## INTRODUCTION AND BACKGROUND

KEY QUESTIONS

• What classification system is used to describe the differential diagnosis of abnormal uterine bleeding (AUB) in women of reproductive age?

• What criteria would you use to determine need for hospital admission in a woman with acute heavy menstrual bleeding (HMB)?

• What medical and surgical management options are available for control of acute HMB?

CASE 53-1

A 34-y.o. obese female presents to the ED for vaginal bleeding. She has a 3-year history of irregular, heavy menses. She notes that for the last 5 days, she has experienced worsening, heavy vaginal bleeding and passage of large clots, requiring one pad per hour. Today, she reports new-onset lightheadedness and dyspnea, which prompted her visit to the ED. On clinical evaluation, the patient is pale and shaking while lying on the stretcher. Vital signs reveal a pulse of 135 bpm, blood pressure of 92/57 mmHg, and O2 saturation of 94%. A point-of-care hemoglobin is 5.4. Upon speculum exam, a large volume of clot fills the vaginal vault and bright red bleeding is noted from the cervical os. Upon bimanual exam, the uterus is enlarged to approximately 19 weeks gestation size, with an irregular contour. The ED attending consults the OB/GYN hospitalist for patient evaluation and management. Based on this patient's clinical presentation, the hospitalist must address the following questions:

• What are the criteria for patient admission in the context of acute AUB in reproductive-aged women?

• What is the differential diagnosis of acute AUB?

• What is the next step for determining the cause of AUB?

• What is the initial treatment plan for control of bleeding?

Abnormal uterine bleeding (AUB) includes heavy, prolonged, or excessive menstrual bleeding that both distresses a woman and interferes with her physical, emotional, social, and/or material quality of life.1 AUB is also described as bleeding from the uterus of abnormal cycle regularity, volume, frequency, or duration.2 It continues to be one of the most common gynecologic complaints,2 with the prevalence varying from 10% to 35% of reproductive-age women.3 Higher prevalence is noted to occur with increasing age, particularly in perimenopause. AUB affects more than 10 million women in the United States each year. Nearly a third of gynecologic office visits and approximately 400,000 hospitalizations per year are due to AUB.1,4 The estimated annual direct costs in the United States range from $1 billion to$1.55 billion, with indirect costs ranging from $12 billion to$36 billion.1

A normal menstrual cycle length is defined as lasting between 21 and 35 days, with an average of 3–7 days of menstrual bleeding.5 Most blood loss typically occurs in the first 3 days of menses, and normal menstrual blood volume ranges from 30 to 50 mL during the entire menstrual cycle.5 AUB is a deviation from this normal menstrual pattern and can be ...

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