How To Diagnose and Treat Abnormal Uterine Bleeding
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Show notes:
It’s easy to think the worst when your patient mentions abnormal bleeding. It can mean so many things! Remember that the context is everything for the patient with abnormal uterine bleeding. Their age, their history, when it started, how long it lasted, their other diagnoses, even their other medications. These are all factors to consider in the patient with abnormal uterine bleeding, and will point you in a starting direction for your assessment and help you to build your differential.
Having a good understanding of what is normal for periods is crucial.
Abnormal uterine bleeding often doesn’t mean the same thing for a young person in their twenties compared to someone who is past menopause. Do you know when people tend to start having periods (menarche)? Do you know when people tend to stop having periods (menopause)? Are you solid on what stopping having periods even means? Once you are solid on what is normal, you will get up to speed with abnormal things much faster.
If you feel unsure about where to start when working with the patient with abnormal uterine bleeding, this week’s episode should help. We will cover the history questions to ask, the labs to order, and the imaging to order - and we will go even deeper. We’ll also talk about:
Normal versus abnormal uterine bleeding
The anatomical factors that are key to your assessment
Potential causes of abnormal uterine bleeding
Other conditions that could cause or contribute to abnormal uterine bleeding
Pearls related to imaging (what to order, and how)
Like so many other concerns in healthcare, abnormal uterine bleeding can be scary, for patients as well as providers. Increasing your knowledge level will increase your comfort level. This will help you to build a strong differential, guide your patients, and address their concerns effectively.
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Hey there, welcome to the Real World NP podcast. I'm Liz Rohr, family nurse practitioner, educator
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and founder of Real World NP, an educational company for nurse practitioners in primary
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care. I'm on a mission to equip and guide new nurse practitioners so that they can
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feel confident, capable, and take the best care of their patients. If you're looking for clinical
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leave a review so you won't miss an episode. Plus, you'll find links to all the episodes
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with extra goodies over at realworldnp.com slash podcast. Hey there, it's Liz Rohr from Real World
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NP. You are watching NP Practice Made Simple, the weekly videos to help save you time,
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frustration, and help you learn faster so you can take the best care of your patients.
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In this week's video, I'm going to be talking about abnormal uterine bleeding, which I'm
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super excited about. Maybe non-clinicians on my team especially are like, what are you
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talking about? That is so weird. I'm a nerd. I'm a professional nerd. We're going to talk
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about that today. I want to talk about the general approach to abnormal uterine bleeding,
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which is an umbrella catch-all term to any vaginal menstrual bleeding that is not expected
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as we expect. Typically speaking, menstruation starts around age, in the teenage years,
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by age 14 or 15 in patients who have uteruses. It continues until menopausal
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which the average age is around 51. I believe that's in the United States.
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That's the typical experience. It occurs once a month, usually at regular intervals, either
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28 days, 30 days. I believe the range is anywhere from 21 days up to 35-ish days,
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maybe 40. Don't quote me on that exact number. Anything above that 35 to 40 plus
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in between cycles is considered to be extended. When it comes to the other qualities,
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it has to do with menstrual flow and how much bleeding there is and how many days. There isn't
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necessarily one set thing that is a quantified amount. The average, I believe, is five to seven
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days. Some patients have longer lasting menstruation than others. These are all
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kind of like baseline information to know. Then you can set your questioning in alignment with
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what the expected findings are. Most of the time, it's every single month. If it's irregular,
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meaning it's longer cycle times or there are missed periods, that's more information.
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Then you want to gather history about the experience. Is it five days, seven days, 14
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days? Is there clotting? How many pads or tampons or menstrual products do they use in
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given time as a quantitative amount for assessing menstrual flow? Because normal,
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quote unquote, normal for one person is different than the other person. Nobody
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knows what's normal. They only know their own body. Those are the general frameworks to
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think about abnormal uterine bleeding to set that context. Where do you go from there?
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It really depends. There's a whole bunch of doorways and pathways to go based on that
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historical information. The main differential diagnoses, regardless of the context of the
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you want to keep in mind, you want to think about anatomical structures. Is this cervical
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bleeding? Is this vaginal bleeding? Is this uterine bleeding? Is this fallopian tube
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abnormalities or ovarian abnormalities that is coming down? Keeping those things in mind,
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what are the potential differentials for that? Vaginally speaking, there's bacterial vaginosis,
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vaginitis, sexually transmitted infections. There are polyps. There are other abnormalities
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physically, structurally. If we're talking uterine, it could be a uterine hyperplasia,
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endometrial hyperplasia. Cancer can be fibroids, things like that. Fallopian tubes,
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cysts, things like that. Other things, pregnancy. Is there something in the uterus
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that is causing vaginal bleeding? And then the other things to think about are systemic
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issues. So this is a very quick and dirty approach of ways to think about uterine bleeding,
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but what are the systemic reasons that one would have vaginal bleeding? A patient with
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not saying women because there are many genders and we're just talking about uteruses here.
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We're talking about anatomy here and physiologies. Hypothyroidism can contribute.
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Bleeding disorders can contribute. Polycystic ovarian syndrome can contribute to abnormal
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menses or unexpected menstrual cycles, things like that. This is not like a comprehensive
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differential diagnosis, but this is really just to help your thinking process of like,
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how are you approaching this? So let's give a couple of examples. So there's a woman,
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there's a girl who's 14, who's having menstrual cycles every other month. So some months it's 30
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days in between, and then other times it's a skip of a month, another month, another month.
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Her menstruation, menage, started when she was 13 and a half. So she's only had her menstrual
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period for about six months. So what do we know about that? Well, physiologically speaking,
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we know that menstruation is irregular, I keep saying abnormal, but irregular in the first
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years after the onset of menage. We still want to think about the other factors. What are the
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risks here for this person based on their lifestyle, based on their age? So is she
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sexually active? Again, that's a whole conversation about using the word sexually active. What does
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that even mean? TB continued. But what is the sexual behavior of this person? What are
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their risk factors for exposure to infection? What other symptoms are they having? What are
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other historical questions we can ask about that? Endometrial hyperplasia and endometrial cancer,
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much lower down on the differential list for this patient, because again, the risk goes up with
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age. Another example, if you have a patient who's 49, who's having skipped periods that are
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getting heavier and heavier and heavier than they were before, but they're not regular
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anymore. What are the first things that we want to think about when it comes to that approach
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of anatomy and physiology and keeping in mind the risk factor? So a person who is over
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age 40 has a much higher risk of endometrial hyperplasia and endometrial cancer than somebody
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who is under 40. The other risk factors, things like diabetes, a BMI over 30, those
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are potentially other risk factors for endometrial hyperplasia, as well as increased
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menstruation over time. So what is the change? Has it been like this this whole time or is
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this brand new? So what is the context of that versus it's just starting to drop and it's
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same flow as it has been before. There are no other risk factors for endometrial hyperplasia,
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et cetera, et cetera. That leads to a different differential and story versus somebody who's
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30 years old, like myself, for example. I'm not 30, but I'm in my 30s, who has
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acne, who has hirsutism, who has some hair loss, and who also is having irregular periods.
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That kind of sounds like PCOS. So what are the different little pieces here? But we don't
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ignore the other things. We don't want to jump to conclusions. So hopefully that's
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helpful in terms of the context setting of the approach in your visit and the way to think
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about it. Because you can always utilize your resources and look at the differential diagnosis
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for abnormal uterine bleeding, but the approach to questioning in your visit, conducting
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your visit and your thought process, that's something that you and I can talk about.
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I love giving all the resources too, but I'm trying to think very mindfully about how I can
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help you the best in terms of the things that we can't learn from our resources.
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Right? So anyway, that's the general thought process approach. When it comes to the initial
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testing, again, goes back to your understanding of anatomy, physiology, and all of that stuff.
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Right? So we want to do a pelvic exam. We want to see if there's anything anatomically
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happening. Right? Are there any vulvar lesions, vaginal lesions, cervical lesions,
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those kinds of things? Are there any other body systemic things? Because the systemic
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etiologies, it's a much longer list than just hypothyroidism and bleeding disorders. Right?
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This just general exam of what we're thinking about. The next step is an HCG. We always want
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to assess for pregnancy in patients with a uterus who are not menopausal or past the
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menopausal, like at least a year past menopause. So thinking about that, we want to consider
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doing a CBC to look and see if there's any sort of, we want to look at the platelets,
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see if there's any anemia. And then we want to think about structurally, what else is going
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on there? Aside from our pelvic exam, considering the other potential like infectious etiologies,
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right? Is there any risk for vaginosis or STI? The next kind of step is an ultrasound. We
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want to assess the anatomy of the uterus to be complete. That's just like the general intro
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to like what we're talking about. Again, keeping in mind, if you have other suspicions
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the systemic disorders, maybe consider a TSH. If we're talking about menorrhagia specifically,
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we're talking about heavy menstrual flow specifically, right? Depends on the type
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of abnormal uterine bleeding that we're talking about. And the last one to consider
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is a pelvic ultrasound. So this is really your differential dependent, right? So
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it's up to you to choose. Not everybody who has a regular menstruation needs a
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pelvic ultrasound because it's a very invasive test. And the same thing for the other labs
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I just talked about. I mean, almost everybody needs an HCG, right? You really have to assess
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history, but almost everybody can qualify for some sort of infectious testing, again,
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depending on their symptoms and their history. But again, pelvic ultrasound is really for
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patients who you have a specific indication of what you're looking for based on the
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history and the exam. So if it sounds like it's consistent with some sort of anatomical
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abnormality, meaning fibroids or a cyst or things like that, you want to consider it.
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Really pearl of practice here, potential pitfall. So I can't help myself. I'm just
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like a voracious learner and I had to have an ultrasound done. Actually, if you were
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wondering if I have an abnormal thyroid, I don't, but I had an ultrasound done because
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I get so many comments on videos of like, is there something wrong with your thyroid?
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Which is very sweet and I very much appreciate, but it's fine. It's chilling. It's just,
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but anyway, I was asking the imaging person, the ultrasonographer, tons of questions in between
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the times that I was not supposed to be talking because she was doing the exam.
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But anyway, I was asking her, I was like, what is one of the pet peeves that you have
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that you would tell a primary care provider? And she said it was about pelvic ultrasounds
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because the way that we order pelvic ultrasounds is that it's on top of the
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abdomen, but it's also transvaginal. And then sometimes providers trying to be considerate
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patients will order just on abdominal pelvic ultrasounds. But unfortunately,
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if you're trying to visualize the whole organ system, the uterus, the uterine lining,
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the ovaries, the fallopian tubes, you unfortunately need both views. And some of
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the times the ultrasonographers won't even complete the study because they don't have
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an order for a transvaginal ultrasound. So things to keep in mind, but that's like
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quick and dirty approach to abnormal uterine bleeding. And I can definitely get into more
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condition specific ones. So let me know what questions you have. And hopefully this video
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was helpful. Thank you so very much for watching. Hang in there and I'll see you soon.
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That's our episode for today. Thank you so much for listening. Make sure you subscribe,
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