Bleeding (abnormal pre-menopausal)

Population Covered By The Guidance

This pathway provides guidance on the imaging of adult female patients with unexplained premenopausal bleeding.

Lead Researcher: Charlotte Humphries

Experts & Contributors: Emmeline Lee, Seonaid Mulroy

Editorial Panel: Core Membership

Date reviewed: October 2013

Date Published: November 2013

Image 1a (Transvaginal Ultrasound): Image demonstrating a thickened hyperechoic endometrium.

Uterine Fibroid

Image 1b (Saline Infusion Sonography): Image confirming that the endometrial thickening is due to a submucosal fibroid.

Uterine Fibroid

Image 2a: Hysterectomy showing expansion of the myometrium by a single intramural fibroid (leiomyoma) demonstrating the typical well circumscribed appearance with a white whorled cut surface.

Uterine Fibroid

Image 2b (H&E, x2.5) and 2c (H&E, x10): Histological sections showing a uterine leiomyoma with pushing margins and composed of sweeping and intercepting fascicles of uniform spindled smooth muscle cells.

Uterine Fibroid

Image 2b (H&E, x2.5) and 2c (H&E, x10): Histological sections showing a uterine leiomyoma with pushing margins and composed of sweeping and intercepting fascicles of uniform spindled smooth muscle cells.

Uterine Fibroid

  • Causes of abnormal premenopausal bleeding
    • Benign uterine pathology
    • Dysfunctional uterine bleeding
    • Endometrial Carcinoma
    • Cervical Pathology
    • Systemic Disorder
    • Pregnancy
  • If the patient has factors that predispose to endometrial hyperplasia/carcinoma, a transvaginal ultrasound is indicated
  • Further investigations may include a hysteroscopy and endometrial biopsy

  1. Farquhar CM, Lethaby A, Sowter M, Verry J, Baranyai J. An evaluation of risk factors for endometrial hyperplasia in premenopausal women with abnormal menstrual bleeding. American journal of obstetrics and gynecology. 1999;181(3):525-529. (Level III evidence)
  2. Gallup DG, Stock RJ. Adenocarcinoma of the endometrium in women 40 years of age or younger. Obstetrics and gynecology. 1984;64(3):417-420. (Level III evidence)
  3. Jeffery JD, Taylor R, Robertson DI, Stuart GCE. Endometril carcinoma occurring in patients under the age of 45 years. American journal of obstetrics and gynecology. 1987 Feb;156(2):366-370. (Level III evidence)
  4. Goldstein SR, Zeltser I, Horan CK, Snyder JR, Schwartz LB. Ultrasonography-based triage for perimenopausal patients with abnormal uterine bleeding. American journal of obstetrics and gynecology. 1997 Jul;177(1):102-108. (Level III evidence)
  5. Scarpellini F, Curto C, Caracussi U, Letta C, Scarpellini L. Transvaginal ultrasound versus histology in endometrial hyperplasia. Clinical and experimental obstetrics & gynecology. 1994;21(4):266-269. (Level III evidence)
  6. Emanuel MH, Verdel MJ, Wamsteker K, Lammes FB. A prospective comparison of transvaginal ultrasonography and diagnostic hysteroscopy in the evaluation of patients with abnormal uterine bleeding: Clinical implications. American journal of obstetrics and gynecology. 1995;172(2, Part 1):547-552. (Level II evidence)
  7. Vercellini P, Cortesi I, Oldani S, Moschetta M, DeGiorgi O, Crosignani PG. The role of transvaginal ultrasonography and outpatient diagnostic hysteroscopy in the evaluation of patients with menorrhagia. Human Reproduction. 1997 Aug;12(8):1768-1771. (Level II evidence)
  8. Fedele L, Bianchi S, Dorta M, Brioschi D, Zanotti F, Vercellini P. Transvaginal ultrasonography versus hysteroscopy in the diagnosis of uterine submucous myomas. Obstetrics and gynecology. 1991;77(5):745-748. (Level III evidence)
  9. Williams CD, Marshburn PB. A prospective study of transvaginal hydrosonography in the evaluation of abnormal uterine bleeding. American journal of obstetrics and gynecology. 1998;179(2):292-298. 
  10. Dijkhuizen FP, Brolmann HA, Potters AE, Bongers MY, Heinz AP. The accuracy of transvaginal ultrasonography in the diagnosis of endometrial abnormalities. Obstetrics and gynecology. 1996;87(3):345-349. (Level II evidence)
  11. Bronz L, Suter T, Rusca T. The value of transvaginal sonography with and without saline instillation in the diagnosis of uterine pathology in pre- and postmenopausal women with abnormal bleeding or suspect sonographic findings. Ultrasound in Obstetrics and Gynecology. 1997;9(1):53-58. (Level II evidence)
  1. Schwarzler P, Concin H, Bosch H, Berlinger A, Wohlgenannt K, Collins WP, et al. An evaluation of sonohysterography and diagnostic hysteroscopy for the assessment of intrauterine pathology. Ultrasound in obstetrics & gynecology. 1998 May;11(5):337-342. (Level II evidence)
  2. de Vries LD, Dijkhuizen FP, Mol BW, BrÃlmann HA, Moret E, Heintz AP. Comparison of transvaginal sonography, saline infusion sonography, and hysteroscopy in premenopausal women with abnormal uterine bleeding. Journal of Clinical Ultrasound. 2000;28(5):217-223. (Level II evidence)
  3. Krampl E, Bourne T, Hurlen-Solbakken H, Istre O. Transvaginal ultrasonography sonohysterography and operative hysteroscopy for the evaluation of abnormal uterine bleeding. Acta Obstetricia Et Gynecologica Scandinavica. 2001 Jul;80(7):616-622. (Level II evidence)
  4. Farquhar C, Ekeroma A, Furness S, Arroll B. A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women. Acta Obstetricia Et Gynecologica Scandinavica. 2003;82(6):493-504. (Level II evidence)
  5. Widrich T, Bradley LD, Mitchinson AR, Collins RL. Comparison of saline infusion sonography with office hysteroscopy for the evaluation of the endometrium. American journal of obstetrics and gynecology. 1996;174(4):1327-1334. (Level II evidence)

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SYMBOL RRL EFFECTIVE DOSE RANGE
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Minimal radiation Minimal < 1 millisieverts
Low radiation Low 1-5 mSv
Medium radiation Medium 5-10 mSv
High radiation High >10 mSv

Disclaimer

Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.

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Obstetric & Gynaecological