Abnormal Uterine Bleeding: A Management Algorithm

Abstract

Abnormal uterine bleeding is a common problem, and its management can be complex. Because of this complexity, concise guidelines have been difficult to develop. We constructed a concise but comprehensive algorithm for the management of abnormal uterine bleeding between menarche and menopause that was based on a systematic review of the literature as well as the actual management of patients seen in a gynecology clinic. We started by drafting an algorithm that was based on a MEDLINE search for relevant reviews and original research. We compared this algorithm to the actual care provided to a random sample of 100 women with abnormal bleeding who were seen in a university gynecology clinic. Discrepancies between the algorithm and actual care were discussed during audiotaped meetings among the 4 investigators (2 family physicians and 2 gynecologists). The audiotapes were used to revise the algorithm. After 3 iterations of this process (total of 300 patients), we agreed on a final algorithm that generally followed the practices we observed, while maintaining consistency with the evidence. In clinic, the gynecologists categorized the patient's bleeding pattern into 1 of 4 types: irregular bleeding, heavy but regular bleeding (menorrhagia), severe acute bleeding, and abnormal bleeding associated with a contraceptive method. Subsequent management involved both diagnostic and treatment interventions, which often occurred simultaneously. The algorithm in this article is designed to help primary care physicians manage abnormal uterine bleeding using strategies that are consistent with the evidence as well as the actual practice of gynecologists. Abnormal uterine bleeding is a common problem, 1 and its management can be complex.2,3 Physicians are often unable to identify the cause of abnormal bleeding after a thorough history and physical examination. 4,5 The management of abnormal bleeding can involve many decisions about diagnosis and treatment, 3,6,7 which often occur simultaneously and without the benefit of comprehensive, evidence-based guidelines. The available evidence tends to focus on narrow treatment questions rather than the broad clinical approach to management. 8,17 It is not difficult to find long lists of potential causes of abnormal bleeding, but primary care physicians need practical advice about how to approach this common problem. Abnormal uterine bleeding includes both dysfunctional uterine bleeding and bleeding from structural causes. Dysfunctional bleeding can be anovulatory, which is characterized by irregular unpredictable bleeding, or ovulatory, which is characterized by heavy but regular periods (ie, menorrhagia).2 Structural causes include fibroids, polyps, endometrial carcinoma, and pregnancy complications. Abnormal bleeding can also result from contraceptive methods. Many articles have reviewed the management of abnormal uterine bleeding, 3,6,7,15,16,18,21 and they often include management algorithms. Although clinical algorithms have potential shortcomings, 22,25 there are data to support their...

Disfonksiyonel kanama yönetimi

“…Evde tedavi edilecek olgulara 30-35 mcg etinil östradiol içerecek flekilde birkaç gün oral kontraseptif tedavi bafllan›r (1, [19][20][21][22][23]. fiiddetli anemisi olan ve klini¤i fliddetli olgular yat›r›larak tedavi edilmelidir.…”

The Management of Dysfunctional Uterine Bleeding

“…If there is any contraindication for oral contraceptive use, cyclic progestogens are chosen instead, however, they do not avoid pregnancy. The contraindications of oral contraceptives are; previous thromboembolic event or stroke, history of estrogen-dependent tumor, active liver disease, pregnancy, hypertriglyceridemia and smoking ˃ 15 cigarettes per day of women older than 35 years (Ely et al, 2006). In addition, long-term use of oral contraceptives are not preferred by many women as a therapy of menorrhagia.…”

“…One common oral contraceptive regimen for severe acute bleeding is one pill four times daily for four days followed by three times daily for three days, followed by twice daily for two days, followed by once daily for three weeks. Then after a break of one week, oral contraceptive is taken on a regular basis using three weeks on and one week off, for at least three months (Ely et al, 2006). In anovulatory cycles in order to prevent the recurrence of heavy bleeding, it should be administered daily throughout following cycles as a maintenance therapy.…”

“…Hyperprolactinemia and diabetes mellitus are associated with anovulation. Policytic ovary syndrome (PCOS) is the most common cause of anovulation with a prevelance of 5% to 8% (Azziz et al, 2004 Conditions that should be ruled out include congenital adrenal hyperplasia (manifested by an elevated early morning 17-hydroxyprogesterone), androgen-secreting tumors (manifested by a serum testosterone ˃200 ng/dl or dehydroepiandrosterone sulfate ˃800 µg/dl), and hyperprolactinemia (Ely et al, 2006). Coagulopathies and anticoagulant drug intake should be taken into account during the evaluation of heavy menstrual bleeding.…”

Introduction of More Editorial Board Members and New Guest Commentary Feature

“…In addition, he is working with colleagues to develop checklists, similar to pilot's checklists, to help physicians avoid making diagnostic errors. Dr. Ely has published 2 articles with very high readership in the JABFM: "Approach to Leg Edema of Unclear Etiology " 2 and "Abnormal Uterine Bleeding: A Management Algorithm" 3 ; both are currently in the top 10 of our most-frequently read articles and were among the 20 most-frequently read articles in 2007 4 and in 2008. Communications and Blood Pressure Monitoring (e-BP)," tested whether home blood pressure monitoring, secure messaging, and pharmacist care improves hypertension control.…”