Abnormal Uterine Bleeding

Diagnosis/Definition

Abnormal uterine bleeding (AUB) is defined as vaginal or uterine bleeding that deviates from the patient’s normal bleeding pattern; may be heavier flow, more frequent bleeding, unscheduled bleeding, or bleeding of any kind in a post-menopausal patient (except minimal withdrawal bleeding in patients on cyclic hormone replacement therapy).

Initial Diagnosis and Management

Diagnosis should be based on the patient’s history of an alteration in menstrual pattern.
The first step in the evaluation of AUB is to obtain a pregnancy test (serum BHCG) in women of reproductive age.
At this point, specialty referral is indicated if the BHCG is positive, the bleeding is excessive, the patient is unstable or in all cases unless the primary care physician has the interest and training in the management of AUB. If so, the next step would be to perform pelvic examination, Pap smear, and endometrial biopsy (biopsy would be excluded initially on the very young patient, and, of course, until pregnancy has been ruled out).
Hormonal assays such as TSH to rule out hypothyroidism would be appropriate in pre-menopausal patients.
At this point, if all tests are negative, consideration of therapy (hormonal) would consist of ovulation induction if fertility is desired, cycling with oral contraceptives if contraception is desired, or cycling with progestins.

Ongoing Management and Objectives

Complete resolution of AUB is expected.
Any continuation or recurrence (beyond two menstrual cycles) of AUB should be referred.

Indications for Specialty Care Referral

Patient request.

Positive result on pregnancy testing (if the Primary Care Manager is not comfortable managing).

If the examination, PAP, endometrial biopsy, or laboratory evaluation are abnormal.

If AUB continues.

Be particularly careful (refer early) with elderly, obese, and patients with long histories of oligo/anovulation.

Criteria for Return to Primary Care