Snapshot A 39-year-old woman presents with abnormal heavy menstrual bleeding along with increased pelvic pressure. She denies pain and is not using any hormonal contraception. She uses multiple sanitary pads per day. On pelvic examination, there is an enlarged uterus with asymmetric contours. The uterus is non-tender to palpation. (Uterine leiomyomas) Introduction Also known as dysfunctional uterine bleeding (DUB) Abnormal menstrual bleeding with regards to quantity, duration, or schedule The patient must not be pregnant therefore, pregnancy must be ruled out Causes include structural abnormalities e.g., adenomyosis, uterine fibroids, malignancy, and polyps bleeding disorders and coagulopathies medications anovulation genital infection mnemonic PALM-COEIN Polyp Adenomyosis Leiomyomas Malignancy & hyperplasia Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic (e.g., medications) Not yet classified (e.g., arteriovenous malformations, and chronic endometritis) Pathogenesis mechanism of AUB due to anovulation corpus luteum does not form absence of progesterone unapposed estrogen continues to proliferate the endometrium the endometrium becomes unstable and outgrows its blood supply endometrial sloughing and breakthrough bleeding results Presentation Symptoms variation of normal menstrual cycle symptoms of anemia light-headedness shortness of breath Physical symptoms dependent on etiology obesity, hirsutism, and acanthosis nigricans can suggests polycystic ovarian syndrome (PCOS) an enlarged pelvic mass may suggest leiomyoma Evaluation Evaluation is dependent on likely cause of AUB β-hCG to rule out pregnancy can be serum and urine Blood testing complete blood count (CBC) coagulation studies consider in patients with a history of bleeding disorder thyroid-stimulating hormone (TSH) in those with a history concerning for thyroid disease Imaging studies transvaginal ultrasound first-line in adult patients when assessing for structural abnormalities Endometrial biopsy can be considered when > 45 years of age when refractory to treatment < 45 years of age with high risk of endometrial cancer Differential Refer to introduction (PALM-COEIN) Treatment Treat the underlying cause of AUB Treatment in cases of heavy menstrual bleeding (most commonly due to leiomyomas or adenomyosis) hormone therapy estrogen-progestin contraception or levonorgestrel-releasing intrauterine devices are first-line progestin-only treatment is reasonable NSAIDs or tranexamic acid can be used in patients who do not want to be treated with hormone therapy, or have contraindications NSAIDs decrease endometrial prostaglandin synthesis results in decreased blood loss tranexamic acid prevents plasminogen from being converted to plasmin this in turn decreases fibrinolysis in cases of menstrual bleeding due to ovulatory dysfunction hormone therapy estrogen-progestin contraceptives, oral progestin therapy, or levonorgestrel-releasing intrauterine device are first-line Surgical treatment used in cases that are refractory to medical therapy or patient preference heavy menstrual bleeding due to leiomyomas or adenomyomas is an indication for surgery must assess whether patient wants to become pregnant or has completed childbearing myomectomy can be an option in patients who desire future pregnancy endometrial ablation uterine artery embolization hysterectomy definitive therapy Prognosis, Prevention, and Complications Prognosis treatment may improve quality of life Complications may be at increased risk for endometrial cancer or hyperplasia in AUB secondary to anovulation