Transcript: How To Diagnose and Treat Abnormal Uterine Bleeding

​Liz Rohr:
Hey there. It's Liz Rohr from Real World NP. You are watching NP Practice Made Simple, the weekly video to help save you time, frustration, and help you learn faster so you can take the best care of your patients. In this week's video, I'm going to be talking about abnormal uterine bleeding, which I'm super excited about and maybe non-clinicians on my team especially are like, "What are you talking about? That is so weird." But I'm a nerd, I'm a professional nerd, so we're going to talk about that today. I want to talk about the general approach to abnormal uterine bleeding, which is an umbrella catch-all term to any vaginal menstrual bleeding that is not expected, as we expect. Typically speaking, menstruation starts in the teenage years by age 14 or 15 in patients who have uteruses, and it continues until menopausal age, which the average age is around 51. I believe that's in the United States.

That's the typical experience. It occurs once a month, usually at regular intervals, either 28 days, 30 days. I believe the range is anywhere from 21 days up to 35-ish days, maybe 40. Don't quote me on that exact number. Anything above that 35 to 40 plus range in between cycles is considered to be extended. And then when it comes to the other qualities, it has to do with menstrual flow and how much bleeding there is and how many days. There isn't necessarily one set thing that is a quantified amount. The average I believe is five to seven days. Some patients have longer-lasting menstruation than others. These are all important baseline information to know, and then you can set your questioning in alignment with what the expected findings are. Most of the time it's every single month. And so if it's irregular, meaning it's longer cycle times or there are missed periods, that's more information.

And then you want to gather history about the experience. Is it five days, seven days, 14 days? Is there clotting? How many pads or tampons or menstrual products do they use in any given time as a quantitative amount for assessing menstrual flow? Because "normal" for one person is different than the other person, and nobody knows what's normal. They only know their own body. Those are the general frameworks to think about abnormal uterine bleeding to set that context. So where do you go from there? It really depends. There's a whole bunch of doorways and pathways to go based on that historical information, but the main differential diagnoses regardless of the context of the situation that you want to keep in mind, you want to think about anatomical structures. Is this cervical bleeding? Is this vaginal bleeding? Is this uterine bleeding? Is this fallopian tube abnormalities or ovarian abnormalities that is coming down?

And so keeping those things in mind, what are the potential differentials for that? So vaginally speaking, there's bacterial vaginosis, vaginitis, sexually transmitted infections. There are polyps. There are other abnormalities physically, structurally. If we're talking uterine, it could be uterine hyperplasia, endometrial hyperplasia, cancer, it can be fibroids, things like that. Fallopian tubes, cysts, things like that. Other things, pregnancy. Is there something in the uterus that is causing vaginal bleeding? And then the other things to think about are systemic issues. This is a very quick and dirty approach of ways to think about uterine bleeding, but what are the systemic reasons that one would have vaginal bleeding? A patient with a uterus? Again, not saying women, because there are many genders, and we're just talking about uteruses here. We're talking about anatomy here and physiology.

Hypothyroidism can contribute. Bleeding disorders can contribute. Polycystic ovarian syndrome can contribute to abnormal menses or unexpected menstrual cycles, things like that. This is not a comprehensive differential diagnosis, but this is really just to help your thinking process of, how are you approaching this? Let's give a couple examples. There's a girl who's 14 who's having menstrual cycles every other month. Some months it's 30 days in between, and then other times it's a skip of a month, another month, another month. Her menstruation, menarche, started when she was 13 and a half, so she's only had her menstrual period for about six months. So what do we know about that? Well, physiologically speaking, we know that menstruation is irregular, I keep saying abnormal, but irregular in the first couple years after the onset of menarche.

And so that is a potential. We still want to think about the other factors. What are the risks here for this person based on their lifestyle, based on their age? Is she sexually active? Again, that's a whole conversation about using the word sexually active. What does that even mean? To be continued. But what is the sexual behavior of this person? What are their risk factors for exposure to infection? What other symptoms are they having? What are the other historical questions we can ask about that? Endometrial hyperplasia and endometrial cancer, much lower down on the differential list for this patient because, again, the risk goes up with age. Another example, if you have a patient who's 49 who's having skipped periods that are getting heavier and heavier and heavier than they were before but they're not regular anymore, what are the first things that we want to think about when it comes to that approach of anatomy and physiology?

And keeping in mind the risk factor. A person who is over the age of 40 has a much higher risk of endometrial hyperplasia and endometrial cancer than somebody who is under 40. The other risk factors, things like diabetes, a BMI over 30, those are potentially other risk factors for endometrial hyperplasia as well as increased menstruation over time. So what is the change? Has it been like this whole time or is this brand new? What is the context of that? Versus it's just starting to drop and it's the same flow as it has been before. There are no other risk factors for endometrial hyperplasia, et cetera, et cetera. That leads to a different differential and story versus somebody who's 30 years old, like myself, for example, I'm not 30, but I'm in my 30s, who has acne, who has hirsutism, who has some hair loss, and who also is having irregular periods.

That sounds like PCOS, right? What are the different little pieces here? But we don't want to ignore the other things. We don't want to jump to conclusions. Hopefully, that's helpful in terms of the context setting of the approach in your visit and the way to think about it. Because you can always utilize your resources and look at the differential diagnosis for abnormal uterine bleeding, but the approach to questioning in your visit, conducting your visit and your thought process, that's something that you and I can talk about. I mean, I love giving all the resources too, but I'm trying to think very mindfully about how I can help you the best in terms of the things that we can't learn from our resources. So, anyway, that's the general thought process approach. When it comes to the initial testing, again, it goes back to your understanding of anatomy, physiology, and all of that stuff.

We want to do a pelvic exam. We want to see if there's anything anatomically happening. Are there any vulva lesions, vaginal lesions, cervical lesions, those kinds of things? Are there any other body systemic things? Because the systemic etiologies, it's a much longer list than just hypothyroidism and bleeding disorders. This is just a general exam of what we're thinking about. The next step is an HCG. We always want to assess for pregnancy in patients with a uterus who are not menopausal or past the menopausal, at least a year past menopause. So thinking about that. We want to consider doing a CBC to look. We want to look at the platelets, see if there's any anemia, and then we want to think about structurally, what else is going on there? Aside from our pelvic exam, considering the other potential like infectious etiologies. Is there any risk for vaginosis or STI?

The next step is an ultrasound. We want to assess the anatomy of the uterus to be complete. This is the general intro to what we're talking about. Again, keeping in mind, if you have other suspicions of the systemic disorders, maybe consider a TSH. If we're talking about menorrhagia specifically, if we're talking about heavy menstrual flow specifically. Depends on the type of abnormal uterine bleeding that we're talking about. And the last one to consider is a pelvic ultrasound. This is really your differential dependent, so it's up to you to choose. Not everybody who has a regular menstruation needs a pelvic ultrasound because it's a very invasive test. And the same thing for the other labs that I just talked about. I mean, almost everybody needs an HCG. You really have to assess history, but almost everybody can qualify for some sort of infectious testing, again, depending on their symptoms and their history.

But, again, pelvic ultrasound is really for patients who you have a specific indication of what you're looking for based on the history and the exam. So if it sounds like it's consistent with some sort of anatomical abnormality, meaning fibroids or a cyst or things like that, you want to consider it. Really, a pearl of practice here, potential pitfall, I can't help myself, I'm just a voracious learner and I had to have an ultrasound done. Actually, if you were wondering if I have an abnormal thyroid, I don't. But I had an ultrasound done because I get so many comments on videos of, "Is there something wrong with your thyroid?" Which is very sweet and I very much appreciate. But it's fine. It's chilling. It's just the way it looks. Anyway, I was asking the imaging person, the ultrasonographer, tons of questions in between the times that I was not supposed to be talking because she was doing the exam.

But, anyway, I was asking her, I was like, "What is one of the pet peeves that you have that you would tell a primary care provider?" And she said it was about pelvic ultrasounds, because the way that we order pelvic ultrasounds is that it's on top of the abdomen, but it's also transvaginal. And then sometimes providers trying to be considerate of patients will order just abdominal pelvic ultrasounds. But, unfortunately, if you're trying to visualize the whole organ system, the uterus, the uterine lining, the ovaries, the fallopian tubes, you, unfortunately, need both views and some of the times the ultrasonographer won't even complete the study because they don't have an order for a transvaginal ultrasound. So things to keep in mind. That's the quick and dirty approach to abnormal uterine bleeding, and I can definitely get into more condition-specific ones. So let me know what questions you have and hopefully, this video was helpful. Thank you so very much for watching. Hang in there and I'll see you soon.