PDF icon PDF herunterladen
Semin Reprod Med 2011; 29(5): 410-422
DOI: 10.1055/s-0031-1287665
© Thieme Medical Publishers

The Need for Investigations to Elucidate Causes and Effects of Abnormal Uterine Bleeding

Malcolm G. Munro1 , Oskari Heikinheimo2 , Rohana Haththotuwa3 , Jaydeep D. Tank4 , Ian S. Fraser5
  • 1Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, California
  • 2Department of Obstetrics and Gynaecology, University of Helsinki, Finland
  • 3Ninewells CARE Mother & Baby Hospital, Colombo, Sri Lanka
  • 4Ashwini Maternity and Surgical Hospital, Center for Advanced Endoscopy, Assisted Reproduction and In Vitro Fertilization (IVF), Mumbai, India
  • 5Department of Obstetrics and Gynaecology, University of Sydney, Australia
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
07. November 2011 (online)

   Lizenzen und Reprints
Preview

ABSTRACT

This article describes a modern perspective on the basic investigations for abnormal uterine bleeding (AUB) in low-resource settings compared with a much more detailed approach for high-resource settings, bearing in mind issues of effectiveness and cost effectiveness. AUB includes any one or more of several symptoms, and it should be evaluated for the characteristics of the woman's specific bleeding pattern, her “complaint” and the presence of other symptoms (especially pain), the impact on several aspects of body functioning and lifestyle, and the underlying cause(s), especially cancer. Ideally, the evaluation is comprehensive, considering each of the potential etiological domains defined by the International Federation of Gynecology and Obstetrics PALM-COEIN system for the classification of causes. However, the detail of the questions and the extent of investigations will be significantly influenced by the technologies available and the time allotted for a consultation. In general, investigations should be performed only if they will make a material difference to the management approaches that can be offered. This should be an important consideration when a range of costly high-technology tests is accessible or when certain tests only have limited availability.

KEYWORDS

Abnormal uterine bleeding - heavy bleeding - investigations - imaging

REFERENCES

  • 1 Fraser IS, Critchley HO, Broder M, Munro MG. The FIGO recommendations on terminologies and definitions for normal and abnormal uterine bleeding.  Semin Reprod Med. 2011;  29 (5) 383-390
    Suche in Google Scholar
  • 2 Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO Working Group on Menstrual Disorders . The FIGO Classification System (“PALM-COEIN”) for causes of abnormal uterine bleeding in non-gravid women of reproductive age.  Int J Gynaecol Obstet. 2011;  113 3-13
    Suche in Google Scholar
  • 3 Munro MG, Critchley HO, Fraser IS. The flexible FIGO classification concept for underlying causes of abnormal uterine bleeding.  Semin Reprod Med. 2011;  29 (5) 391-399
    Suche in Google Scholar
  • 4 O'Donovan PJ, Miller CE. Modern Management of Abnormal Uterine Bleeding. London, UK: Informa Healthcare; 2008
    Suche in Google Scholar
  • 5 Munro MG. Abnormal Uterine Bleeding. Cambridge, UK: Cambridge University Press; 2010
    Suche in Google Scholar
  • 6 Lieng M, Istre O, Sandvik L, Engh V, Qvigstad E. Clinical effectiveness of transcervical polyp resection in women with endometrial polyps: randomized controlled trial.  J Minim Invasive Gynecol. 2010;  17 (3) 351-357
    Suche in Google Scholar
  • 7 Matteson K, Munro MG, Fraser IS. The structured menstrual history: developing a tool to facilitate diagnosis and to aid in symptom management.  Semin Reprod Med. 2011;  29 (5) 423-435
    Suche in Google Scholar
  • 8 Santer M, Wyke S, Warner P. What aspects of periods are most bothersome for women reporting heavy menstrual bleeding? Community survey and qualitative study.  BMC Womens Health. 2007;  7 8
    Suche in Google Scholar
  • 9 Fraser IS, Critchley HO, Munro MG, Broder M. Writing Group for this Menstrual Agreement Process . A process designed to lead to international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding.  Fertil Steril. 2007;  87 (3) 466-476
    Suche in Google Scholar
  • 10 Rahn DD, Abed H, Sung VW et al.. Systematic review highlights difficulty interpreting diverse clinical outcomes in abnormal uterine bleeding trials.  J Clin Epidemiol. 2011;  64 (3) 293-300
    Suche in Google Scholar
  • 11 Warner PE, Critchley HO, Lumsden MA, Campbell-Brown M, Douglas A, Murray GD. Menorrhagia II: is the 80-mL blood loss criterion useful in management of complaint of menorrhagia?.  Am J Obstet Gynecol. 2004;  190 (5) 1224-1229
    Suche in Google Scholar
  • 12 National Institute for Health and Clinical Excellence .Clinical Guideline 44; Heavy menstrual bleeding. Available at: http://www.nice.org.uk/nicemedia/pdf/CG44FullGuideline.pdf Accessed May 23, 2011
    Suche in Google Scholar
  • 13 Matteson KA, Clark MA. Questioning our questions: do frequently asked questions adequately cover the aspects of women's lives most affected by abnormal uterine bleeding? Opinions of women with abnormal uterine bleeding participating in focus group discussions.  Women Health. 2010;  50 (2) 195-211
    Suche in Google Scholar
  • 14 Lukes AS, Muse K, Richter HE, Moore KA, Patrick DL. Estimating a meaningful reduction in menstrual blood loss for women with heavy menstrual bleeding.  Curr Med Res Opin. 2010;  26 (11) 2673-2678
    Suche in Google Scholar
  • 15 Padilla LA, Radosevich DM, Milad MP. Limitations of the pelvic examination for evaluation of the female pelvic organs.  Int J Gynaecol Obstet. 2005;  88 (1) 84-88
    Suche in Google Scholar
  • 16 Trasi SA, Pathare AV, Shetty SD, Ghosh K, Salvi V, Mohanty D. The spectrum of bleeding disorders in women with menorrhagia: a report from Western India.  Ann Hematol. 2005;  84 (5) 339-342
    Suche in Google Scholar
  • 17 Saxena R, Gupta M, Gupta PK, Kashyap R, Choudhry VP, Bhargava M. Inherited bleeding disorders in Indian women with menorrhagia.  Haemophilia. 2003;  9 (2) 193-196
    Suche in Google Scholar
  • 18 Kouides PA, Conard J, Peyvandi F, Lukes A, Kadir R. Hemostasis and menstruation: appropriate investigation for underlying disorders of hemostasis in women with excessive menstrual bleeding.  Fertil Steril. 2005;  84 (5) 1345-1351
    Suche in Google Scholar
  • 19 Kadir RA, Chi C. Women and von Willebrand disease: controversies in diagnosis and management.  Semin Thromb Hemost. 2006;  32 (6) 605-615
    Suche in Google Scholar
  • 20 James AH, Kouides PA, Abdul-Kadir R et al.. Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel.  Am J Obstet Gynecol. 2009;  201 (1) 12 e1-e8
    Suche in Google Scholar
  • 21 Kadir RA, Economides DL, Sabin CA, Owens D, Lee CA. Frequency of inherited bleeding disorders in women with menorrhagia.  Lancet. 1998;  351 (9101) 485-489
    Suche in Google Scholar
  • 22 Abu JI, Habiba MA, Baker R et al.. Quantitative and qualitative assessment of women's experience of a one-stop menstrual clinic in comparison with traditional gynaecology clinics.  BJOG. 2001;  108 (9) 993-999
    Suche in Google Scholar
  • 23 Vercellini P, Cortesi I, De Giorgi O, Merlo D, Carinelli SG, Crosignani PG. Transvaginal ultrasonography versus uterine needle biopsy in the diagnosis of diffuse adenomyosis.  Hum Reprod. 1998;  13 (10) 2884-2887
    Suche in Google Scholar
  • 24 Farquhar C, Ekeroma A, Furness S, Arroll B. A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women.  Acta Obstet Gynecol Scand. 2003;  82 (6) 493-504
    Suche in Google Scholar
  • 25 Grimbizis GF, Tsolakidis D, Mikos T et al.. A prospective comparison of transvaginal ultrasound, saline infusion sonohysterography, and diagnostic hysteroscopy in the evaluation of endometrial pathology.  Fertil Steril. 2010;  94 (7) 2720-2725
    Suche in Google Scholar
  • 26 Toth M, Patton DL, Esquenazi B, Shevchuk M, Thaler H, Divon M. Association between Chlamydia trachomatis and abnormal uterine bleeding.  Am J Reprod Immunol. 2007;  57 (5) 361-366
    Suche in Google Scholar
  • 27 Baerwald AR, Pierson RA. Endometrial development in association with ovarian follicular waves during the menstrual cycle.  Ultrasound Obstet Gynecol. 2004;  24 (4) 453-460
    Suche in Google Scholar
  • 28 Emanuel MH, Verdel MJ, Wamsteker K, Lammes FB. A prospective comparison of transvaginal ultrasonography and diagnostic hysteroscopy in the evaluation of patients with abnormal uterine bleeding: clinical implications.  Am J Obstet Gynecol. 1995;  172 (2 Pt 1) 547-552
    Suche in Google Scholar
  • 29 Schwärzler P, Concin H, Bösch H et al.. An evaluation of sonohysterography and diagnostic hysteroscopy for the assessment of intrauterine pathology.  Ultrasound Obstet Gynecol. 1998;  11 (5) 337-342
    Suche in Google Scholar
  • 30 Guido RS, Kanbour-Shakir A, Rulin MC, Christopherson WA. Pipelle endometrial sampling. Sensitivity in the detection of endometrial cancer.  J Reprod Med. 1995;  40 (8) 553-555
    Suche in Google Scholar
  • 31 Stovall TG, Ling FW, Morgan PL. A prospective, randomized comparison of the Pipelle endometrial sampling device with the Novak curette.  Am J Obstet Gynecol. 1991;  165 (5 Pt 1) 1287-1290
    Suche in Google Scholar
  • 32 Ben-Baruch G, Seidman DS, Schiff E, Moran O, Menczer J. Outpatient endometrial sampling with the Pipelle curette.  Gynecol Obstet Invest. 1994;  37 (4) 260-262
    Suche in Google Scholar
  • 33 Dijkhuizen FP, Mol BW, Brölmann HA, Heintz AP. The accuracy of endometrial sampling in the diagnosis of patients with endometrial carcinoma and hyperplasia: a meta-analysis.  Cancer. 2000;  89 (8) 1765-1772
    Suche in Google Scholar
  • 34 Nilsson L, Rybo G. Treatment of menorrhagia.  Am J Obstet Gynecol. 1971;  110 (5) 713-720
    Suche in Google Scholar
  • 35 Grimes DA. Diagnostic dilation and curettage: a reappraisal.  Am J Obstet Gynecol. 1982;  142 (1) 1-6
    Suche in Google Scholar
  • 36 Farquhar CM, Lethaby A, Sowter M, Verry J, Baranyai J. An evaluation of risk factors for endometrial hyperplasia in premenopausal women with abnormal menstrual bleeding.  Am J Obstet Gynecol. 1999;  181 (3) 525-529
    Suche in Google Scholar
  • 37 Ash SJ, Farrell SA, Flowerdew G. Endometrial biopsy in DUB.  J Reprod Med. 1996;  41 (12) 892-896
    Suche in Google Scholar
  • 38 Gibson M. Reproductive health and polycystic ovary syndrome.  Am J Med. 1995;  98 (1A) 67S-75S
    Suche in Google Scholar
  • 39 Morgan RW. Risk of endometrial cancer after tamoxifen treatment.  Oncology (Williston Park). 1997;  11 (2, Suppl 1) 25-33
    Suche in Google Scholar
  • 40 Lu KH, Dinh M, Kohlmann W et al.. Gynecologic cancer as a “sentinel cancer” for women with hereditary nonpolyposis colorectal cancer syndrome.  Obstet Gynecol. 2005;  105 (3) 569-574
    Suche in Google Scholar
  • 41 Fraser IS, Critchley HO, Munro MG. Abnormal uterine bleeding: getting our terminology straight.  Curr Opin Obstet Gynecol. 2007;  19 (6) 591-595
    Suche in Google Scholar
  • 42 Vercellini P, Cortesi I, Oldani S, Moschetta M, De Giorgi O, Crosignani PG. The role of transvaginal ultrasonography and outpatient diagnostic hysteroscopy in the evaluation of patients with menorrhagia.  Hum Reprod. 1997;  12 (8) 1768-1771
    Suche in Google Scholar
  • 43 Clark TJ. Outpatient hysteroscopy and ultrasonography in the management of endometrial disease.  Curr Opin Obstet Gynecol. 2004;  16 (4) 305-311
    Suche in Google Scholar
  • 44 Dueholm M, Lundorf E, Hansen ES, Ledertoug S, Olesen F. Evaluation of the uterine cavity with magnetic resonance imaging, transvaginal sonography, hysterosonographic examination, and diagnostic hysteroscopy.  Fertil Steril. 2001;  76 (2) 350-357
    Suche in Google Scholar
  • 45 Huang GS, Gebb JS, Einstein MH, Shahabi S, Novetsky AP, Goldberg GL. Accuracy of preoperative endometrial sampling for the detection of high-grade endometrial tumors.  Am J Obstet Gynecol. 2007;  196 (3) 243 e1–e5
    Suche in Google Scholar
  • 46 Krampl E, Bourne T, Hurlen-Solbakken H, Istre O. Transvaginal ultrasonography sonohysterography and operative hysteroscopy for the evaluation of abnormal uterine bleeding.  Acta Obstet Gynecol Scand. 2001;  80 (7) 616-622
    Suche in Google Scholar
  • 47 Ossola MW, Bertulessi C, Iasi L et al.. Comparison of saline infusion sonography to transvaginal echography and hysteroscopy in the diagnostic evaluation of abnormal uterine bleeding.  Int J Gynaecol Obstet. 1999;  11 145-150
    Suche in Google Scholar
  • 48 Munro MG, Brooks PG. Use of local anesthesia for office diagnostic and operative hysteroscopy.  J Minim Invasive Gynecol. 2010;  17 (6) 709-718
    Suche in Google Scholar
  • 49 Mohan S, Page LM, Higham JM. Diagnosis of abnormal uterine bleeding.  Best Pract Res Clin Obstet Gynaecol. 2007;  21 (6) 891-903
    Suche in Google Scholar
  • 50 Marret H, Fauconnier A, Chabbert-Buffet N CNGOF Collège National des Gynécologues et Obstétriciens Français et al. Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause.  Eur J Obstet Gynecol Reprod Biol. 2010;  152 (2) 133-137
    Suche in Google Scholar
  • 51 Chiang CH, Chang MY, Hsu JJ et al.. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography.  J Assist Reprod Genet. 1999;  16 (5) 268-275
    Suche in Google Scholar
  • 52 Perrot N, Frey I, Mergui JL, Bazot M, Uzan M, Uzan S. Picture of the month. Adenomyosis: power Doppler findings.  Ultrasound Obstet Gynecol. 2001;  17 (2) 177-178
    Suche in Google Scholar
  • 53 Mark AS, Hricak H, Heinrichs LW et al.. Adenomyosis and leiomyoma: differential diagnosis with MR imaging.  Radiology. 1987;  163 (2) 527-529
    Suche in Google Scholar
  • 54 Bazot M, Cortez A, Darai E et al.. Ultrasonography compared with magnetic resonance imaging for the diagnosis of adenomyosis: correlation with histopathology.  Hum Reprod. 2001;  16 (11) 2427-2433
    Suche in Google Scholar
  • 55 Critchley HO, Warner P, Lee AJ, Brechin S, Guise J, Graham B. Evaluation of abnormal uterine bleeding: comparison of three outpatient procedures within cohorts defined by age and menopausal status.  Health Technol Assess. 2004;  8 (34) iii-iv 1-139
    Suche in Google Scholar
  • 56 Burton KA, Henderson TA, Hillier SG et al.. Local levonorgestrel regulation of androgen receptor and 17beta-hydroxysteroid dehydrogenase type 2 expression in human endometrium.  Hum Reprod. 2003;  18 (12) 2610-2617
    Suche in Google Scholar
  • 57 Timan IS, Tatsumi N, Aulia D, Wangsasaputra E. Comparison of haemoglobinometry by WHO Haemoglobin Colour Scale and copper sulphate against haemiglobincyanide reference method.  Clin Lab Haematol. 2004;  26 (4) 253-258
    Suche in Google Scholar
  • 58 Eisenberg JM, Williams SV, Garner L, Viale R, Smits H. Computer-based audit to detect and correct overutilization of laboratory tests.  Med Care. 1977;  15 (11) 915-921
    Suche in Google Scholar
  • 59 Schroeder SA, Kenders K, Cooper JK, Piemme TE. Use of laboratory tests and pharmaceuticals. Variation among physicians and effect of cost audit on subsequent use.  JAMA. 1973;  225 (8) 969-973
    Suche in Google Scholar
  • 60 Dixon RH, Laszlo J. Ultilization of clinical chemistry services by medical house staff. An analysis.  Arch Intern Med. 1974;  134 (6) 1064-1067
    Suche in Google Scholar
  • 61 Schoenenberger RA, Tanasijevic MJ, Jha A, Bates DW. Appropriateness of antiepileptic drug level monitoring.  JAMA. 1995;  274 (20) 1622-1626
    Suche in Google Scholar
  • 62 Deeks JJ. Systematic reviews in health care: Systematic reviews of evaluations of diagnostic and screening tests.  BMJ. 2001;  323 (7305) 157-162
    Suche in Google Scholar
  • 63 Lijmer JG, Mol BW, Heisterkamp S et al.. Empirical evidence of design-related bias in studies of diagnostic tests.  JAMA. 1999;  282 (11) 1061-1066
    Suche in Google Scholar
  • 64 van Dongen H, de Kroon CD, Jacobi CE, Trimbos JB, Jansen FW. Diagnostic hysteroscopy in abnormal uterine bleeding: a systematic review and meta-analysis.  BJOG. 2007;  114 (6) 664-675
    Suche in Google Scholar
  • 65 Matteson KA, Boardman LA, Munro MG, Clark MA. Abnormal uterine bleeding: a review of patient-based outcome measures.  Fertil Steril. 2009;  92 (1) 205-216
    Suche in Google Scholar
  • 66 Hallberg L, Nilsson L. Determination of menstrual blood loss.  Scand J Clin Lab Invest. 1964;  16 244-248
    Suche in Google Scholar
  • 67 Hoppe-Seyler G, Broderson A, Rudolph A. Uber den Blutverlist bei der menstruation [in German].  Ztschr F Physiol Chem.. 1904;  42 545-553
    Suche in Google Scholar
  • 68 Fraser IS, McCarron G, Markham R. A preliminary study of factors influencing perception of menstrual blood loss volume.  Am J Obstet Gynecol. 1984;  149 (7) 788-793
    Suche in Google Scholar
  • 69 Magnay JL, Nevatte TM, Dhingra V, O'Brien S. Menstrual blood loss measurement: validation of the alkaline hematin technique for feminine hygiene products containing superabsorbent polymers.  Fertil Steril. 2010;  94 (7) 2742-2746
    Suche in Google Scholar
  • 70 Fraser IS, McCarron G, Markham R, Resta T. Blood and total fluid content of menstrual discharge.  Obstet Gynecol. 1985;  65 (2) 194-198
    Suche in Google Scholar
  • 71 Fraser IS, Warner P, Marantos PA. Estimating menstrual blood loss in women with normal and excessive menstrual fluid volume.  Obstet Gynecol. 2001;  98 (5 Pt 1) 806-814
    Suche in Google Scholar
  • 72 Reid PC. Assessment of menorrhagia by total menstrual fluid loss.  J Obstet Gynaecol. 2006;  26 (5) 438-441
    Suche in Google Scholar
  • 73 Higham JM, O'Brien PM, Shaw RW. Assessment of menstrual blood loss using a pictorial chart.  Br J Obstet Gynaecol. 1990;  97 (8) 734-739
    Suche in Google Scholar
  • 74 Reid PC, Coker A, Coltart R. Assessment of menstrual blood loss using a pictorial chart: a validation study.  BJOG. 2000;  107 (3) 320-322
    Suche in Google Scholar

Malcolm G MunroM.D. 

Department of Obstetrics and Gynaecology, David Geffen School of Medicine at UCLA, Kaiser Permanente, Los Angeles Medical Center

Station 3-B, 4900 Sunset Boulevard, Los Angeles, CA 90027

eMail: mmunro@ucla.edu