Emergency Department Management of Abnormal Uterine Bleeding in the Nonpregnant Patient

Table of Contents

 

About This Issue

Abnormal uterine bleeding (AUB) affects women of all ages, from childhood to postmenopause. AUB can negatively impact a woman’s quality of life, in addition to being a sign of a potentially life-threatening condition. This issue presents a strategy for diagnosing likely causes and managing this distressing condition.

Developing a differential diagnosis based on age: 12-17 years, 19-39 years, 40+ years: what are the most common causes of AUB in each?

What is the PALM-COEIN classification system, and how can it assist emergency clinicians in determining the cause of the abnormal bleeding?

What are physical examination findings that may suggest trauma, polycystic ovarian syndrome, pelvic inflammatory disease, or coagulopathy?

When is transfusion indicated? Fluids?

Is ultrasound required, or can it be deferred to the outpatient setting?

What are the indications and contraindications for high-dose IV estrogen for the unstable patient?

For stable patients, when should hormonal therapies, transfusions, NSAIDs, or tranexamic acid be used?

When is gynecologic consult needed?

What are the special concerns in women on anticoagulant therapy?

What new therapies are emerging?

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of The Literature
6. Etiology and Pathophysiology
   1. The PALM-COEIN Classification System
7. Differential Diagnosis
   1. Girls Aged 12 to 18 Years
   2. Women Aged 19 to 39 Years
   3. Women Aged 40 Years and Older
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Pregnancy Test
    2. Complete Blood Cell Count
    3. Coagulation Studies
    4. Other Studies
    5. Imaging Studies
11. Treatment
    1. Management of the Unstable Patient
    2. Management of the Stable Patient
       1. Hormonal Therapies
          • Combination Oral Contraceptive Pills
          • Oral Progestin
       2. Nonhormonal Therapies
          • Transfusion of Packed Red Blood Cells
          • Nonsteroidal Anti-inflammatory Drugs
          • Tranexamic Acid
    3. Nonsurgical Treatment Summary
    4. Surgical Treatment
12. Special Populations
    1. Patients Taking Direct Oral Anticoagulants
    2. Prepubescent Girls
    3. Genital Injuries
       1. Accidental Injuries
       2. Intentional Injuries
       3. Sexual Abuse
13. Controversies and Cutting Edge
    1. Levonorgestrel-Releasing Intrauterine System
    2. Elagolix
14. Disposition
15. Risk Management Pitfalls for Abnormal Uterine Bleeding In Nonpregnant Patients
16. Summary
17. Time- and Cost-Effective Strategies
18. Case Conclusions
19. Clinical Pathway for Emergency Department Management of Abnormal Uterine Bleeding in Nonpregnant Patients
20. Tables and Figures
    1. Table 1. Pharmacologic Treatment Regimens for Acute Abnormal Uterine Bleeding
    2. Figure 1. The Normal Menstrual Cycle
    3. Figure 2. Differential Diagnosis of Abnormal Uterine Bleeding Based on PALM-COEIN Classification
    4. Figure 3. Transvaginal Ultrasound Showing Endometrial Polyp
    5. Figure 4. Transvaginal Ultrasound Showing Adenomyosis
    6. Figure 5. Transvaginal Ultrasound in Sagittal View Showing Leiomyoma/Fibroid
    7. Figure 6. Transvaginal Ultrasound Showing Intrauterine Device
    8. Figure 7. Transvaginal Ultrasound in Sagittal View Showing Endometrial Thickening
21. References

Abstract

Uterine bleeding that is abnormal in timing, duration, or quantity affects nearly one-third of women and carries a substantial financial and quality-of-life burden. An estimated 5% of ED visits are for vaginal bleeding, and 1% of those patients will have a life-threatening cause that must be identified. Emergency clinicians need to have a comprehensive understanding of the pathophysiology and etiologies of abnormal uterine bleeding to manage and treat these patients. This issue reviews the most recent updates on common causes and the approach to abnormal uterine bleeding in the nonpregnant patient, including vaginal bleeding in prepubescent females.

Case Presentations

A 29-year-old woman presents with vaginal bleeding for 3 weeks…

• The patient states that she has been unable to get an appointment with her gynecologist until the end of the week, and she is concerned over the increasing blood loss. She has a history of irregular menstrual periods, and she was having intermittent spotting that has become heavier, with clots, over the past 5 days. She is using multiple pads a day.
• In triage, her vital signs are within normal limits. You order a pregnancy test, which is negative.
• You wonder whether and how you should begin treatment, or whether you should do nothing and defer to her gynecologist…

The red phone in the ED rings with a prenotification that an 18-year-old woman with active, profuse vaginal bleeding for the past 4 hours is on her way…

• EMS says that the patient appears pale and weak, and she is tachycardic and hypotensive. They said the patient told them that she had begun spotting 1 week prior, but the bleeding had become acutely worse. EMS also notes that the patient told them that she had a nosebleed a few days ago.
• As you prepare the resuscitation bay, you consider the differential of this patient’s presentation and how best to prepare for her arrival…

A distressed mother has brought her 4-year-old daughter to the ED because the girl has blood in her underwear…

• The girl is sitting calmly on her mother’s lap, and mother says that the girl was “completely fine” yesterday.
• The girl’s vital signs are within normal limits.
• You wonder what could be causing the bleeding and how best to examine this child without traumatizing her…

Clinical Pathway for Emergency Department Management of Abnormal Uterine Bleeding in Nonpregnant Patients

Subscribe to access the complete flowchart to guide your clinical decision making.

Table and Figures

Subscribe for full access to all Tables and Figures.

Key References

Following are the most informative references cited in this paper, as determined by the authors.

Subscribe to get the full list of 48 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

1. * Munro MG, Critchley HOD, Fraser IS. 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;143(3):393-408. (Practice guidelines) DOI: 10.1002/ijgo.12666

2. * Levy-Zauberman Y, Pourcelot AG, Capmas P, et al. Update on the management of abnormal uterine bleeding. J Gynecol Obstet Hum Reprod. 2017;46(8):613-622. (Practice guidelines) DOI: 10.1016/j.jogoh.2017.07.005

23. * Borhart J. Emergency department management of vaginal bleeding in the nonpregnant patient. Emerg Med Pract. 2013;15(8):1-20. (Review)

29. * Bofill Rodriguez M, Lethaby A, Low C, et al. Cyclical progestogens for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019;8(8):CD001016. (Cochrane review; 15 randomized controlled trials, 1071 women) DOI: 10.1002/14651858.CD001016.pub3

45. * Lopez HN, Focseneanu MA, Merritt DF. Genital injuries acute evaluation and management. Best Pract Res Clin Obstet Gynaecol. 2018;48:28-39. (Review) DOI: 10.1016/j.bpobgyn.2017.09.009

47. * Lethaby A, Hussain M, Rishworth JR, et al. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2015(4):CD002126. (Cochrane review; 21 randomized controlled trials, 2082 women) DOI: 10.1002/14651858.CD002126.pub4

Keywords: uterine, vaginal, bleeding, menstrual, nonpregnant, estrogen, progesterone, progestin, PALM-COEIN, von Willebrand, polyp, fibroid, adenomyosis, leiomyoma, PCOS, malignancy, intrauterine device, IUD, oral contraceptive pill, OCP, Chlamydia, anemia, thrombocytopenia, ultrasound, packing, tranexamic acid, transfusion, NSAID, anticoagulant, DOAC, FGM, levonorgestrel, LNG-IUS, elagolix