without cycle (menometrorrhagia) Hypothalamic dysfunction anatomic abnormalities • Anorexia • Excessive exercising • Menarche or perimenopause Bleeding with a Usually menometrorrhagia Thyroid dysfunction systemic illness Elevated prolactin levels Liver or renal disease Coagulopathy Leukemia Iatrogenic bleeding Usually menometrorrhagia Oral contraceptives Depot medroxyprogesterone acetate Postmenopausal hormone therapy Anticoagulants Herbal supplements ❚ Refer for a look myometrium or ovaries as saline infusion FAST TRACK inside the uterus sonography can. TABLE 2 details the pros The LNG-IUS is Patients with a pelvic exam that is in- and cons of these diagnostic procedures. the most effective conclusive or suggests an enlarged uter- us will likely benefi t from referral for medical therapy transvaginal sonography. This procedure ❚ What’s to be done? for treating is considered by many to be the test of In many cases clinicians can direct a plan menorrhagia. choice for abnormal uterine bleeding.6 of care on the basis of an accurate diagno- Saline infusion vaginal sonography, how- sis. For example, patients with endome- ever, is considered a more sensitive test trial polyps or submucous uterine fi broids by some authorities.7 In saline infusion will benefi t from referral to a gynecologist sonography, the clinician infuses a small for outpatient surgical intervention. Oth- amount of sterile saline into the uterus erwise, a variety of medical or minimally via a small catheter, which distends the invasive surgical options are available. normally compressed uterine walls and Patients unaware of other options allows visualization of any endometrial may come in asking about a hysterec- cavity abnormalities, such as polyps or tomy, the second most common surgical fi broids FIGURE( ). procedure in the United States.8 Although Offi ce or outpatient hysteroscopy can this procedure is the defi nitive treatment also help visualize the endometrial cavity for abnormal uterine bleeding, it carries to diagnose cavity defects. Although hys- the risk of surgical bleeding, ureteral or teroscopy is an excellent and usually well- intestinal damage, incision breakdown, tolerated technique for visualizing the venous thromboembolism, and other endometrial cavity, it cannot visualize the intra- and postoperative problems. 138 VOL 58, NO 3 / MARCH 2009 THE JOURNAL OF FAMILY PRACTICE 138_JFP0309 138 2/17/09 12:09:37 PM Abnormal uterine bleeding: Avoid the rush to hysterectomy ▼ FIGURE What a difference saline can make Routine transvaginal sonography shows the endometrium A previously undiagnosed endometrial polyp (calipers) in PHOTOS USED WITH PERMISSION OF D. ASHLEY HILL, MD. (calipers) without apparent abnormality. the same patient, revealed after saline infusion. While it is certainly appropriate to searchers randomized 56 women waiting counsel the patient that hysterectomy is to undergo hysterectomy for heavy men- an option, there are many other options strual bleeding to either continuation of to consider. We now have a number of their existing medical treatment or an randomized trials that provide evidence- LNG-IUS. At 6 months, 64% of the based guidance for the management of women in the IUS group canceled their chronic abnormal uterine bleeding with- hysterectomy, whereas only 14% in the out hysterectomy (TABLE 3). These op- medical therapy group did so.11 tions can allow the patient to avoid the IUS candidates should have a uter- risks of major surgery and return to work us free of congenital abnormalities that and normal activities more rapidly.