A common and often debilitating condition, affecting women of reproductive age.
Abnormal uterine bleeding (AUB) is any variance of the normal menstrual cycle, which is defined on the basis of four parameters (frequency, regularity, duration, and volume).
The International Federation of Gynecology and Obstetrics PALM-COEIN classification system improves the understanding of the causes of AUB, facilitates effective history taking and examination, and allows for shared decision-making toward tailored investigations and management plans.
A range of medical and surgical management options are available, and the choice of treatment is guided by the underlying cause of AUB alongside the patient's age, parity, co-morbidities, need for uterine and fertility preservation, and personal preference.
Abnormal uterine bleeding (AUB) is the term used to describe any symptomatic variation from normal menstruation in terms of regularity, frequency, volume, or duration. It also includes intermenstrual bleeding (IMB). This differs from dysfunctional uterine bleeding (DUB), which is diagnosed by excluding pregnancy, iatrogenic causes, systemic conditions, and genital tract pathology.
History and exam
Key diagnostic factors
- uterine bleeding
Other diagnostic factors
- use of medications
- menstrual irregularity
- premenstrual molimina
- hirsutism, acne, acanthosis nigricans
- existing medical illness
- women at the extremes of reproductive age (just after puberty and before menopause)
- polycystic ovary syndrome
- endocrine disorders
- other anovulatory disorders
1st investigations to order
- pregnancy test
Investigations to consider
- coagulation profile
- serum TSH level
- ultrasound scan
- endometrial biopsy
emergency management of excessive uterine bleeding
anovulatory AUB: progestogens and estrogens not contraindicated
anovulatory AUB: progestogens and estrogens contraindicated
significant uterine bleeding resistant to medical treatment; desiring future fertility
significant uterine bleeding resistant to medical treatment; not desiring future fertility
Janesh Gupta, MSc, MD, FRCOG
Professor of Obstetrics and Gynaecology
Centre for Women's and Newborn Health
Institute of Metabolism and Systems Research
University of Birmingham
Birmingham Women’s and Children’s Hospital
JG is an advisory member for Femcare Nikomed UK for the Filshie clip. He has received an HTA grant for the ECLIPSE trial; a randomized controlled trial comparing the Mirena coil with oral medical treatments for heavy menstrual bleeding. He has received travel costs for training workshops for Dilapan-S osmotic dilators for abortion and the induction of labour (Medicem).
Akanksha Sood, MBBS, MS (OBGY), DNB, MRCOG, FACOG
Senior Clinical Fellow
Department of Reproductive Medicine
St. Mary’s Hospital
AS declares that she has no competing interests.
Rohan Chodankar, MBBS, MD, MRCOG
Clinical Research Fellow
MRC Centre for Reproductive Health
The Queen's Medical Research Institute
University of Edinburgh
RC is supported as a Clinical Research Fellow by Bayer AG; RC declares that he has no other competing interests.
Professor Gupta, Dr Sood, and Dr Chodankar would like to gratefully acknowledge Dr Mohamed Mitwally and Dr Intisar Elnahhas, the previous contributors to this topic. MM owns a patent on the use of aromatase inhibitors for endometrial thinning before hysteroscopic surgery. The patent is licensed to Meditrina Company. IE declares that she has no competing interests.
Janet Albers, MD
Department of Family and Community Medicine
Southern Illinois University School of Medicine
JA is an author of a reference cited in this topic.
Sarina Schrager, MD, MS
Associate Professor (CHS)
Department of Family Medicine
University of Wisconsin
SS declares that she has no competing interests.
- Pregnancy-related bleeding
- Genital lesions
- Heavy menstrual bleeding: assessment and management
- Service standards for sexual and reproductive healthcare
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