Evaluation of patients with abnormal uterine bleeding

Abnormal uterine bleeding: a focus on polycystic ovary syndrome

Abnormal uterine bleeding imposes major medical, social and financial problems for women, their families and the health services. Abnormal uterine bleeding refers to the regularity, frequency, duration and volume of bleeding. Irregular menstrual bleeding is most common at the extremes of reproductive life, in the initial 12-18 months after menarche and 5-6 years before the menopause begins. In Australia, the estimated cost of investigating and managing heavy menstrual bleeding alone is approximately AUS $6 million per annum. This article addresses the common causes of irregular bleeding in pre- and peri-menopausal women and presents an investigational approach.

Gonadotropin-releasing hormone analog combined with a low-dose oral contraceptive to treat heavy menstrual bleeding

OBJECTIVE

To compare the effects of low-dose oral contraceptives used alone and in combination with a gonadotropin-releasing hormone (GnRH) analog to treat heavy menstrual bleeding.

METHODS

Fifty-eight patients with heavy menstrual bleeding were prospectively randomized into two treatment groups to receive either a low-dose oral contraceptive alone (group 1), or combined with a GnRH analog (group 2) for 6 months. The patients' hormonal profiles, and hemoglobin and hematocrit levels were measured at the beginning and at the end of the treatment period.

RESULTS

Hemoglobin and hematocrit levels significantly improved in both groups after 6 months of treatment (P<0.05 and P<0.01, respectively). Even in the first month of the study, the number of pads used and the duration of menstruation were significantly decreased in both groups and markedly lower in group 2 (P<0.01).

CONCLUSION

The addition of a GnRH analog to low-dose oral contraceptive treatment for heavy menstrual bleeding resulted in better control of vaginal bleeding, even in the first month of therapy.

Profound hypothyroidism-induced acute menorrhagia resulting in life-threatening anemia

BACKGROUND

Menorrhagia is a very common gynecologic entity with a broad differential diagnosis which includes both hypothyroidism and hyperthyroidism.

CASE

We present the case of a 31-year-old patient with acute menorrhagia causing life-threatening anemia that resulted from profound hypothyroidism. Despite timely institution of thyroid replacement, the patient required emergent embolization of a uterine arteriovenous malformation after dilatation and curettage failed to control her bleeding. She was stabilized and discharged to home on the sixth hospital day. Three years later, she successfully conceived and delivered a healthy infant.

CONCLUSION

Our case demonstrates the importance of thyroid evaluation in the patient who presents with menorrhagia. Timely management with medical treatment as well as conservative surgical or radiological interventions can facilitate resolution of symptoms and preserve the patient's fertility potential.

A systematic review evaluating health-related quality of life, work impairment, and health-care costs and utilization in abnormal uterine bleeding

OBJECTIVES

Abnormal uterine bleeding (AUB) impacts women's health-related quality of life (HRQoL) and puts a heavy economic burden on society. To date, this burden has not been systematically studied. We conducted a systematic review of the medical literature to evaluate the impact of AUB on HRQoL and to quantify the economic burden of AUB from a societal perspective.

METHODS

We searched the PubMed and Cochrane databases, and article bibliographies for the period up to July 2005. Teams of two reviewers independently abstracted data from studies that reported outcomes of interest: prevalence, HRQoL, work impairment, and health-care utilization and costs associated with AUB.

RESULTS

The search yielded 1009 English-language articles. Ninety-eight studies (including randomized controlled trials, observational studies, and reviews) that met the inclusion and exclusion criteria underwent a full-text review. The prevalence of AUB among women of reproductive age ranged from 10% to 30%. The HRQoL scores from the 36-item Short-Form Health Survey Questionnaire (SF-36) suggested that women with AUB have HRQoL below the 25th percentile of that for the general female population within a similar age range. The conservatively estimated annual direct and indirect economic costs of AUB were approximately $1 billion and $12 billion, respectively. These figures do not account for intangible costs and productivity loss due to presenteeism.

CONCLUSIONS

The burden of AUB needs further and more thorough investigation. Additional research should prospectively evaluate the impact of AUB and the value of treatment provided to help guide future health resource allocation and clinical decision-making.

Abnormal genital tract bleeding

The etiology of abnormal genital tract bleeding encompasses a wide range of disorders that can be secondary to anatomic changes of the female genital tract, infection, endocrinologic disorders, malignancies, and systemic illness. Appropriate workup is guided by age-related differential diagnoses for abnormal bleeding. Modern diagnostic tools can quickly focus the evaluation and allow timely intervention. Most abnormal genital tract bleeding is uterine bleeding, which is one of the most common gynecologic problems that health care providers will face. It accounts for approximately 15% of office visits and 25% of gynecologic operations. Abnormal uterine bleeding in reproductive-age women is defined as bleeding at abnormal or unexpected times or by excessive flow at the time of an expected menses. The average menstrual cycle length and duration of flow is 28 days and 4 days, respectively, with an average blood loss of 35 cc (1). Any bleeding should be considered abnormal in premenarchal girls and in post-menopausal women except for those with predictable withdrawal bleeding taking hormone replacement therapy. This article will review the categories of abnormal genital tract bleeding and the diagnostic tools needed to establish the correct diagnosis. Common clinical cases will be presented to illustrate the presenting symptoms, differential diagnoses, workup, treatment, and long-term follow-up.

Abnormal uterine bleeding. Diagnostic considerations, management options

The approach to diagnosis of abnormal uterine bleeding is guided by a sound knowledge of menstrual physiology and differential diagnosis. Often, simple anovulation is the underlying problem, although the possibility of pregnancy, endometrial hyperplasia with atypia, or benign reproductive tract disease must be considered. In the majority of cases, abnormal uterine bleeding can be fully evaluated and effectively treated medically without the need for gynecologic referral.

Pathophysiology of abnormal uterine bleeding

Abnormal uterine bleeding is a frequent patient complaint. Recognition of the severity of the problem, appropriate and timely evaluation, and treatment with good outcomes is the goal. The physician must determine which method of diagnosis he or she is most comfortable with, carefully consider the economic impact, and offer treatment that is best suited for each patient. With this practice patients will obtain maximum benefit from the newer treatments in development.