Assessment

HISTORY. Determine the duration of the present bleeding, the amount of blood loss, and the presence of associated symptoms such as cramping, nausea, and vomiting, fever, abdominal pain, or passing of blood clots. Ask the patient to compare the amount of pads or tampons used in a normal period with the amount they are presently using. Obtain a menstrual and obstetric history. Recent episodes of easy bruising or prolonged, heavy bleeding may indicate abnormal clotting times. The use of contraceptives, especially an intrauterine device (IUD), may contribute to abnormal uterine bleeding. Other possible causative factors, such as pregnancy, pelvic inflammatory disease, or other medical conditions, can be ruled out through a complete history.

PHYSICAL EXAMINATION. A complete examination is essential to eliminate organic causes of bleeding. A pelvic speculum and bimanual examination should be done, with particular attention to the presence of cervical erosion, polyps, presumptive signs of pregnancy, masses, tenderness or guarding, or other signs of pathology that may cause abnormal uterine bleeding. Assess for petechiae, purpura, and mucosal bleeding (gums) to rule out hematologic pathology. Check for pallor and absence of conjunctival vessels to gauge anemia.

PSYCHOSOCIAL. For many women, DUB results in distress related to the uncertainty of the timing, duration, and amount of bleeding. A woman may feel that her usual activities need to be curtailed, a situation that may contribute to feelings of loss of control. Assess the woman's concerns and coping patterns to establish a framework for determining appropriate interventions.

Diagnostic Highlights

General Comments: Diagnosis of DUB is made by ruling out organic causes.

Test

Normal Result

Abnormality with Condition

Explanation

Endometrial biopsy Hysteroscopy

Presence of a "secretory-type" endometrium 3-5 days before normal menses; no pathological conditions

No pathology visualized

Hyperplastic proliferative polyps are found with DUB (polyps stimulate estrogen). With anovulation, no secretory changes are noted. Adenocarcinoma indicates uterine cancer.

Polyps indicate DUB; other tumors or structural variations may be seen with other conditions

Other organic conditions must be ruled out before a diagnosis of DUB is made.

Direct visualization of the uterus is possible

Other Tests: Pelvic exam, uterine ultrasound, complete blood count, cultures for sexually transmitted infections; prothrombin time, activated partial thromboplastin time, human chorionic gonadotopin (to rule out pregnancy), thyroid tests, pelvic ultrasound (to rule out structural lesions)

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