Abnormal uterine bleeding (AUB) describes uterine bleeding that is abnormal in regularity, quantity, frequency, or duration, in the nonpregnant person. Historically, AUB was described as in Table E1. The term dysfunctional uterine bleeding was applied when no clear etiology could be identified. These terms have fallen out of favor. In 2011, the FIGO Working Group on Menstrual Disorders released a classification system intended to simplify these definitions. It is known by the acronym PALM-COEIN (Box E1), which is further described later. This classification system divides the causes of AUB into two groups: Structural (PALM) and nonstructural (COEIN). Today, AUB is described according to these criteria.

A normal menstrual cycle (Fig. E1) is typically described as lasting 21 to 35 days with up to 7 days of bleeding per cycle. Total blood loss for normal menses is thought to be less than 80 ml.

• Abnormal uterine bleeding (AUB)
• Dysfunctional uterine bleeding

• One third of outpatient visits to the gynecologist are for AUB.
• Most cases of AUB result from structural (uterine) pathology (the PALM portion of the acronym).
• Up to 20% of women presenting with heavy menstrual bleeding will be found to have a coagulopathy or underlying bleeding disorder.

• The clinical presentation of AUB is variable. Although many patients complain of the abnormality of their cycles, some will present with symptoms of anemia, with AUB being elicited only with a careful history.
• Physical findings depend on the etiology. For example, an enlarged or irregular uterine contour may suggest fibroids, or a polyp may be seen on the cervix during a speculum examination.
• A thorough physical and pelvic examination should be done in every case.
• Workup should be performed to exclude the other causes of abnormal bleeding such as thyroid or endocrine diseases.

• Table E2 describes many of the various causes of AUB.
• Endocrinopathies, including hyperprolactinemia, hyperthyroidism, and hypothyroidism, may also contribute to heavy or irregular menstrual bleeding.

• PALM-COEIN:
  1. Polyps (AUB-P)
  2. Adenomyosis (AUB-A)
  3. Leiomyoma (AUB-L)
  4. Malignancy/hyperplasia (AUB-M)
  5. Coagulopathy (AUB-C; most commonly von Willebrand disease)
  6. Ovulatory dysfunction (AUB-O; most commonly polycystic ovarian syndrome [PCOS])
  7. Endometrial (AUB-E)
  8. Iatrogenic (AUB-I; e.g., anticoagulants, hormonal contraception, and some herbal remedies)
  9. Not yet classified (AUB-N)
• Anatomic nonuterine causes:
  1. Cervix: Cervical neoplasia, cervicitis
  2. Vagina: Vaginal neoplasia, adhesions, trauma, foreign body, atrophic vaginitis, infections, condyloma
  3. Vulva: Vulvar trauma, infections, neoplasia, condyloma, dystrophy, varices
  4. Urinary tract: Urethral caruncle, diverticulum, hematuria, neoplasia
  5. Gastrointestinal tract: Hemorrhoids, anal fissure, colorectal lesions, or neoplasia
• Systemic diseases/effects:
  1. Exogenous hormone intake: Hormone replacement therapy
  2. Medications
  3. Coagulopathies: von Willebrand disease, thrombocytopenia, hepatic failure
  4. Endocrinopathies: Thyroid disorder, hyperprolactinemia, diabetes mellitus
  5. Renal diseases: Generally causing acquired coagulopathy
  6. Impaired nutritional status: Anorexia/bulimia, excessive exercise

• Obtain a detailed history, including age of menarche and current and prior menstrual characteristics. The severity of bleeding is important to discern but can be difficult for patients to describe objectively. Asking specifics regarding size of tampon/pads used, frequency of changing menstrual products, use of concomitant tampons and pads, and saturating clothes can be useful to estimate severity. Review of systems should include symptoms of anemia, hyper- or hypothyroidism, and hyperprolactinemia
• Medical and surgical history, which could suggest of other causes/contributors
• Family history of bleeding disorders, gynecologic conditions such as uterine fibroids, endometriosis, or neoplasia
• Thorough physical examination, including a pelvic examination (bimanual and speculum)
  1. Includes thyroid, breast, liver, skin (e.g., presence or absence of ecchymotic lesions)
  2. Patient habitus: Obese and hirsute (e.g., polycystic ovarian disease) or underweight (e.g., anorexia nervosa or excessive exercise)
  3. Presence or absence of vulvar, vaginal, or cervical lesions; uterine (fibroid) or ovarian tumors; urethral caruncles or diverticula; hemorrhoids; anal fissures; colorectal lesions
  4. Complete pelvic exam to identify lesions and the size and shape of the uterus

• Pregnancy test (blood or urine)
• Complete blood count
• Targeted screening for bleeding disorders, when indicated per history or physical exam
  1. Prothrombin/international normalization ratio and partial thromboplastin (or PFA-100 assay) if coagulopathy is suspected
  2. von Willebrand panel, particularly in women with heavy bleeding since menarche if initial testing suggests coagulopathy
• Iron studies
• Thyroid function tests
• Chlamydia trachomatis testing and other sexually transmitted infection testing
• Endometrial biopsy or dilation and curettage. This is a required component of the workup for AUB in patients over 45 yr old. It should also be performed in younger patients with a history of unopposed estrogen exposure (such as in obesity or PCOS) or in patients who have failed medical management and have persistent AUB
• Pap smear if indicated
• Stool testing for occult blood
• Urinalysis for hematuria

• Pelvic ultrasound (Fig. E2), generally performed transvaginally, including measurement of endometrial thickness in the postmenopausal woman and assessment of myometrial or endometrial defects is considered first line.
• Fluid contrast ultrasound (also called saline sonogram, sonohysterogram, or saline infusion sonogram) may be indicated if the endometrium appears thickened or irregular. It distends the uterine cavity so that "filling defects" of the endometrium can be assessed for possible endometrial polyp, uterine fibroid, or neoplasm.
• Hysteroscopy may be performed to both assess and treat intracavitary fibroids or polyps.
• MRI may help better characterize large fibroids or uterine pathology and can be particularly helpful in diagnosing adenomyosis.

• Increase dietary iron intake or consider oral iron supplementation for anemia.
• Initiate lifestyle changes, including weight loss, exercise, and low-carb diet, if indicated.

• Pharmacologic:
  1. Medroxyprogesterone acetate (oral), up to 20 mg PO tid daily for 7 days
  2. Combined oral contraceptives (containing 35 mcg ethinyl estradiol): One tablet tid for 7 days; patient should then continue on oral contraceptives daily
  3. Tranexamic acid, 1.3 g PO or 10 mg/kg IV (max 600 mg per dose), tid for 5 days
  4. Conjugated equine estrogen 25 mg IV every 4 to 6 h for a maximum of 24 h
  5. NSAIDs
• Nonpharmacologic:
  1. Intrauterine tamponade with 16-F Foley catheter inflated with 30 cc saline

• Progestins:
  1. Medroxyprogesterone acetate 10 mg daily for 12 days, then either continuously or cyclically to induce monthly withdrawal bleeding. If taken continuously, patients should be counseled about the possibility of irregular breakthrough bleeding.
  2. Norethindrone 2.5 to 10 mg daily for 12 days each month, or can be continued daily, at a dose of 0.35 mg (marketed as the "mini-pill").
  3. Depo-Provera 150 mg IM every 3 mo.
  4. Combined hormonal contraceptives, one tablet daily either cyclically or continuously using only active pills (or patch or ring).
  5. Levonorgestrel-releasing intrauterine device (LNG-IUD)-Mirena IUD has an FDA indication for heavy menstrual bleeding and is now approved for use for up to 8 yr.
• Others:
  1. Antiprostaglandins-ibuprofen or naproxen sodium can reduce bleeding by 40%.
  2. Danazol-suppresses estrogen and progesterone receptors in the endometrium, leading to endometrial atrophy and reduced menstrual loss but is rarely used due to side-effect profile (androgenism, menopause-like symptoms, weight gain, acne).
  3. Gonadotropin-releasing hormone (GnRH) analogues-often used to reduce bleeding and ameliorate anemia in preparation for a surgical procedure.
  4. Tranexamic acid-antifibrinolytic agent FDA approved for cyclic heavy menstrual bleeding. Dosage in normal renal function is 3900 mg daily (650 mg tablets, 2 tablets tid) for up to 5 days during menses.
• Surgical treatment:
  1. Dilation and curettage
  2. Operative hysteroscopy
  3. Endometrial ablation
  4. Uterine artery embolization
  5. Hysterectomy for definitive management

Can consider cyclical treatment on birth control pills or Provera for several cycles, then discontinue pill and watch patient for onset of regular menses. If the patient does not desire pregnancy, cycle management with a hormonal contraceptive or placement of LNG-IUD are commonly used.

To gynecologist in case of failure of treatment or for comprehensive workup

Patient education material may be obtained from the American College of Obstetricians and Gynecologists, 409 12th Street SW, Washington, DC, 20024-2188; phone 202-638-5577.

• Abnormal Uterine Bleeding (Patient Information)
• Endometrial Cancer (Related Key Topic)
• Heavy Menstrual Bleeding (Menorrhagia) (Related Key Topic)
• Uterine Fibroids (Related Key Topic)