Abnormal uterine bleeding. Finding and treating the cause

Abnormal vaginal bleeding is a common presenting symptom with an extensive list of potential causes. In evaluating abnormal bleeding, nonuterine causes and pregnancy should first be excluded; after that, it is important to differentiate between ovulatory and anovulatory bleeding (dysfunctional uterine bleeding). Initial laboratory tests, in addition to a sensitive pregnancy test, include hemoglobin and hematocrit determinations, platelet count, and occasionally coagulation studies. An endometrial biopsy or dilation and curettage may be necessary to rule out endometrial hyperplasia or other pathology associated with the long-term unopposed estrogen stimulation experienced by anovulatory patients. In evaluating abnormal ovulatory bleeding, hysteroscopy with selected biopsy or curettage is superior to routine dilation and curettage. Anovulatory patients should be treated with an oral progestin, an oral contraceptive, or, if pregnancy is desired, an ovulation stimulant. Treatment options for patients having ovulatory cycles include an oral contraceptive, an oral progestin, danazol (Danocrine), a gonadotropin-releasing hormone agonist, mefenamic acid (Ponstel), and surgery.