Abnormal uterine bleeding in the reproductive years. Part I—Pathogenesis and clinical investigation

Abstract

Summary A number of mechanisms are involved in the genesis AUB including disorders of pregnancy, structural abnormalities such as polyps or submucous myomas, anovulation, and abnormalities in local endometrial hemostatic mechanisms. The patient's personal and family history are extremely important for triage, and measurement of β-hCG is essential to determine pregnancy. Ovulatory status is a critically important component of the clinical assessment as it affects both selection of further analytic tests and patient counseling regarding expectant and therapeutic options. The physical examination may be misleading when evaluating for causative leiomyomas. Palpable masses suggestive of leiomyomas may not involve the endometrial cavity and therefore may not contribute to the etiology of the bleeding. Furthermore, although uncommon, such masses may actually be manifestations of nodular adenomyosis. On the other hand, the uterus, normal to palpation, may harbor small but clinically significant submucous myomas or other focal or generalized pathology such as polyps or endometritis that could explain the AUB. As a result, and particularly in the presence of ovulatory AUB, the clinician should judiciously rely on imaging techniques. Women with chronic anovulatory DUB present the clinician an opportunity to detect an array of clinical entities ranging from significant endocrinopathies to serious psychosocial pathology. Chronic anovulation creates the milieu necessary for development of endometrial neoplasia including hyperplasia and adenocarcinoma. Consequently, evaluation of these women should focus on endometrial histology and the reason for the systemic disorder. Such a rigorous but tailored approach to AUB isnecessary to provide women with a full range of therapeutic options. Management can evolve from the traditional, often unsatisfactory, empiric approach, dominated by hysterectomy, to an individualized strategy that offers women a variety of expectant, medical, and surgical options tailored to their particular needs.