Abnormal Uterine

bleeding
 Abnormal uterine bleeding
• Abnormal uterine bleeding is a broad term that describes
irregularities in the menstrual cycle.

• Involving frequency, regularity, duration, and volume of flow

outside of pregnancy.

• Up to one-third of women will experience abnormal uterine

bleeding in their life, with irregularities most commonly occurring
at menarche and perimenopause.
 What is normal?
• A normal menstrual cycle has a frequency of 24 to 38 days

• lasts 7 to 9 days

• with 5 to 80 milliliters of blood loss.

• Variations in any of these 4 parameters constitute abnormal

uterine bleeding.
• Abnormal uterine bleeding can also be divided into acute versus
chronic.

• Acute AUB is excessive bleeding that requires immediate intervention

to prevent further blood loss.

• Chronic AUB, which refers to irregularities in menstrual bleeding for

most of the previous 6 months
 Etiology
• PALM-COEIN is a useful acronym provided by the International Federation of Obstetrics
and Gynecology (FIGO) to classify the underlying etiologies of abnormal uterine
bleeding. The first portion, PALM, describes structural issues. The second portion, COEI,
describes non-structural issues. The N stands for "not otherwise classified."
• P: Polyp
• A: Adenomyosis
• L: Leiomyoma
• M: Malignancy and hyperplasia
• C: Coagulopathy
• O: Ovulatory dysfunction
• E: Endometrial disorders
• I: Iatrogenic
• N: Not otherwise classified
• Conditions to be included in not otherwise classified include
• pelvic inflammatory disease,
• chronic liver disease,
• and cervicitis.
 Epidemiology
• The prevalence of abnormal uterine bleeding among reproductive-aged
women internationally is estimated to be between 3% to 30%, with a higher
incidence occurring around menarche and perimenopause.

• Many studies are limited to heavy menstrual bleeding (HMB), but when
irregular and intermenstrual bleeding are considered, the prevalence rises to
35% or greater.

• Many women do not seek treatment for their symptoms, and some
components of diagnosis are objective while others are subjective, making
exact prevalence difficult to determine.
Pathophysiology
• The uterine and ovarian arteries supply blood to the uterus. These arteries become
the arcuate arteries; then the arcuate arteries send off radial branches which supply
blood to the two layers of the endometrium, the functionalis and basalis layers.
• Progesterone levels fall at the end of the menstrual cycle, leading to enzymatic
breakdown of the functionalis layer of the endometrium. This breakdown leads to
blood loss and sloughing, which makes up menstruation.
• Functioning platelets, thrombin, and vasoconstriction of the arteries to the
endometrium control blood loss.
• Any derangement in the structure of the uterus (such as leiomyoma, polyps,
adenomyosis, malignancy, or hyperplasia), derangements to the clotting pathways
(coagulopathies or iatrogenically), or disruption of the hypothalamic-pituitary-
ovarian axis (through ovulatory/endocrine disorders or iatrogenically) can affect
menstruation and lead to abnormal uterine bleeding.
 History and Physical Examination
• Specific aspects of the history include:
• Menstrual history age at menarche

• Last menstrual period

• Menses frequency, regularity, duration, the volume of flow

• Frequency can be described as frequent (less than 24 days), normal (24 to 38

days), or infrequent (greater than 38 days)

• Regularity can be described as absent, regular (with a variation of +/- 2 to 7

days), or irregular (variation greater than 20 days)
• The duration can be described as prolonged (greater than 8 days), normal
(approximately 4 to 8 days), or shortened (less than 4 days)

• The volume of flow can be described as heavy (greater than 80 mL), normal
(5 to 80 mL), or light (less than 5 mL of blood loss)
• Exact volume measurements are difficult to determine outside research
settings;
• therefore, detailed questions regarding frequency of sanitary product changes
during each day, passage and size of any clots, need to change sanitary
products during the night, and a "flooding" sensation are important.
• Intermenstrual and postcoital bleeding
• Sexual and reproductive history
• Obstetrical history including the number of pregnancies and mode of delivery
• Fertility desire and subfertility
• Current contraception
• History of sexually transmitted infections (STIs)
• PAP smear history
• Associated symptoms/Systemic symptoms Weight loss
• Pain, Discharge
• Bowel or bladder symptoms
• Signs/symptoms of anemia
• Signs/symptoms or history of a bleeding disorder
• Signs/symptoms or history of endocrine disorders
• Current medications
• Family history, including questions concerning coagulopathies, malignancy,
endocrine disorders

• Social history, including tobacco, alcohol, and drug uses;

• occupation; the impact of symptoms on quality of life

• Surgical history
 The physical exam should include:
• Vital signs, including blood pressure and body mass index (BMI)
• Signs of pallor, such as skin or mucosal pallor
• Signs of endocrine disorders, Examination of the thyroid for enlargement or
tenderness
• Excessive or abnormal hair growth patterns, clitoromegaly, acne, potentially
indicating hyperandrogenism
• Moon facies, abnormal fat distribution, striae that could indicate Cushing's
• Signs of coagulopathies, such as bruising or petechiae
• Abdominal exam to palpate for any pelvic or abdominal masses
• Pelvic exam: Speculum and bimanual Pap smear if indicated
• STI screening (such as for gonorrhea and chlamydia) and wet prep if indicated
• Endometrial biopsy, if indicated
 Evaluation
• A urine pregnancy test, Complete blood count, Coagulation panel,

• Thyroid function tests, gonadotropins, prolactin.

• Imaging studies -Transvaginal ultrasound does not expose the patient to radiation and can show
uterus size and shape, leiomyomas (fibroids), adenomyosis, endometrial thickness, and ovarian
anomalies. should be obtained early

• MRI provides detailed images that can prove useful in surgical planning.

• Hysteroscopy and sonohysterography are helpful in situations where endometrial polyps are
noted, transvaginal ultrasound are inconclusive, or submucosal leiomyomas are seen.

• Endometrial tissue sampling may not be necessary for all women with AUB but should be
performed on women at high risk for hyperplasia or malignancy. An endometrial biopsy is
 Treatment / Management

• Treatment of abnormal uterine bleeding depends on multiple factors, such as

the etiology of the AUB,
• fertility desire,
• the clinical stability of the patient, and other medical comorbidities.

• Treatment should be individualized based on these factors.

• In general, medical options are preferred as initial treatment for AUB.

• For acute abnormal uterine bleeding, hormonal methods are the first-line in
medical management.
• Intravenous conjugated equine estrogen, combined oral contraceptive pills,
and oral progestins are all options for treating acute AUB.
• Tranexamic acid prevents fibrin degradation and can be used to treated acute
AUB.
• Tamponade of uterine bleeding with a Foley bulb is a mechanical option for
the treatment of acute AUB.
• It is important to assess the patient's clinical stability and replace volume with
intravenous fluids and blood products while attempting to stop the acute
abnormal uterine bleeding.
• Desmopressin, administered intranasally, subcutaneously, or intravenously,
can be given for acute AUB secondary to the coagulopathy von Willebrand
disease.
• Some patients may require dilation and curettage
 Based on the PALM-COEIN

• Polyps are treated through surgical resection.

• Adenomyosis is treated via hysterectomy. Less often, adenomyomectomy is
performed.
• Leiomyomas (fibroids) can be treated through medical or surgical
management depending on the patient's desire for fertility, medical
comorbidities, pressure symptoms, and distortion of the uterine cavity.
Surgical options include uterine artery embolization, endometrial ablation, or
hysterectomy. Medical management options include a levonorgestrel-releasing
intrauterine device (IUD),
• GnRH agonists, systemic progestins, and tranexamic acid with non-steroidal
anti-inflammatory drugs (NSAIDs).
• Malignancy or hyperplasia can be treated through surgery, +/- adjuvant
treatment depending on the stage, progestins in high doses when surgery is not
an option, or palliative therapy, such as radiotherapy.
• Coagulopathies leading to AUB can be treated with tranexamic acid or
desmopressin (DDAVP).
• Ovulatory dysfunction can be treated through lifestyle modification in women
with obesity, PCOS, or other conditions in which anovulatory cycles are
suspected. Endocrine disorders should be corrected using
appropriate medications, such as cabergoline for hyperprolactinemia and
levothyroxine for hypothyroidism.
• Endometrial disorders have no specific treatment as mechanisms are not clearly
understood.
• Iatrogenic causes of AUB should be managed based on the offending drug
and/or drugs. If a certain contraception method is the suspected culprit for
AUB, alternative methods can be considered. If other medications are
suspected and cannot be discontinued, the aforementioned methods can also
help control AUB.
• Not otherwise classified causes of AUB include entities such as endometritis
Complications
• Complications of chronic abnormal uterine bleeding can include anemia,
infertility, and endometrial cancer. With acute abnormal uterine bleeding,
severe anemia, hypotension, shock, and even death may result if prompt
treatment and supportive care are not initiated.
Consultations
• Consultations with obstetrics and gynecology should be initiated early on for
proper evaluation and treatment. Depending on the etiology of the abnormal
uterine bleeding, other specialties may need to become involved in patient care.
For coagulopathies, consultations with hematology/oncology are warranted. If
the patient wishes to undergo a uterine artery embolization, Interventional
radiology will need to be consulted. Malignancy may require both gynecologic
oncology and hematology/oncology specialties for proper treatment.
.
 Deterrence and Patient Education
• Worldwide, many women do not report abnormal uterine bleeding to their
healthcare providers, so it is important to foster an environment of open
discussion on menstruation.
• Primary care physicians should ask women about their last menstrual cycle,
regularity, desire for fertility, contraception, and sexual health.
• If abnormal uterine bleeding can be identified at the primary care level,
then further history, examination, and testing can be performed, and the
proper consultations can be arranged.
• Patients with abnormal uterine bleeding should be educated on any
pertinent lifestyle changes, treatment options, and when to seek emergency
care
• Abnormal uterine bleeding is common among women worldwide.

• A detailed history is an important first step in evaluating a woman who presents

with AUB, and clinicians should be familiar with the normal pattern of
menstruation, including frequency, regularity, duration, and volume of flow.

• After a detailed history is obtained, and a physical exam is performed, further

tests and imaging may be warranted depending on the suspected etiology.

• PALM COEIN is a useful acronym for common etiologies of AUB, with PALM
representing structural causes (polyps, adenomyosis, leiomyomas, and
malignancy or hyperplasia) and COEIN representing non-structural causes
(coagulopathies, ovulatory disorders, endometrial disorders, iatrogenic causes,
and not otherwise classified).
• Women older than 45 years of age or women younger than 45 with risk factors
for malignancy require endometrial sampling as part of the evaluation for AUB.
Treatment is based on etiology, desire for fertility, and medical comorbidities.

Enhancing Healthcare Team Outcomes

• Health professionals should coordinate care in an interprofessional approach to
evaluate and treat women with abnormal uterine bleeding. Nurses and physicians
in primary care, such as family medicine and internal medicine, might be the first
to discover AUB and should consult with obstetrics and gynecology early on.
Patients should be informed of all of their options for control of AUB, based on
etiology.
• A detailed discussion concerning the desire for fertility, medical versus surgical
management, and prognosis should be conducted. Physicians and pharmacists
should educate patients concerning any possible side effects of medical
management.
Reference
• Davis E, Sparzak PB. Abnormal Uterine Bleeding.
[Updated 2021 Jul 14]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls
Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK532913/