[Abnormal uterine bleeding: Taking the stress out of controlling the flow].

Candace, a 49-year-old office administrator, comes to see you for her annual periodic health examination. She reports that her periods are becoming more irregular and unpredictable. Previously her menstrual cycle was 30 days, but during the past 6 months it has been 24 to 40 days. Her menses have been heavy since her second pregnancy 21 years ago and are getting worse. During the first 2 days of her period she has to change a supersize tampon and pad (used simultaneously) every 1 to 2 hours to prevent leaking onto her clothing; there is associated mild cramping but no appreciable blood clots. Her periods have become so bad that she often needs to take time off work during this time. She denies any spotting between periods or bleeding after coitus. She has occasional hot flashes with no other menopausal symptoms. Candace recently started taking 25 mg/d of hydrochlorothiazide for essential hypertension. She has no other medical conditions. For menstrual cramps she takes 325 mg of acetaminophen every 6 hours when needed and 200 mg of ibuprofen once daily when needed. She has no known allergies. Surgical history includes a tonsillectomy as a child and tubal ligation. Her obstetric and gynecologic history includes a monogamous relationship with her husband and gravida 2, para 2—both were spontaneous vaginal deliveries with no complications or postpartum hemorrhage. Candace is a non-smoker and drinks alcohol only occasionally. Her family history is remarkable for hypertension in her mother; there is no family history of breast cancer or coagulopathies. Her mother had a hysterectomy at age 40 for fibroids. Candace’s physical examination reveals normal vital signs and a body mass index of 32 kg/m2. All physical examination findings are unremarkable except for a “bulky” uterus found during bimanual examination. Results of a recent Papanicolaou test were normal. You perform an endometrial biopsy and order tests for complete blood count and thyroid-stimulating hormone levels, a urine test for chlamydia and gonorrhea, and a pelvic ultrasound. Abnormal uterine bleeding (AUB) is a condition that affects approximately 30% of women during their reproductive years.1 It is a considerable health care burden for women and has a definite effect on quality of life. Health care practitioners deal with this problem frequently.2 Abnormal uterine bleeding has various definitions and classifications. It can be loosely defined as a variation from the normal menstrual cycle. The variation can be in regularity, frequency, duration of flow, or amount of blood loss. Often the bleeding is “heavy,” which is “excessive menstrual blood loss which interferes with a woman’s physical, social, emotional and/or material quality of life.”3 The terms menorrhagia and metrorrhagia, as well as other combinations, have become outdated. Abnormal uterine bleeding might be classified as premenopausal, perimenopausal, or postmenopausal. In premenopausal and perimenopausal women, AUB can be further categorized as ovulatory and anovulatory. Ovulatory bleeding occurs at regular menstrual intervals and is typically associated with premenstrual symptoms and painful periods. Anovulatory bleeding is more common around menarche and menopause and is typified by heavy, irregular, and prolonged periods. There is a greater association of endometrial hyperplasia and cancer with anovulatory bleeding in perimenopausal and menopausal women.2