Bleeding (Abnormal Pre-Menopausal)

Pathway

Images

Image Gallery Note: These images open in a new page
1a		Uterine Fibroid Image 1a (Transvaginal Ultrasound): Image demonstrating a thickened hyperechoic endometrium.
1b		Image 1b (Saline Infusion Sonography): Image confirming that the endometrial thickening is due to a submucosal fibroid.
2a		Uterine Fibroid Image 2a: Hysterectomy showing expansion of the myometrium by a single intramural fibroid (leiomyoma) demonstrating the typical well circumscribed appearance with a white whorled cut surface.
2b		Image 2b (H&E, x2.5) and 2c (H&E, x10): Histological sections showing a uterine leiomyoma with pushing margins and composed of sweeping and intercepting fascicles of uniform spindled smooth muscle cells.
2c

Teaching Points

Teaching Points

• Causes of abnormal premenopausal bleeding
• Benign uterine pathology
• Dysfunctional uterine bleeding
• Endometrial Carcinoma
• Cervical Pathology
• Systemic Disorder
• Pregnancy
• If the patient has factors that predispose to endometrial hyperplasia/carcinoma, a transvaginal ultrasound is indicated
• Further investigations may include a hysteroscopy and endometrial biopsy

References

References

Date of literature search: July 2013

The search methodology is available on request. Email

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

1. 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):525-9. (Level III evidence)
2. Gallup DG, Stock RJ. Adenocarcinoma of the endometrium in women 40 years of age or younger. Obstet Gynecol. 1984;64(3):417-20. (Level III evidence)
3. Jeffery JD, Taylor R, Robertson DI, Stuart GCE. Endometrial carcinoma occurring in patients under the age of 45 years. Am J Obstet Gynecol. 1987;156(2):366-70. (Level III evidence)
4. Goldstein SR, Zeltser I, Horan CK, Snyder JR, Schwartz LB. Ultrasonography-based triage for perimenopausal patients with abnormal uterine bleeding. Am J Obstet Gynecol. 1997;177(1):102-8. (Level III evidence)
5. Scarpellini F, Curto C, Caracussi U, Letta C, Scarpellini L. Transvaginal ultrasound versus histology in endometrial hyperplasia. Clin Exp Obstet Gynecol. 1994;21(4):266-9. (Level III evidence)
6. 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,Part 1):547-52. (Level II evidence)
7. Vercellini P, Cortesi I, Oldani S, Moschetta M, DeGiorgi O, Crosignani PG. The role of transvaginal ultrasonography and outpatient diagnostic hysteroscopy in the evaluation of patients with menorrhagia. Hum Reprod. 1997;12(8):1768-71. (Level II evidence)
8. Fedele L, Bianchi S, Dorta M, Brioschi D, Zanotti F, Vercellini P. Transvaginal ultrasonography versus hysteroscopy in the diagnosis of uterine submucous myomas. Obstet Gynecol. 1991;77(5):745-8. (Level III evidence)
9. Williams CD, Marshburn PB. A prospective study of transvaginal hydrosonography in the evaluation of abnormal uterine bleeding. Am J Obstet Gynecol. 1998;179(2):292-8. (Level III evidence)
10. Dijkhuizen FP, Brolmann HA, Potters AE, Bongers MY, Heinz AP. The accuracy of transvaginal ultrasonography in the diagnosis of endometrial abnormalities. Obstet Gynecol. 1996;87(3):345-9. (Level II evidence)
11. Bronz L, Suter T, Rusca T. The value of transvaginal sonography with and without saline instillation in the diagnosis of uterine pathology in pre- and postmenopausal women with abnormal bleeding or suspect sonographic findings. Ultrasound Obstet Gynecol. 1997;9(1):53-8. (Level II evidence)
12. Schwarzler P, Concin H, Bosch H, Berlinger A, Wohlgenannt K, Collins WP, et al. An evaluation of sonohysterography and diagnostic hysteroscopy for the assessment of intrauterine pathology. Ultrasound Obstet Gynecol. 1998;11(5):337-42. (Level II evidence)
13. de Vries LD, Dijkhuizen FP, Mol BW, BrÒlmann HA, Moret E, Heintz AP. Comparison of transvaginal sonography, saline infusion sonography, and hysteroscopy in premenopausal women with abnormal uterine bleeding. J Clin Ultrasound. 2000;28(5):217-23. (Level II evidence)
14. 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 Scan. 2001;80(7):616-22. (Level II evidence)
15. 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. (Level II evidence)
16. Widrich T, Bradley LD, Mitchinson AR, Collins RL. Comparison of saline infusion sonography with office hysteroscopy for the evaluation of the endometrium. Am J Obstet Gynecol. 1996;174(4):1327-34. (Level II evidence)

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