72 Abnormal Uterine Bleeding Gynecology Clinic

Obtain a detailed menstrual history

S Normal cycle
r Length
◆ Normal cycle length is 21 to 35 days.
r Menstruation characteristics
◆ Normal menstruation lasts 4 to 7 days and has an average flow of 30 cc.
Features of complaint
r Cycle changes, flow changes, intermenstrual bleeding
r Duration of problem
r Dysmenorrhea symptoms confirm presence of ovulation.
Is the pt currently using any contraception or medicines?
Contraceptive hormones, IUDs, numerous medications, and herbs can cause abnormal
uterine bleeding (AUB).
Does the pt smoke?
Smoking can be an independent etiology of AUB.
Does the pt have any risk factors for endometrial cancer?
AUB is the most common presentation of uterine cancer.
The following are risk factors for uterine cancer:
- Hypertension - Obesity
- Nulligravidas - Long history of anovulation
- Diabetes - Tamoxifen use
Does the pt have a history of easy bleeding or bruising?
Consider a coagulopathy as the etiology.
Does the pt have any history that precludes estrogen therapy?
Estrogen therapy plays an important role in the medical treatment of AUB.
r Smokers > 35 y/o or pts with a history of deep vein thrombosis should not use
estrogen therapy.

Perform PE
O General
r Note obesity (BMI > 30).
Neck
r Check thyroid for presence of goiter.
Skin
r Examine for bruising, hirsutism, or acanthosis nigricans.
Abdomen
r Check for hepatosplenomegaly, which can suggest systemic disease as underlying
cause.
Pelvic
r Inspect and palpate for evident pathology and possible foreign bodies.
Check labs
- ␤-hCG (rule out pregnancy) - CBC (check for anemia)
- TSH - Prolactin
- PT/PTT and Von Willebrand’s disease (if coagulopathy is suggested)
- Pap, gonococcus, and chlamydia testing (if not current)
Consider transvaginal U/S
U/S may detect intracavitary lesion such as polyp or fibroid.
Gynecology Clinic Abnormal Uterine Bleeding 73

Consider endometrial biopsy (EMB)

Rule out cancer with EMB in any pt > 35 y/o or with risk factors.

Abnormal Uterine Bleeding

A This is the general diagnosis given to these pts while a workup attempts to find a
definitive etiology.
Possible etiologies include:
- Uterine cancer - Uterine hyperplasia
- Polyps - Fibroids
- Adenomyosis - Systemic disease
- Coagulopathies - Endocrinopathies (thyroid, prolactin,
- Infection polycystic ovary syndrome)
- Trauma
Many times, a definite etiology is not found, and a diagnosis of exclusion is made.
r If no apparent etiology can be found and pt has evidence of ovulation, the
diagnosis can further be specified as:
◆ Ovulatory AUB
r If no apparent etiology can be found and pt does not have evidence of ovulation,
the diagnosis can further be specified as:
◆ Anovulatory AUB, also known as dysfunctional uterine bleeding (DUB)

Identify and treat any underlying (organic) disease

P Treat any etiology identified during above workup.
r If no organic etiology can be found, treat according to the diagnosis of exclusion.
Treat ovulatory AUB with hormones, NSAIDs, antifibrinolytic agents,
or progesterone IUD
Oral contraceptives
r Numerous formulations available
NSAIDs
r Motrin 400 mg PO tid for 1st 3 to 4 days of period
Antifibrinolytic agents
r Tranexamic acid 1 g PO qid for 1st 3 to 4 days of period
Progesterone (levonorgestrel) IUD
Treat DUB with hormones
Oral contraceptives
Progestins
r Medroxyprogesterone acetate 10 mg PO for 10 days each month
Consider surgery
AUB refractory to medical treatment may require surgical therapy.
r Options include:
◆ Hysterectomy
◆ Ablation: The use of heat or electrical energy to “burn” endometrial lining.
74 Breast Mass Gynecology Clinic

Does the pt feel a lump?

S Pts frequently present with having “felt a lump” on breast self-examination.
r Masses appreciated by patient and not clinician still warrant complete workup.
How long has the mass been present?
New masses are more suspicious for malignancy.
Consider fibroadenoma in an established mass.
r Fibroadenoma is a benign, slow-growing tumor common in the reproductive
years (onset usually before 20 y/o).
Has the mass increased in size?
Any rapidly growing mass should be excised, even if previous biopsy has documented it
as benign.
Does pt have any symptoms associated with her menstrual cycle?
Consider fibrocystic breast disease in pts who complain of multiple, bilateral lumps
that increase in size and become tender or “burn” before menstruation.
Is pt experiencing any breast discharge?
Unilateral bloody or serous nipple discharge may indicate malignancy.
Is pt having screening mammograms?
Mammograms are recommended every 1 to 2 yrs (begin screening at age 40 or 10 yrs
before pt reaches the age a first-degree relative was diagnosed with cancer).
Does the pt have any risk factors for breast cancer?
Risk factors for breast cancer should be reviewed; however, all palpable masses must be
worked up regardless of risk factors.
- History of breast cancer - First-degree relatives with breast
- History of ductal carcinoma in situ cancer
- History of atypical hyperplasia
Perform breast exam
O Best timing is shortly after menstruation (document where pt is in menstrual cycle).
General
r Sitting exam
◆ Inspection: Note any area of skin thickening or nipple retraction.
◆ Palpation: Assess axillae for lymph node enlargement.
r Supine exam
◆ Arms lifted above head
◆ Palpate lightly, medium, and deeply to assess tissue at various depths.
◆ Use the pads of three fingers with circular, coin-sized movement.
◆ Examine a large area (from the sternum to the midaxillary line and from the
clavicle to the bra line) in vertical, overlapping rows.
◆ Squeeze areola to extract any nipple discharge.
Mass
r Size
r Consistency → Fibroadenomas are rubbery.
r Mobility → Fixed masses are suspicious for malignancy.
r Contour → Smooth (likely benign) vs. irregular (suspicious)
r Skin changes → Peau d’orange (interstitial fibrosis secondary to edema)