Evaluation of abnormal uterine bleeding

Performed to exclude nonclassical congenital adrenal hyperplasia.

Performed to exclude hyperprolactinemia as the cause of symptoms.

Performed to exclude hypothyroidism as the cause of symptoms. If TSH is abnormal, T4 and T3 should be measured.

Performed if an abnormal result would support the diagnosis of PCOS. May not be needed if the patient has clinical signs of hyperandrogenism.

Limited role in the diagnosis of PCOS and not needed if the patient has clinical signs of hyperandrogenism.[33]International PCOS Network. International evidence-based guideline for the assessment and management of polycystic ovary syndrome. 2018 [internet publication]. https://www.monash.edu/__data/assets/pdf_file/0004/1412644/PCOS_Evidence-Based-Guidelines_20181009.pdf [34]Azziz R, Carmina E, Dewailly D, et al. Positions statement: criteria for defining polycystic ovary syndrome as a predominantly hyperandrogenic syndrome: an Androgen Excess Society guideline. J Clin Endocrinol Metab. 2006 Nov;91(11):4237-45. https://academic.oup.com/jcem/article/91/11/4237/2656314 http://www.ncbi.nlm.nih.gov/pubmed/16940456?tool=bestpractice.com ​​

Helpful only if positive, and is not diagnostic.

May be helpful in women with suspected PCOS who have regular menstrual cycles to establish whether ovulation has occurred. Performed on day 20 to 24.

Uterine fibroids have characteristic ultrasonographic appearance, with sonographic shadows cast behind them. The number, size, and location of the uterine fibroids in relation to the uterine cavity are important sonographic features.

Should be performed for all women with heavy menstrual bleeding.[20]American College of Obstetricians and Gynecologists. ACOG committee opinion, number 785: screening and management of bleeding disorders in adolescents with heavy menstrual bleeding. Sep 2019 (reaffirmed 2023) [internet publication]. https://journals.lww.com/greenjournal/Fulltext/2019/09000/Screening_and_Management_of_Bleeding_Disorders_in.47.aspx http://www.ncbi.nlm.nih.gov/pubmed/31441825?tool=bestpractice.com [23]American College of Obstetricians and Gynecologists. Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Jul 2012 [internet publication].​​[24]Munro MG, Critchley HOD, Fraser IS, et al. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018 Dec;143(3):393-408. https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/ijgo.12666 http://www.ncbi.nlm.nih.gov/pubmed/30198563?tool=bestpractice.com [25]National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication]. https://www.nice.org.uk/guidance/ng88 ​​

Obtained to investigate whether the uterine fibroid is causing distortion of the uterine cavity: an important finding for women trying to achieve pregnancy.

Obtained to investigate whether the uterine fibroid is causing distortion of the uterine cavity: an important finding for women trying to achieve pregnancy.

MRI is important when the sonographic features are not typical. It is also important in differentiating uterine fibroids from other conditions that can be confused with fibroids on ultrasound (e.g., adenomyosis).[42]Yoon SW, Lee C, Cha SH, et al. Patient selection guidelines in MR-guided focused ultrasound surgery of uterine fibroids: a pictorial guide to relevant findings in screening pelvic MRI. Eur Radiol. 2008 Dec;18(12):2997-3006. http://www.ncbi.nlm.nih.gov/pubmed/18618119?tool=bestpractice.com

Uterine polyps usually have characteristic appearance.

Helpful when diagnosis remains in doubt after performance of pelvic ultrasound.

Performed to exclude structural causes.

Should be performed for all women with heavy menstrual bleeding.[20]American College of Obstetricians and Gynecologists. ACOG committee opinion, number 785: screening and management of bleeding disorders in adolescents with heavy menstrual bleeding. Sep 2019 (reaffirmed 2023) [internet publication]. https://journals.lww.com/greenjournal/Fulltext/2019/09000/Screening_and_Management_of_Bleeding_Disorders_in.47.aspx http://www.ncbi.nlm.nih.gov/pubmed/31441825?tool=bestpractice.com [23]American College of Obstetricians and Gynecologists. Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Jul 2012 [internet publication].​​[24]Munro MG, Critchley HOD, Fraser IS, et al. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018 Dec;143(3):393-408. https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/ijgo.12666 http://www.ncbi.nlm.nih.gov/pubmed/30198563?tool=bestpractice.com [25]National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication]. https://www.nice.org.uk/guidance/ng88 ​​

Should be performed for all women with heavy menstrual bleeding.[20]American College of Obstetricians and Gynecologists. ACOG committee opinion, number 785: screening and management of bleeding disorders in adolescents with heavy menstrual bleeding. Sep 2019 (reaffirmed 2023) [internet publication]. https://journals.lww.com/greenjournal/Fulltext/2019/09000/Screening_and_Management_of_Bleeding_Disorders_in.47.aspx http://www.ncbi.nlm.nih.gov/pubmed/31441825?tool=bestpractice.com [23]American College of Obstetricians and Gynecologists. Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Jul 2012 [internet publication].​​[24]Munro MG, Critchley HOD, Fraser IS, et al. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018 Dec;143(3):393-408. https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/ijgo.12666 http://www.ncbi.nlm.nih.gov/pubmed/30198563?tool=bestpractice.com [25]National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication]. https://www.nice.org.uk/guidance/ng88 ​​

May be performed to exclude structural causes.

May be appropriate in women taking tamoxifen.

Outpatient biopsy may be performed using an endometrial suction catheter.

Hysteroscopy and dilation and curettage is performed if a suction biopsy is not feasible or cannot be tolerated.

Useful to evaluate the endometrium in the presence of leiomyomata or adenomyosis, which can obscure the endometrium on ultrasound.[36]American College of Radiology. ACR appropriateness criteria abnormal uterine bleeding. 2020 [internet publication]. https://acsearch.acr.org/docs/69458/Narrative  

Should be performed for all women with heavy menstrual bleeding.[20]American College of Obstetricians and Gynecologists. ACOG committee opinion, number 785: screening and management of bleeding disorders in adolescents with heavy menstrual bleeding. Sep 2019 (reaffirmed 2023) [internet publication]. https://journals.lww.com/greenjournal/Fulltext/2019/09000/Screening_and_Management_of_Bleeding_Disorders_in.47.aspx http://www.ncbi.nlm.nih.gov/pubmed/31441825?tool=bestpractice.com [23]American College of Obstetricians and Gynecologists. Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Jul 2012 [internet publication].​​[24]Munro MG, Critchley HOD, Fraser IS, et al. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018 Dec;143(3):393-408. https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/ijgo.12666 http://www.ncbi.nlm.nih.gov/pubmed/30198563?tool=bestpractice.com ​​[25]National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication]. https://www.nice.org.uk/guidance/ng88 ​​​​

Prolonged PT may indicate coagulopathy, but is rarely sufficient to rule-in most bleeding disorders. A hematologist should direct further testing if a coagulation disorder is suspected.[1]Munro MG, Critchley HOD, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011 Apr;113(1):3-13. https://obgyn.onlinelibrary.wiley.com/doi/full/10.1016/j.ijgo.2010.11.011 http://www.ncbi.nlm.nih.gov/pubmed/21345435?tool=bestpractice.com

Prolonged aPTT may indicate coagulopathy, but is rarely sufficient to rule-in most bleeding disorders. A hematologist should direct further testing if a coagulation disorder is suspected.[1]Munro MG, Critchley HOD, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011 Apr;113(1):3-13. https://obgyn.onlinelibrary.wiley.com/doi/full/10.1016/j.ijgo.2010.11.011 http://www.ncbi.nlm.nih.gov/pubmed/21345435?tool=bestpractice.com

Repeat testing if result within normal range but diagnosis suspected.

Values decrease in parallel to vWF antigen, except in type 2 disease.

The factor VIII activity value is frequently higher than the vWF antigen level in type 1 vWD.

Elevated in most patients with autoimmune thyroiditis, the most common cause of primary hypothyroidism.

Performed to exclude physiologic hyperprolactinemia or pregnancy.

Elevated in 80% of patients with epithelial ovarian cancer at diagnosis.

Definitive test. Surgical extirpation of the affected ovary is usually necessary.