Rethinking the Abnormal Uterine Bleeding Consult: Creating a Patient-Centered, See-and-Treat Model of Care

We describe a model of care that streamlines multi-visit, prolonged evaluations for abnormal uterine bleeding.

Abstract

Historically, the evaluation of abnormal uterine bleeding (AUB) has involved a multi-visit process that uses a multitude of care settings (eg, in-office, imaging, laboratory), with the potential for lengthy delays in care due to the now-commonplace scheduling difficulties many clinics face. Although there is strong evidence for the use of in-office uterine assessment as a best practice, uptake has been limited by the learning curve, technology acquisition costs, and other factors. However, due to the coronavirus disease 2019 (COVID-19) pandemic, clinical practice has faced rapid adaptations that have resulted in the redesigned clinical care model of evaluating this common gynecologic condition in a more patient-centered and streamlined way while maximizing the patient experience, health care efficiency, and physician engagement. This procedure would specifically involve one telehealth or initial visit to assess patient history, perform necessary laboratory testing, review results, and plan outpatient procedures to be conducted in the office or the operating room. Due to the COVID-19 pandemic, clinics have, by necessity, implemented this proposed reimagined pathway in a variety of outpatient settings nationally. We propose that, moving forward, this new procedure be permanently adopted in clinics nationwide as the patient-focused evaluation strategy for AUB.

A theoretical 44-year-old multiparous patient calls to schedule an appointment for worsening heavy menstrual periods. She is scheduled for her 20-minute consultation visit. She completes her initial detailed discussion of her history of present illness, her full obstetric and gynecologic menstrual history, her medical and surgical history, a pregnancy test, and a basic pelvic and speculum examination. The visit concludes with a plan for additional evaluation. She receives a hormonal prescription in an initial attempt at bleeding management, and she is tasked with tracking her bleeding, completing a pelvic transvaginal ultrasound examination, obtaining laboratory tests, and then returning to clinic for a follow-up visit for possible additional in-office evaluation. At her return visit several weeks later, the transvaginal ultrasonogram is reviewed and is notable for small intramural leiomyoma and a thickened endometrial echo consistent with clot or polyp. After a review of the patient’s laboratory findings she is offered an endometrial biopsy or a hysteroscopic evaluation. At this point, she is sent to the front desk to make a follow-up procedure appointment.

By now, this compliant patient has been to two office visits, a blood draw, and an ultrasound visit and is asked to return for a third visit for endometrial evaluation—a visit that could have been the initial “See and Treat” visit (Fig. 1). Each visit is an encroachment on her life, her time, her ability to work, and her ability to care for her family.¹

Fig. 1. Comparison of the traditional multi-visit approach with the reimagined use of telehealth and fewer, more streamlined visits. TVUS, transvaginal ultrasonogram; SIS, saline infusion sonogram; EMB, endometrial biopsy.

Robinson. Rethinking the AUB Consult. O&G Open 2024.

The coronavirus disease 2019 (COVID-19) pandemic, although devastating to our communities, forced the technophobic tendencies of the medical field to progress, and long overdue positive changes have been seen in clinical medicine. Health care can at times be slow to adapt to new technology and change; however, one of the silver linings from the COVID-19 pandemic for health care is telemedicine. Telehealth was finally forced into mainstream reality for physicians and patients. Although initially met with trepidation, telehealth was quickly embraced and demonstrated to be a great success for improving health care access for individuals with gynecologic conditions.^2–6

Abnormal uterine bleeding (AUB) is a broad diagnosis with multiple underlying causes. This is represented well in the PALM-COEIN model of describing AUB.⁷ The complete evaluation of AUB can be extensive and the underlying treatment can be variable. As we learn early in our medical education, the history and how the patient describes their symptoms can assist greatly in the initial narrowing of the differential diagnosis. Some common descriptions of structural causes of bleeding are noted in Table 1. More than 70% of gynecologic consults in the perimenopausal and postmenopausal years and one third of all outpatient gynecology visits are attributed to AUB.⁸

Table 1.

Common Patient Descriptions of Bleeding Patterns

Cause	Symptom(s)
Polyp	Bleeding between cycles, heavy bleeding
Adenomyosis	“Heavy-feeling uterus,” heavy bleeding, dysmenorrhea, clots; “a bowling ball” before menses begins
Leiomyoma	Heavy bleeding, pressure, change in bowel or bladder function
Malignancy or hyperplasia	Heavy bleeding despite hormonal management, postmenopausal bleeding
Coagulopathies	Bleeding can be heavy, often associated with medications or bleeding disorders
Ovulatory dysfunction	Unpredictable bleeding and flow
Endometrial disorders	Can cause intermenstrual bleeding or prolonged bleeding
Iatrogenic causes	Irregular bleeding due to medical interventions or devices

Incorporation of a See and Treat model for AUB would be effective given the volume of visits driven by this etiology. In addition to the findings on physical examination regarding uterine size and mobility, the level of suspicion for a structural cause is based on the history and patient description of their bleeding. Some of the key phrases as noted in the table can often cue the physician into what may be contributing to the bleeding picture. During the initial visit, the likely diagnoses are quickly narrowed to allow for formation of the clinical plan. This may include a pelvic examination, imaging using traditional pelvic ultrasonography or saline-infused ultrasonography, pathological evaluation (endometrial sampling), and direct uterine evaluation (hysteroscopic evaluation in the office or operative setting). The decision for evaluation largely depends on the suspicion regarding endometrial involvement, and sometimes a combination of modalities is necessary. However, the process can be streamlined by using directed questioning and trusting the patient as a reliable historian while incorporating uterine assessment in the office to allow for immediate assessment and treatment of pathology within the uterine cavity, if necessary.^9,10

Historically, patients often have had multiple visits just for completion of the evaluation, many times having four or more touch points with the health care system before even having care options reviewed. Over the span of the evaluation, they may or may not be treated with hormonal options. These multiple visits, however, have a detrimental effect on patient health, patient satisfaction, and physician efficiency.¹ The time from presentation to treatment is prolonged, multiple visits are difficult to schedule on both the patient and physician side, and it increases overall costs. Additionally, if outpatient hysteroscopy is warranted and performed in a surgery center or operating room setting, the cost increases dramatically.¹¹ In one study from 2014, office hysteroscopy provided an estimated $1,498 per patient if they were able to avoid also undergoing a procedure in the operating room.¹¹

With a See and Treat model, the goal is to decrease time from presentation to diagnosis and therapeutic intervention. This improves patient satisfaction with fewer visits and decreased costs while improving health system and physician efficiency. Based on the information gathered an initial telehealth consultation, the physician and patient can determine the need and desire for further endometrial assessment. Because hysteroscopy has better sensitivity and specificity than other diagnostic and imaging tests for endometrial pathology,¹² hysteroscopic evaluation may be warranted for high suspicion of polyp, isthmocele, hyperplasia, or other suspected structural cause. At this point, a follow-up visit would be arranged for a pelvic examination, in-office uterine assessment with office hysteroscopy, possible endometrial sampling, and possible intrauterine device placement in one visit, as indicated.

In-office uterine assessment with office hysteroscopy has been demonstrated to be safe and effective.¹³ It is reimbursed by public and private insurers, and has been noted to decrease overall health system costs.¹⁴ Additionally, over the past decade, technological advances have expanded the tools available to perform these procedures in the office. No longer are rigid, multiuse tower hysteroscopes the only available instrumentation for these examinations; flexible, disposable scopes allow for any examination room to become a procedure room. This along with the minimal setup time allows for the office staff to accommodate for the addition of these procedures. With operative channels and scopes smaller than before, the See and Treat option for same day services and results is more affordable and reasonable. Additionally, office hysteroscopy, especially with the improved techniques and technology, is well tolerated with minimal-to-no sedation necessary for the patient.⁶

Based on the pelvic and uterine findings during the visit, the physician and patient are empowered to initiate an effective treatment plan immediately, which decreases the time from presentation to treatment to two visits. Additional next steps may include symptom and bleeding tracking, hormonal initiation, or consideration of a more definitive option, such as hysterectomy; however, the primary preoperative evaluation is already completed.

With this See and Treat model in mind, let us revisit the initial vignette. A 44-year-old multiparous patients calls to schedule an appointment for worsening heavy menstrual periods. With the See and Treat model, she is scheduled for a telehealth consultation with her physician (Fig. 1). Based on her intake and history, her physician suspects a uterine polyp. Her physician concludes the visit with the recommendation to complete further evaluation in the form of physical examination and office hysteroscopy. The See and Treat model allows for shared decision making, with the patient and the physician reviewing the possibilities of direct uterine assessment in the office with possible endometrial sampling or removal of potential pathology and considerations of hormonal therapy if benign. The patient concludes the initial virtual visit with next steps already under consideration, likely more rapidly due to the telehealth nature of the visit, and without leaving the comfort of her home or office. She schedules time off from work and arranges child care only once for the scheduled combined pelvic examination, procedure visit, endometrial sampling, and See and Treat hysteroscopy for diagnostic and, hopefully, therapeutic management in the event of intrauterine pathology. She leaves the in-person appointment having completed an in-office uterine assessment with the plan for tracking her symptoms as she begins the hormonal management option that was reviewed. She plans to follow up with a telehealth visit in 3–4 months or sooner pending her pathology findings and symptoms. With this model to AUB, this patient requires fewer health care touch points. She can be seen during a break at work or at home using telehealth, and then have just one in-person visit for evaluation and treatment initiation.

CONCLUSION

Moving from the multi-visit, several-week evaluations to a patient-centered, technology-enabled approach to the AUB evaluation allows for improved efficiency for all stakeholders—patients, health care professionals, and the health care system—with the potential to improve patient and physician satisfaction. In addition, it allows for more appropriate use of limited health care resources. The potential for fewer visits simplifies the clinical care pathway for the patient: Scheduling, time off, child care, and travel expenses are all decreased with the incorporation of telehealth into the evaluation pathway. By providing evaluation of the uterine cavity in the office, higher level of care resources maybe allocated for more complex procedures when indicated. As several studies have shown, office hysteroscopy with standard 5-French scopes is feasible and reasonable with a 93–94% success rate.^15,16 When failures occur, it is typically due to pain or stenosis, which often can be predicted based on discussions and examination. Vaginoscopy and instrument-free approaches have been adopted to decrease discomfort, but no set medication regimen has been found to be preferred.

Adaptation of our traditional clinical care pathways¹⁷ allows us to assess and treat patients with AUB more efficiently. In a world evolving into quality metrics, improved patient satisfaction with less time to treatment, improved clinician office efficiency with fewer appointments per patient chief symptom, and optimized and appropriate resource allocation are going to be the keys to success.^1,18