Evaluation of patients with abnormal uterine bleeding.

An accurate, efficient diagnosis of disorders responsible for abnormal uterine bleeding depends on a systematic consideration of all the possible causes. Careful history and physical and pelvic examinations provide the framework for evaluation. Many adjunctive diagnostic aids can be used to evaluate women with abnormal uterine bleeding. These tests include complete blood cell count, pregnancy test, hormone levels (estradiol, progesterone, follicle-stimulating hormone, luteinizing hormone, prolactin, testosterone, dehydroepiandrosterone sulfate), thyroid function tests, liver function tests, and coagulation profile. The need for these tests are individualized and based primarily on the patient's presentation. In women of reproductive age a complication of pregnancy should always be ruled out. Ectopic pregnancies can be life threatening. The prognosis in women with trophoblastic disease can be altered by a delay in establishing the correct diagnosis. Ultrasonographic studies, particularly transvaginal ultrasonography and hysteroscopy, have played an increasing role in the evaluation of patients with abnormal uterine bleeding over the past decade, especially for cases of intrauterine space-occupying lesions, including endometrial polyps, submucosal myomas, and retained placental fragments. Suspicion of reproductive tract malignancies is heightened in patients > 35 years old, those with a history of oligoovulation or anovulation suggestive of long-term unopposed estrogen exposure, those who are obese, and those who do not respond to first-line medical management. Diagnostic techniques available for the evaluation of these cases include endometrial biopsy, dilatation and curettage, transvaginal ultrasonography, and hysteroscopy. These procedures not only allow accurate diagnosis but may permit immediate therapeutic measures to be taken when organic causes are discovered. In summary, the key to the evaluation of abnormal uterine bleeding is a through history and physical and pelvic examinations governed by the differential diagnosis of excessive uterine bleeding and the selected use of adjunctive diagnostic tests and procedures only when absolutely necessary.