Rosen & Barkin's 5-Minute Emergency Medicine Consult (226 page)

• Abdominal Trauma, Blunt
  
• Abdominal Trauma, Imaging
  
• Abdominal Trauma, Penetrating
  

CODES

• 863.21 Injury to duodenum, without open wound into cavity
  
• 863.31 Injury to duodenum, with open wound into cavity
  

BASICS

• Abnormal uterine bleeding is an alteration in pattern or volume of normal menses
  
  • Typical blood loss during a normal menstrual cycle is 30–80 mL
    
  • Normal interval between menses 28 (+/− 7) days
    
• 2 classifications
  
  • Dysfunctional uterine bleeding (DUB)
    
    • Hormonally related
      
    • Anovulatory and ovulatory categories
      
    • Not due to organic or iatrogenic causes
      
    • Diagnosis of exclusion
      
  • Organic uterine bleeding
    
    • Bleeding related to systemic illness or disease of the reproductive tract
      

• Anovulatory (most common):
  
  • Unopposed estrogen stimulation of proliferative endometrium
    
  • Alteration of neuroendocrine function due to:
    
    • Polycystic ovarian syndrome (PCOS)
      
    • Very low calorie diets, rapid weight change, intense exercise, anorexia
      
    • Psychological stress
      
    • Obesity
      
    • Drugs
      
    • Hypothyroidism
      
    • Primary hypothalamic dysfunction
      
• Ovulatory:
  
  • Inadequate uterine PGF2α
    
    • Increased uterine contractility
      
  • Excessive uterine prostacycline
    
    • Diminishes platelet function and increases uterine vasodilation
      

Anovulatory bleeding common in adolescence owing to immaturity of the hypothalamic–pituitary–ovarian axis

DIAGNOSIS

• Abnormal uterine bleeding in the absence of systemic or structural disease
  
• Most common in perimenarcheal, perimenopausal women
  
• Typically painless
  
• Anovulatory presentations:
  
  • Metrorrhagia:
    
    • Irregular bleeding between periods
      
  • Menorrhagia:
    
    • Regular periods with excess flow (>80 mL) or >7 days of bleeding
      
  • Oligomenorrhea:
    
    • Periods with intermenstrual cycles >35 days
      
  • Menometrorrhagia:
    
    • Excessive bleeding with and between menses
      

• Acne, hirsutism, obesity suggest PCOS
  
• Mild to moderate bleeding on pelvic exam
  
• Pallor, tachycardia, hypotension, orthostasis in severe cases
  
• Evaluate for trauma, foreign bodies
  

Pregnancy test

• Pregnancy test, CBC, PT/PTT
  
• May send iron studies, TSH, LH, FSH, prolactin level, cervical cultures for routine follow-up by primary medical doctor (PMD)/gynecology
  

Pelvic ultrasound may show uterine, tubal, or ovarian abnormality; may be needed to rule out other organic or iatrogenic causes on differential diagnoses.

• Dilation and curettage (D&C) may be required for heavy bleeding unresponsive to other interventions
  
• Refer for endometrial biopsy if >35 yr of age
  

• Pregnancy complications:
  
  • Threatened, incomplete, or spontaneous abortion
    
  • Ectopic pregnancy
    
  • Molar pregnancy
    
• Infectious:
  
  • Vaginitis
    
  • Cervicitis
    
  • Pelvic inflammatory disease (PID)
    
• Coagulopathies:
  
  • von Willebrand disease
    
  • Idiopathic thrombocytopenic purpura
    
  • Platelet defects
    
  • Thalassemia
    
• Medications:
  
  • Warfarin
    
  • Aspirin
    
  • Oral contraceptives
    
  • Tricyclic antidepressants
    
  • Major tranquilizers
    
• Systemic illness:
  
  • Adrenal, hepatic, renal or thyroid dysfunction, diabetes mellitus, other endocrinopathies
    
• Anatomic lesions:
  
  • Fibroids
    
  • Endometriosis
    
  • Polyps
    
  • Endometrial hyperplasia
    
  • Neoplasm
    
• Intrauterine devices
  
• Trauma
  

See anovulatory and ovulatory etiologies

TREATMENT

IV crystalloid boluses as needed for hypotension, tachycardia secondary to heavy bleeding

ABCs:

• Packed RBCs for significant bleeding unresponsive to crystalloids
  

• Observation usually adequate if bleeding mild
  
• IV crystalloid, packed RBCs for continued bleeding, or hemodynamic instability
  
• Gynecology consultation if bleeding is severe and unresponsive to crystalloids, medications:
  
  • D&C may be necessary for hemodynamic instability
    
  • Endometrial ablation or hysterectomy for continued heavy bleeding unresponsive to other measures
    

• Conjugated estrogen (Premarin) for heavy bleeding, hemodynamic instability:
  
  • 2.5 mg PO q6h
    
  • 25 mg IV, repeat in 3 hr if needed
    
• Ibuprofen 400–800 mg PO q8h (reduces prostaglandin synthesis)
  
• IV dosing has not been shown to be superior to oral route:
  
  • Medroxyprogesterone acetate 5–10 mg/d PO is added when bleeding subsides
    
• Oral contraceptive pills:
  
  • Ethinyl estradiol 35 μg and norethindrone 1 mg PO QID for 1 wk
    
• Antifibrinolytic agents:
  
  • Tranexamic acid: 1,300 mg PO TID × 5 days
    
  • May be used in conjunction with OCPs
    
  • Use limited by GI effects and allergy
    
• Medications may be deferred in mild cases with referral to gynecology
  
• Transdermal or long-acting estrogens are other options
  

FOLLOW-UP

• Significant blood loss
  
• Continued bleeding
  
• Hemodynamic instability requiring aggressive resuscitation and/or operative intervention
  

Most patients can be discharged with gynecology referral once bleeding is controlled and patient is hemodynamically stable.

Endometrial biopsy if >35 yr old:

• Follow-up with either gynecologist or primary care physician is necessary for patients with DUB
  
• Must evaluate for ongoing blood loss or potential malignancy as cause
  

• DUB is a diagnosis of exclusion
  
• Only 2% of endometrial carcinoma occur before age 40 yr
  
• If hemodynamic instability, unlikely diagnosis of DUB
  

• Casablanca Y. Management of dysfunctional uterine bleeding.
  Obstet Gynecol Clin North Am
  . 2008;35:219–234.
  
• LaCour DE, Long DN, Perlman SE. Dysfunctional uterine bleeding in adolescent females with endocrine causes and medical conditions.
  J Pediatr Adolesc Gynecol
  . 2010;23:62–70.
  
• Lentz G, Lobo R, Gershenson D, et al.
  Comprehensive Gynecology
  . 6th ed. Philadelphia, PA: Mosby; 2012.
  
• Lethaby A, Farquhar C, Cooke I. Antifibrinolytics for heavy menstrual bleeding.
  Cochrane Database Syst Rev.
  2000;(4):CD000249.
  
• Pitkin J. Dysfunctional uterine bleeding.
  BMJ
  . 2007;334:1110–1111.