Abnormal Uterine Bleeding in Premenopausal Women
- 1 April 2019
- journal article
- research article
- Vol. 99 (7), 435-443
Abstract
Abnormal uterine bleeding is a common symptom in women. The acronym PALM-COEIN facilitates classification, with PALM referring to structural etiologies (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia), and COEIN referring to nonstructural etiologies (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified). Evaluation involves a detailed history and pelvic examination, as well as laboratory testing that includes a pregnancy test and complete blood count. Endometrial sampling should be performed in patients 45 years and older, and in younger patients with a significant history of unopposed estrogen exposure. Transvaginal ultrasonography is the preferred imaging modality and is indicated if a structural etiology is suspected or if symptoms persist despite appropriate initial treatment. Medical and surgical treatment options are available. Emergency interventions for severe bleeding that causes hemodynamic instability include uterine tamponade, intravenous estrogen, dilation and curettage, and uterine artery embolization. To avoid surgical risks and preserve fertility, medical management is the preferred initial approach for hemodynamically stable patients. Patients with severe bleeding can be treated initially with oral estrogen, high-dose estrogen-progestin oral contraceptives, oral progestins, or intravenous tranexamic acid. The most effective long-term medical treatment for heavy menstrual bleeding is the levonorgestrel-releasing intrauterine system. Other long-term medical treatment options include estrogen-progestin oral contraceptives, oral progestins, oral tranexamic acid, nonsteroidal anti-inflammatory drugs, and depot medroxyprogesterone. Hysterectomy is the definitive treatment. A tower-risk surgical option is endometrial ablation, which performs as well as the levonorgestrel-releasing intrauterine system. Select patients with chronic uterine bleeding can be treated with myomectomy, polypectomy, or uterine artery embolization. Copyright (C) 2019 American Academy of Family Physicians.Keywords
This publication has 34 references indexed in Scilit:
- The prevalence of underlying bleeding disorders in patients with heavy menstrual bleeding with and without gynecologic abnormalitiesAmerican Journal of Obstetrics and Gynecology, 2013
- Endometrial resection and ablation techniques for heavy menstrual bleedingEmergencias, 2013
- Diagnosis and Management of Endometrial Polyps: A Critical Review of the LiteratureJournal of Minimally Invasive Gynecology, 2011
- FIGO classification system (PALM‐COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive ageInternational Journal of Gynecology & Obstetrics, 2011
- Gynecologic Examination for Adolescents in the Pediatric Office SettingPEDIATRICS, 2010
- Malignancy in endometrial polyps: a 12-year experienceAmerican Journal of Obstetrics and Gynecology, 2009
- A Systematic Review Evaluating Health-Related Quality of Life, Work Impairment, and Health-Care Costs and Utilization in Abnormal Uterine BleedingValue in Health, 2007
- Abnormal uterine bleeding and underlying hemostatic disorders: report of a consensus processFertility and Sterility, 2005
- Hemostasis and menstruation: appropriate investigation for underlying disorders of hemostasis in women with excessive menstrual bleedingFertility and Sterility, 2005
- Self-reported heavy bleeding associated with uterine leiomyomataObstetrics & Gynecology, 2003