Bleeding pattern | Other associated clinical features | Differential diagnosis | Evaluation | |
Common etiologies | Less common etiologies | |||
Regular menses that are heavy or prolonged | Enlarged uterus on examination, discrete masses may be noted | Uterine leiomyoma | - Pelvic ultrasound - Saline infusion sonography or hysteroscopy (if intracavitary pathology is suspected) | |
- Dysmenorrhea - Enlarged, boggy uterus on examination | Adenomyosis | Pelvic ultrasound | ||
- Family history of bleeding disorder - Symptoms of bleeding diathesis - Anticoagulant therapy | Bleeding disorder | Testing for bleeding disorder | ||
Risk factors for uterine malignancy | Endometrial carcinoma or uterine sarcoma | Endometrial sampling | ||
Regular menses with intermenstrual bleeding | Endometrial polyp | - Pelvic ultrasound - Saline infusion sonography or hysteroscopy (if available) | ||
Risk factors for uterine malignancy | Endometrial carcinoma or uterine sarcoma | Endometrial sampling | ||
Recent history of uterine or cervical procedure or childbirth, particularly if infection was present | Chronic endometritis | Endometrial sampling | ||
Irregular bleeding, may be more or less frequent than normal menses and volume and duration may vary | Ovulatory dysfunction: | |||
Hirsutism, acne, and/or obesity | PCOS | Total testosterone and/or other androgens (may not be increased in all women with PCOS) | ||
Galactorrhea | Hyperprolactinemia | Prolactin | ||
- Recent weight gain or loss - Heat or cold intolerance - Family history of thyroid dysfunction | Thyroid disease | Thyroid function tests | ||
Risk factors for uterine malignancy | Endometrial carcinoma or uterine sarcoma | Endometrial sampling | ||
Secondary amenorrhea | History of irregular bleeding | Ovulatory dysfunction | Refer to ovulatory dysfunction above | |
Poor nutrition or intense exercise | Hypothalamic amenorrhea | - Follicle-stimulating hormone - Luteinizing hormone - Estradiol | ||
Hot flushes | Premature ovarian insufficiency | Follicle-stimulating hormone | ||
Recent history of uterine or cervical procedure or childbirth, particularly if infection was present (menses may present, but abnormally light or brief) | Cervical stenosis | On pelvic examination, instrument cannot be passed through internal cervical os | ||
Intrauterine adhesions (Asherman syndrome) | Hysteroscopy | |||
Irregular or heavy bleeding in a patient using hormonal contraceptives or with an intrauterine device | Iatrogenic AUB |
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