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let's now talk about the diagnostic
evaluation of abnormal uterine bleeding
first you want to ask them what the age
of menarche was and if they've already
had menopause when that was again the
average age for menarche is 12
well it's 51.4 for menopause then you
want to ask them their menstrual
bleeding patterns do they have all ago
materia Pali materia amenorrhea you want
to make sure that's clearly documented
in your medical record then you want to
ask them about the severity of bleeding
do they pass clots do they ruin their
nightgown at night do they have to
change their pants at work which can be
very embarrassing and very distressing
for many women do they have pain with
their periods this is sometimes called
dysmenorrhea you want to ask about the
character the severity and in what they
do at home to treat the pain then you
want to ask them about medical
conditions do they have hypothyroidism
are they on any medications that could
send their blood then you want to ask
about surgical history recall you want
to ask if they've had any bleeding after
a surgery or postoperatively ask them
about any medications they could be
using sometimes patients are treating
themselves with things that can actually
increase bleeding such as certain
non-fda-approved medicinals and
supplements then you want to ask them if
they have any signs and symptoms of a
possible hemostatic disorder such as von
Willebrand disease then on physical exam
you should do a detailed general
physical exam but especially you should
do a detailed gynecologic exam first
look externally to see if they're a
lesions on the vulva then a speculum
exam with a pap smear needs to be done
if it is required and she's due for her
pap smear we talked about pap smears in
another lecture and then a bimanual exam
needs to occur so that you can feel the
cervix make sure that it feels normal
it should feel like the tip of your nose
and then you should also do a bimanual
to see how large the uterus is and
usually we express that in terms of
weeks
does she have a 20-week sized uterus
that
be an indication that she has fibroids
or adenomyosis or a combination so in
terms of laboratory tests what we want
to do is a pregnancy test first and
foremost to rule it out
sometimes we need to do blood and urine
depending on the clinical scenario a CBC
or a complete blood count is important
to make sure the patient does not
already have anemia then based on the
history we should do targeted screening
for bleeding disorders only when
indicated a TSH should also be checked
to make sure the patient is not
hypothyroid and in the patients who are
younger especially a chlamydia test need
to be done to rule out chlamydia
trachomatis in terms of the diagnostic
tests we review this a little bit before
but again a saline infusion so no
history goofy is very important and it
can show us a polyp or a fibroid or any
other lesion that could be causing the
bleeding a transvaginal ultrasound is
also helpful as we can actually measure
the size of the uterus and MRI is
sometimes helpful especially when you
have a large uterus that can be either
caused by leiomyomas or adenomyosis
and lastly hysteroscopy where we insert
a small camera through the vagina into
the cervix and into the uterus to
actually visualize any pathology that
could be there the other things that we
can do in the office especially in the
perimenopausal or postmenopausal woman
over forty-five is to do an endometrial
biopsy well that sounds really painful
it's just a straw that provides gentle
suction to allow us to take some of the
endometrium to sample it usually this is
done in several passes to make sure that
we have enough tissue to send to
pathology again in the office we can do
a hysteroscopy directed endometrial
sampling but this is usually not done
because the pipe L is usually sufficient
pipe L is another term for endometrial
biopsy so a UB management really depends
on the etiology first you have to
determine what type of a EB you think
the patient has
and then evaluate her with a good
general physical exam a GYN exam after
obtaining a very thorough history then
you can manage based on the etiology so
if a patient comes into the emergency
room with acute bleeding this is
important to remember you can stop acute
heavy bleeding with 25 milligrams of
conjugated equine IV estrogen and this
would help and sometimes these patients
are taken to the operating room for
dilation and curettage to actually take
some of this endometrium away so that
the bleeding is less this is normally
only given to a young healthy patient
who has no other medical comorbidities
which would be a contraindication to
estrogen let's remember some things now
about AUB don't forget to check for
foreign bodies and young girls the most
common foreign body that you'll recover
is toilet tissue fibroids are very
common especially in women of African
descent so you might get a case with a
woman who is of African or Caribbean or
african-american descent don't forget to
remember fibroids thyroid abnormalities
are also a possibility with severe AUB
and a TSH should always be checked in
these patients also in the young girl's
platelet dysfunction is the most common
coagulopathy and don't forget to ask
about a history of bleeding after
surgery or with brushing your teeth or
after cutting yourself these things will
be helpful to delineate this diagnosis
let's now review some cases of AUB here
we have a 25 year old g-zero with a BMI
of 45 who presents the emergency room
with an extremely heavy period her last
period was 6 months ago that should be a
red flag you should have a period every
month her exam is notable for hirsutism
hmm she has a high BMI and hirsutism
what does this sound like
what's your differential diagnosis PCOS
should be your most likely given the
fact that it's very common
she has an elevated BMI most PCOS
patients are obese and they also have to
have some type of hyper androgen emia
which leads to hirsutism oftentimes but
you should not forget to rule out
pregnancy fibroids infection
coagulopathy and thyroid abnormalities
especially in obese patient who may have
thyroid abnormalities let's now review
another case of AUB here we have a 65
year old woman who presents to you
she's a g2 p10 one one who underwent
menopause at 52 years of age just a year
after the normal average she now
presents with onset of vaginal bleeding
her only medications include calcium and
vitamin D so she's pretty healthy what's
in your differential diagnosis I'll wait
while you think about that
so the first thing that you should think
about new differentials should be
atrophic bleeding so she can have a
little bleeding from her vagina due to
atrophy which means that after to
estrogen it stops being made the vagina
can become smaller atrophic and some can
sometimes bleed with penetration or just
by itself also the line of the
endometrium can also bleed because it's
thinned and sometimes that can cause
spontaneous bleeding these patients are
also at risk for endometrial cancer
while this patient seems normal and
healthy the very obese patient has
unopposed estrogen because of peripheral
aromatization that occurs in the
adipocytes that estrogen does affect the
line of the endometrium and that can
lead to endometrial cancer polycystic
ovarian syndrome patients during their
reproductive years can also be at risk
for endometrial cancer and their
postmenopausal years also these patients
are older and they can be on blood
thinners for cardiovascular reasons
thank you for listening and I hope you
do well in your exam
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you