Understanding the Diagnosis of Abnormal Uterine Bleeding (AUB): A Comprehensive Guide for Healthcare Professionals

Abnormal uterine bleeding (AUB) is a prevalent health concern among women of reproductive age, significantly affecting their quality of life. It is defined as any uterine bleeding outside of pregnancy that deviates from the normal parameters of regularity, frequency, volume, or duration of menstruation. Understanding the Diagnosis Aub Meaning is crucial for healthcare professionals to effectively evaluate and manage this condition. The PALM-COEIN classification system is a cornerstone in categorizing AUB, distinguishing between structural (PALM: polyp, adenomyosis, leiomyoma, malignancy and hyperplasia) and nonstructural (COEIN: coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified) causes. It’s estimated that up to one-third of women will experience AUB at some point in their lives, with the likelihood increasing around menarche and perimenopause.

The diagnostic process for AUB typically begins with a thorough clinical assessment and laboratory investigations. Imaging studies and endometrial sampling are employed as necessary to pinpoint the underlying cause. Management strategies are then tailored to address the specific etiology, aiming to control bleeding and improve the patient’s well-being. Treatment plans are individualized, considering the severity and cause of AUB, as well as the patient’s preferences. While severe, acute cases might necessitate interventions like uterine tamponade, many stable cases can be effectively managed with medical treatments. Surgical interventions such as hysterectomy or endometrial ablation are reserved for cases that do not respond to other treatments or when fertility preservation is not a concern. The overarching goals of AUB management are to alleviate bleeding, enhance quality of life, and minimize potential health risks, such as anemia and the increased risk of endometrial cancer associated with unopposed estrogen exposure. This educational resource is designed to improve healthcare professionals’ proficiency in selecting appropriate diagnostic methods, managing the root cause of AUB, and applying a comprehensive interprofessional approach to optimize patient outcomes.

Objectives:

• Differentiate the various causes of abnormal uterine bleeding, understanding the diagnosis AUB meaning within the context of each etiology.
• Recognize and select the appropriate diagnostic evaluations for patients presenting with abnormal uterine bleeding to clarify the diagnosis AUB meaning.
• Implement optimal management strategies for patients diagnosed with abnormal uterine bleeding, based on a clear diagnosis AUB meaning.
• Utilize interprofessional team strategies to enhance care coordination and improve outcomes for patients experiencing abnormal uterine bleeding, ensuring a holistic understanding of diagnosis AUB meaning and its implications.

Deciphering Abnormal Uterine Bleeding: Introduction to Diagnosis

Abnormal uterine bleeding (AUB) is an umbrella term encompassing any irregularities in a woman’s menstrual cycle during her reproductive years, excluding pregnancy. These irregularities manifest as changes in the frequency, regularity, duration, and volume of menstrual flow. To fully grasp the diagnosis AUB meaning, it’s essential to understand that it’s not a diagnosis in itself, but rather a symptom pointing to various underlying conditions. For detailed information on bleeding in postmenopausal women, please refer to resources on “Postmenopausal Bleeding.” A significant proportion of women, up to one-third, will experience AUB in their lifetime, with the highest incidence observed at the onset of menstruation (menarche) and the transition to menopause (perimenopause). A normal menstrual cycle typically occurs every 24 to 38 days, lasts for 2 to 7 days, and involves a blood loss volume between 5 to 80 mL. Deviations from these parameters are what define AUB, and understanding these deviations is key to the diagnosis AUB meaning.

To ensure clarity and consistency in diagnosis and research, the terminology and classification of AUB have been refined over the years. The International Federation of Obstetrics and Gynecology (FIGO) has played a crucial role in this evolution, publishing revisions to AUB terminology in 2007, followed by updates in 2011 and 2018. FIGO System 1, introduced in 2007, established precise descriptive terms for non-gestational AUB based on frequency, regularity, duration, and flow volume. The previously used, less specific terms such as menorrhagia, metrorrhagia, and oligomenorrhea were replaced with more defined terms. Heavy menstrual bleeding (HMB) now refers to bleeding exceeding 80 mL or bleeding that significantly disrupts a woman’s quality of life. Intermenstrual bleeding (IMB) describes bleeding occurring between menstrual periods, whether cyclical or random. Breakthrough bleeding (BTB) is specifically used to describe bleeding experienced while on hormone medication. [¹][²] (Further details on AUB descriptions are available in the History and Physical section). FIGO System 2 introduced the PALM-COEIN classification, a critical framework for understanding the diagnosis AUB meaning. This system categorizes AUB etiologies into structural (PALM) and nonstructural (COEIN) causes. [³][⁴] Irregular bleeding is defined as any bleeding falling outside the normal 5th to 95th percentile range for menstrual parameters, highlighting the spectrum of what constitutes abnormal. [¹]

AUB can also be classified based on its onset and duration into acute and chronic forms. Acute AUB is characterized by heavy bleeding requiring immediate intervention to prevent further blood loss. It can occur independently or on top of chronic AUB, which is defined as menstrual irregularities persisting for the majority of the preceding six months. [⁵] Differentiating between acute and chronic AUB is vital for clinicians to tailor their diagnostic and management approaches effectively, ensuring optimal patient care. [²] The process of diagnosis AUB meaning involves a detailed patient history, physical examination, laboratory tests, and, when necessary, diagnostic imaging or endometrial sampling. Management strategies are primarily focused on treating the underlying cause and managing bleeding, with treatment plans customized according to the severity and cause of AUB, as well as the patient’s individual preferences.

Etiology of Abnormal Uterine Bleeding: Unpacking the PALM-COEIN Classification for Diagnosis

The PALM-COEIN classification system, developed by FIGO, is instrumental in understanding the diagnosis AUB meaning by organizing the diverse causes of AUB into structural and nonstructural categories. This framework simplifies the diagnostic process and guides effective management strategies:

• Nonstructural Etiologies (COEIN)
  • Coagulopathy (C): Systemic bleeding disorders, such as von Willebrand disease, are recognized as significant contributors to heavy menstrual bleeding, especially in adolescent and young adult women. When considering diagnosis AUB meaning, coagulopathies highlight the importance of systemic health factors.
  • Ovulatory Dysfunction (O): Conditions like polycystic ovary syndrome (PCOS), hypothalamic disorders, and thyroid dysfunction can disrupt normal ovulation, leading to irregular, heavy, prolonged, or infrequent bleeding. Ovulatory dysfunction is a common nonstructural cause and a key aspect of diagnosis AUB meaning.
  • Endometrial Disorders (E): These involve issues within the endometrium itself that impair its ability to regulate bleeding. This could be due to inflammation, infection, or abnormalities in vasoconstriction. Endometrial disorders represent a localized nonstructural cause within the broader diagnosis AUB meaning.
  • Iatrogenic (I): Medical treatments, including hormonal contraceptives, anticoagulants, and tamoxifen, as well as surgical injuries like Asherman syndrome, can induce abnormal bleeding. Notably, AUB related to anticoagulants is now classified under this iatrogenic category. Iatrogenic causes underscore the influence of medical interventions on diagnosis AUB meaning.
  • Not Otherwise Classified (N): This category encompasses rare or poorly understood causes, such as arteriovenous malformations, chronic endometritis, or cesarean scar defects. These less common causes are considered when the diagnosis AUB meaning remains elusive after investigating more common etiologies. [¹][⁶][³][²]

It’s important to recognize that multiple factors can simultaneously contribute to AUB in a patient. Structural abnormalities, such as polyps or leiomyomas, are not always the primary cause. Diagnostic imaging techniques play a crucial role in identifying structural causes, while nonstructural causes often require thorough clinical and laboratory assessments for accurate diagnosis. This complexity underscores the need for individualized evaluation and treatment strategies when considering the diagnosis AUB meaning. [⁶][³][²]

Epidemiology of Abnormal Uterine Bleeding: Understanding Prevalence in Diagnosis

The prevalence of AUB among women of reproductive age globally ranges from 3% to 30%, with a notable increase in incidence around menarche and perimenopause. Many studies focus primarily on heavy menstrual bleeding (HMB), but when irregular and intermenstrual bleeding are also considered, the prevalence rises to 35% or higher. [¹] A survey of European women indicated a 27% prevalence of HMB, while other studies have reported HMB prevalence exceeding 50% worldwide. [³][⁶] The variability in reported prevalence highlights the challenges in diagnosis AUB meaning in epidemiological terms. Many women do not seek medical attention for their symptoms, and the subjective nature of some diagnostic criteria, alongside objective measures, makes it difficult to determine the exact prevalence. Understanding the epidemiological context is important for healthcare planning and resource allocation related to diagnosis AUB meaning and management. [⁷]

Pathophysiology of Abnormal Uterine Bleeding: Biological Mechanisms in Diagnosis

The pathophysiology of AUB involves a complex interplay of endocrine, immune, and vascular systems within the endometrium. Disruptions in these systems can lead to menstrual bleeding irregularities. Normal menstruation is initiated by progesterone withdrawal at the end of the menstrual cycle, which triggers a coordinated sequence of endometrial events. These include apoptosis of epithelial and stromal cells, release of inflammatory mediators, and activation of matrix metalloproteinases, all facilitating endometrial shedding and subsequent repair. Effective hemostasis relies on spiral arteriole constriction, clot formation, and tissue regeneration. In women with AUB, these processes are dysregulated, resulting in excessive or irregular bleeding. Understanding these pathophysiological mechanisms is fundamental to the diagnosis AUB meaning and developing targeted treatments. [³][⁶]

The specific pathophysiologic mechanisms underlying AUB can vary depending on hormonal and structural influences. For example, ovulatory dysfunction, resulting from disruptions in the hypothalamic-pituitary-ovarian axis, leads to unpredictable progesterone withdrawal, causing unregulated endometrial growth and shedding. In contrast, endometrial dysfunction is linked to impaired vascular and hemostatic responses, often involving reduced hypoxia signaling and abnormal endometrial repair. [³] Structural causes, such as fibroids and adenomyosis, further complicate the picture by disrupting myometrial contractility, paracrine signaling, and vascular function. Fibroids, for instance, can contribute to excessive bleeding by increasing endometrial surface area, altering angiogenesis, and impairing clotting factor expression. The precise mechanisms by which polyps contribute to AUB are still under investigation. [³][⁶] A thorough understanding of these diverse pathophysiological pathways is crucial for refining the diagnosis AUB meaning and tailoring management strategies to the specific underlying mechanisms.

History and Physical Examination: Clinical Steps in AUB Diagnosis

Clinical History

The clinical assessment of AUB begins with a systematic evaluation to identify potential underlying causes and determine the severity of bleeding. Screening tools like the Menstrual Distress Questionnaire (MEDI-Q) can be valuable in assessing the impact of HMB on a patient’s daily life, particularly for those with conditions like uterine fibroids. [³] In cases of acute AUB, hemodynamic stability should be the immediate priority. Resuscitative measures must be initiated in unstable patients before proceeding with a detailed history. Once the patient is stabilized, a comprehensive menstrual history is essential for understanding the diagnosis AUB meaning. This history should include:

• Menstrual History:

  • Age at menarche (onset of menstruation)
  • Date of the last menstrual period (LMP)
  • Menstrual cycle characteristics: frequency, regularity, duration, and volume of flow.
    • Frequency: Described as frequent (<24 days), normal (24-38 days), infrequent (>38 days), or absent (amenorrhea).
    • Regularity: Classified as regular (variation within 2-7 days), irregular (variation >20 days), or absent.
    • Duration: Described as prolonged (>8 days) or normal (≤8 days).
    • Volume of flow: Categorized as heavy (>80 mL), normal (5-80 mL), or light (<5 mL). Since accurate volume measurement is challenging outside of research settings, detailed questioning about sanitary product usage is crucial. This includes the frequency of pad or tampon changes, the presence and size of blood clots, the need for nighttime protection changes, interference with daily activities, and subjective reports of “flooding.” [⁸] These details are vital for understanding the diagnosis AUB meaning in terms of bleeding severity.
  • Presence of intermenstrual bleeding (bleeding between periods) and postcoital bleeding (bleeding after intercourse).

• Sexual and Reproductive History:

  • Obstetric history, including the number of pregnancies and modes of delivery.
  • Fertility desires and history of subfertility.
  • Current contraceptive methods being used.
  • History of sexually transmitted infections (STIs).
  • History of PAP smear results and cervical health.

• Associated or Systemic Symptoms:

  • Unexplained weight loss.
  • Pelvic pain.
  • Vaginal discharge.
  • Bowel or bladder symptoms.
  • Signs and symptoms of anemia (fatigue, weakness, pallor).
  • Signs and symptoms or known history of bleeding disorders.
  • Signs and symptoms or known history of endocrine disorders.

• Current Medications: List of all medications, including over-the-counter drugs and supplements.

• Family History: Inquire about family history of coagulopathies, malignancies, and endocrine disorders.

• Social History: Information on tobacco, alcohol, and drug use, occupation, and the impact of AUB symptoms on the patient’s quality of life.

• Surgical History: Previous surgeries, particularly gynecological procedures. [²]

Physical Examination

The physical examination begins with assessing for hemodynamic instability, such as orthostatic hypotension or tachycardia. [²][⁹] The examination should then focus on identifying signs of potential underlying etiologies, contributing to the diagnosis AUB meaning:

• Vital Signs: Measure blood pressure and calculate body mass index (BMI).
• Dermatologic Examination: Assess for pallor (indicating anemia), petechiae, and bruising (suggestive of coagulopathies).
• Tanner Staging: In adolescent patients, assess Tanner stage to correlate bleeding patterns with sexual maturity (bleeding is less likely to be due to ovulatory dysfunction before Tanner stage III).
• Signs of Endocrine Disorders:
  • Thyroid examination for enlargement or tenderness.
  • Assess for hirsutism (excessive hair growth), acne, and clitoromegaly, which may indicate hyperandrogenism.
  • Look for moon facies, abnormal fat distribution, and striae, which could suggest Cushing syndrome.
• Abdominal Examination: Palpate for any pelvic or abdominal masses.
• Pelvic Examination:
  • Perform speculum and bimanual exams.
  • Collect Pap smear and cultures for STI screening (gonorrhea and chlamydia), and wet prep, if indicated. [¹⁰][⁹] The pelvic exam is crucial in identifying structural abnormalities that contribute to the diagnosis AUB meaning.

Evaluation: Diagnostic Tools for Understanding AUB Meaning

The diagnostic evaluation of AUB is a multi-faceted approach that integrates laboratory testing, imaging studies, and endometrial assessment. This comprehensive evaluation is essential to accurately determine the diagnosis AUB meaning, differentiate between structural and nonstructural causes, and guide effective management strategies.

Laboratory Studies

In all women of reproductive age presenting with AUB, pregnancy must be ruled out first using a urine or serum human chorionic gonadotropin (hCG) test. A complete blood count (CBC) should also be performed to assess for anemia and thrombocytopenia. Additional laboratory investigations should be conducted based on clinical indications to further clarify the diagnosis AUB meaning:

• Hormonal Evaluation: Specific hormone tests, such as prolactin, androgens, and estrogen levels, are indicated when there is clinical suspicion of endocrine dysfunction, such as anovulation or hyperprolactinemia. [²][⁹] Hormonal assays are crucial for understanding the endocrine contributions to diagnosis AUB meaning.
• Ferritin Levels: In cases of heavy menstrual bleeding (HMB), serum ferritin levels should be measured to evaluate iron stores. Low ferritin levels indicate iron deficiency. However, normal ferritin levels do not exclude iron deficiency, especially in the presence of inflammatory conditions. [²][⁹] Ferritin levels help assess the impact of AUB on iron status, informing the diagnosis AUB meaning in terms of systemic consequences.
• Coagulation Studies: If a coagulopathy is suspected based on history (e.g., personal or family history of bleeding disorders, easy bruising, heavy bleeding with dental procedures or surgery), coagulation studies such as von Willebrand factor assays, factor levels, prothrombin time (PT), and partial thromboplastin time (PTT) should be considered. These tests are essential for identifying bleeding disorders as part of the diagnosis AUB meaning.

Imaging Studies

Diagnostic imaging is primarily used to evaluate suspected structural etiologies of AUB. Imaging is indicated when abnormalities are detected during a bimanual examination or when AUB symptoms persist despite initial medical treatment. Routine imaging is generally not recommended in adolescents unless initial management fails. [⁹] Transvaginal ultrasound (TVUS) and transabdominal ultrasound are the preferred first-line imaging modalities for most patients when indicated. They are particularly effective in identifying structural causes such as polyps, adenomyosis, or leiomyomas. [¹²][²][³] Transabdominal ultrasound may be more appropriate in adolescents. [⁹] Imaging is a cornerstone in clarifying the structural aspects of diagnosis AUB meaning.

Saline-infused sonohysterography (SIS) can be considered to enhance the detection of intracavitary lesions. This technique involves introducing sterile saline into the uterine cavity during TVUS to improve visualization. However, SIS is less helpful for endometrial assessment if the endometrium was not adequately visualized on the initial ultrasound. [¹²] Magnetic resonance imaging (MRI) is typically reserved for cases where TVUS is inadequate, such as in patients with complex anatomy, or for further characterizing leiomyomas or adenomyosis. Diffusion-weighted MRI can improve diagnostic accuracy, particularly in differentiating between benign and malignant lesions. [¹²][²][³] Advanced imaging techniques like MRI can be crucial for complex cases and refining the diagnosis AUB meaning.

Endometrial Biopsy

Endometrial sampling is indicated for women aged 45 years or older with AUB, as age is a significant risk factor for endometrial cancer. It is also recommended for younger patients with persistent bleeding, a history of unopposed estrogen exposure (e.g., obesity, PCOS), or failure of medical management. Office-based endometrial biopsy is the initial approach. Hysteroscopic dilation and curettage (D&C) is recommended if office sampling is unsuccessful, inadequate, or cannot be performed. [²][³] In patients with persistent symptoms despite normal biopsy results, hysteroscopy should be performed, as blind sampling may miss focal lesions such as polyps or hyperplasia. [²][⁵] Please refer to the StatPearls resource, “Endometrial Biopsy,” for more detailed information. Endometrial biopsy is critical for excluding malignancy and hyperplasia, significantly contributing to the diagnosis AUB meaning, especially in at-risk populations.

Treatment and Management of Abnormal Uterine Bleeding: Addressing the Diagnosis

Treatment decisions for AUB are guided by several factors, including the underlying cause, the acuity of bleeding, the patient’s fertility and contraceptive goals, comorbidities, treatment efficacy, potential adverse effects, and cost. When an identifiable cause can be treated directly, AUB symptoms may resolve without further intervention. Treatment is indicated when AUB leads to anemia or significantly impacts the patient’s quality of life. For anovulatory AUB, interventions are necessary to counteract the effects of unopposed estrogen, such as inducing ovulatory cycles or administering progesterone. The management approach is always tailored to the specific diagnosis AUB meaning.

Management of Acute Emergent Abnormal Uterine Bleeding

For hemodynamically unstable patients with severe AUB, immediate interventions are crucial. These may include mechanical control with intrauterine tamponade using a balloon, Foley catheter, or gauze packing. High-dose medical interventions can also be employed, such as intravenous (IV) or oral estrogen (if not contraindicated), combined oral contraceptives (COCs), oral progestins, or IV tranexamic acid. Contraindications for estrogen use include migraine with aura, a history of thromboembolic disease or risk factors for thrombosis, hypertension, and congenital cardiac anomalies. [⁹] In rare, severe cases, surgical procedures like dilation and curettage (D&C), uterine artery embolization (UAE), or hysterectomy may be necessary. [⁴][²][³] Acute management aims to stabilize the patient and address the immediate bleeding crisis, guided by the initial diagnosis AUB meaning as much as possible in an emergency setting.

Hospitalization is indicated for hemodynamically unstable patients or those with severe, refractory bleeding despite 24 hours of outpatient management. Criteria for hospitalization include saturating more than one pad per hour or bleeding through a pad within two hours, hemoglobin levels <7 g/dL, or significant orthostatic changes in vital signs. [⁴][²][³] For patients with acute AUB, medical treatment depends on clinical stability and the suspected etiology, aligning treatment with the initial understanding of diagnosis AUB meaning.

Nonemergent Treatment of Abnormal Uterine Bleeding

Hemodynamically stable patients with severe bleeding can often be managed with oral hormonal and nonhormonal therapies. For nonemergent AUB, medical management is typically preferred, especially for patients wishing to avoid surgery and preserve fertility. Medical options include:

• Hormonal Contraceptives: Combined oral contraceptives (COCs), the vaginal ring, and the transdermal patch can regulate the menstrual cycle and reduce bleeding.
• Progestin Therapy: Oral progestins (medroxyprogesterone acetate, norethindrone acetate), the levonorgestrel-releasing intrauterine device (LNG-IUD), and injectable progestogens (depot medroxyprogesterone acetate) can effectively manage AUB, particularly in cases of ovulatory dysfunction and endometrial causes. The LNG-IUD is often a first-line treatment for HMB.
• Nonsteroidal Anti-inflammatory Drugs (NSAIDs): NSAIDs such as ibuprofen and naproxen can reduce menstrual bleeding and pain by inhibiting prostaglandin synthesis. They are most effective for ovulatory AUB and can be used in conjunction with other treatments.
• Tranexamic Acid: This antifibrinolytic agent reduces bleeding by inhibiting plasminogen activation, stabilizing clots. It is particularly useful for HMB associated with various causes.
• GnRH Agonists and Antagonists: Gonadotropin-releasing hormone (GnRH) agonists (leuprolide, goserelin) and antagonists (elagolix, relugolix) can suppress ovarian hormone production, reducing bleeding associated with fibroids and adenomyosis. However, their use is often limited by side effects and bone loss with long-term use, necessitating “add-back” therapy (e.g., estradiol and norethisterone acetate).

Long-term management and maintenance therapy often involve hormonal therapies, including COCs, oral or injectable progestins, and LNG-IUDs. Continuous or extended regimens can help stabilize bleeding. Nonhormonal treatments include oral iron supplementation and dietary optimization to address anemia. GnRH agonists or antagonists are effective for fibroid-related bleeding, offering symptom relief and volume reduction, but their side effects require careful management and add-back therapy. Nonemergent management aims for long-term control of AUB, guided by the diagnosis AUB meaning and patient preferences.

Surgical Management

Surgical management is typically reserved for patients who do not respond to medical treatment or who desire definitive treatment. Minimally invasive techniques are preferred when fertility preservation is desired. Surgical therapies include:

• Dilation and Curettage (D&C): Sharp endometrial curettage can be used to treat AUB, especially when imaging reveals clots in the endometrial cavity. However, it should be avoided in patients with bleeding disorders. [⁹] D&C can be both diagnostic and therapeutic but is generally not a long-term solution.
• Hysterectomy: This is a definitive surgical solution with high patient satisfaction rates. Hysterectomy is frequently considered for adenomyosis and leiomyomas in women who do not desire future fertility. Hysterectomy provides a permanent solution, especially when the diagnosis AUB meaning points to structural issues unresponsive to other treatments.
• Endometrial Ablation: Destruction of the endometrial lining is an effective alternative to hysterectomy, comparable to LNG-IUD in outcomes, but it is not recommended for women who wish to preserve fertility. [¹³] Endometrial ablation is a less invasive surgical option for managing chronic AUB.
• Hysteroscopic or Laparoscopic Myomectomy: Removal of leiomyomas (fibroids) while preserving the uterus can be performed to maintain fertility, depending on the size, type, and location of the fibroids, as well as patient goals.
• Hysteroscopic Polypectomy: Surgical removal of endometrial polyps.
• Uterine Artery Embolization (UAE): This interventional radiology procedure involves catheterizing the bilateral uterine arteries and occluding blood flow with particulate material. UAE is particularly considered for AUB caused by leiomyomas. [⁴][²][³] UAE offers a less invasive alternative to surgery for fibroid-related AUB.

Management Based on PALM-COEIN Etiologies

Treatment strategies vary according to the PALM-COEIN classification of AUB. Etiology-specific management includes:

• Polyps (P): Surgical resection, typically hysteroscopic polypectomy, is the treatment of choice.
• Adenomyosis (A): Hysterectomy is the primary definitive treatment. In rare cases, adenomyomectomy (surgical removal of adenomyosis) may be considered for fertility preservation, but it is not always effective.
• Leiomyomas (L): Management can be medical or surgical, depending on fertility desires, medical comorbidities, symptoms from uterine pressure, and distortion of the uterine cavity.
  • Surgical Options: UAE, endometrial ablation, myomectomy (hysteroscopic, laparoscopic, or abdominal), or hysterectomy.
  • Medical Options: LNG-IUD, GnRH agonists, systemic progestins, tranexamic acid, and NSAIDs.
• Malignancy and Hyperplasia (M): Treatment depends on the type and stage of malignancy or hyperplasia. It typically involves surgery (hysterectomy), often with adjuvant therapy (radiation, chemotherapy). For cases where surgery is not feasible, high-dose progestins or palliative treatments like radiotherapy may be considered.
• Coagulopathies (C): Management of coagulopathies (e.g., von Willebrand disease) may include tranexamic acid or desmopressin (DDAVP) to reduce bleeding. Hematology consultation is essential for comprehensive management.
• Ovulatory Dysfunction (O): Management focuses on addressing underlying conditions. For PCOS, lifestyle modifications (weight loss) and medications to induce ovulation (clomiphene citrate, letrozole) may be used. Correction of endocrine disorders includes medications like cabergoline for hyperprolactinemia or levothyroxine for hypothyroidism.
• Endometrial Disorders (E): Currently, there are no specific targeted treatments for endometrial disorders due to an incomplete understanding of their mechanisms. Management is often empirical and may involve hormonal therapies to regulate bleeding.
• Iatrogenic Causes (I): Management of medication-induced AUB depends on the causative agent and bleeding severity. For breakthrough bleeding (BTB) with continuous COCs, reassurance and observation may be sufficient initially. Adjusting medication dosage or changing to an alternative contraceptive method (e.g., LNG-IUD or systemic progestins) may be necessary. If other medications (e.g., anticoagulants) are the cause and discontinuation is not possible, individualized treatment plans should consider the patient’s reproductive goals and medical conditions.
• Not Otherwise Classified (N): Treatment is guided by the specific condition. Antibiotics are used for endometritis, and uterine artery embolization may be used for arteriovenous malformations (AVMs). [⁵][¹⁰][⁸]

For further information on managing specific conditions, refer to StatPearls resources: “Bleeding Disorders“, “Endometrial Cancer,” “Adenomyosis,” and “Leiomyoma.” Etiology-specific management is crucial for effective long-term outcomes, ensuring the treatment aligns with the precise diagnosis AUB meaning.

Differential Diagnosis of Abnormal Uterine Bleeding

It is crucial to consider that bleeding from other sources within the genitourinary or gastrointestinal tracts can mimic AUB. Therefore, the differential diagnosis must include and exclude bleeding from these other sources. Differential diagnoses for genital tract bleeding based on anatomic location or system include:

• Vulva: Benign growths, malignancy, trauma, infections.
• Vagina: Benign growths, sexually transmitted infections, vaginitis, malignancy, trauma, foreign bodies.
• Cervix: Benign growths, sexually transmitted infections, cervicitis, malignancy, polyps.
• Fallopian Tubes and Ovaries: Pelvic inflammatory disease (PID), ectopic pregnancy (though technically pregnancy-related, can mimic AUB symptoms in early stages), ovarian cysts, malignancy.
• Urinary Tract: Urinary tract infections (UTIs), bladder or kidney stones, malignancy, hematuria from other renal conditions.
• Gastrointestinal Tract: Inflammatory bowel disease (IBD), hemorrhoids, anal fissures, colorectal cancer, Behçet syndrome.
• Pregnancy and Pregnancy-Associated Complications: Intrauterine pregnancy (implantation bleeding), spontaneous abortion, ectopic pregnancy, placenta previa, placental abruption. Although pregnancy-related bleeding is technically distinct from AUB (defined as non-pregnancy related), it is a critical differential, especially in women of reproductive age.
• Uterus: Etiologies of bleeding arising from the uterine corpus itself are categorized under the PALM-COEIN system, which aids in systematically exploring the diagnosis AUB meaning within the uterus. [¹][⁵][¹⁴]

A thorough evaluation, including history, physical exam, and appropriate investigations, is necessary to differentiate AUB from these other potential sources of bleeding. Accurate differential diagnosis is vital to ensure the correct diagnosis AUB meaning is established and appropriate treatment is initiated.

Prognosis of Abnormal Uterine Bleeding

The prognosis for AUB is generally favorable, but it largely depends on the underlying etiology identified through accurate diagnosis AUB meaning. The primary goals of evaluating and treating chronic AUB are to rule out serious conditions such as malignancy, improve the patient’s quality of life, and tailor management to their current and future fertility goals and any existing medical conditions that may influence treatment or symptoms. Prognosis also varies depending on whether medical or surgical treatment approaches are used.

Nonhormonal treatments, such as antifibrinolytic medications (tranexamic acid) and NSAIDs, have been shown to reduce menstrual blood loss by up to 50%. [⁸] Oral contraceptive pills can be effective in managing AUB, although robust randomized controlled trials are still needed to definitively quantify their effectiveness compared to other treatments.

For women with heavy menstrual bleeding (HMB) as the primary symptom of AUB, the LNG-IUD has been proven more effective than other medical therapies in reducing bleeding and improving quality of life. Injectable progestogens and GnRH agonists can induce amenorrhea (absence of menstruation) in up to 50% and 90% of women, respectively. However, injectable progestogens can cause breakthrough bleeding, and GnRH agonists are typically used for short durations (usually up to 6 months) due to adverse effects associated with low estrogen levels, such as bone density loss. [⁸]

In terms of surgical techniques, randomized clinical trials and reviews have shown that endometrial ablation is more effective in controlling bleeding in the short term (up to 4 months postoperatively) compared to medical management. However, at 5 years, no significant difference in bleeding control is observed between endometrial ablation and medical management. When hysterectomy is compared to LNG-IUD, hysterectomy shows better outcomes at 1 year in terms of bleeding control. No significant difference in quality of life is observed at 5 and 10 years between these two treatments, but many women initially treated with LNG-IUD eventually undergo hysterectomy within 10 years due to persistent symptoms or other gynecological issues. [⁸] Overall, with appropriate diagnosis AUB meaning and tailored management, most women with AUB can achieve significant symptom relief and improved quality of life.

Complications of Abnormal Uterine Bleeding

Complications of chronic AUB can include anemia, infertility, and, in some cases, endometrial hyperplasia or cancer (particularly if AUB is due to unopposed estrogen exposure). Acute AUB can lead to serious complications related to critical blood loss, including severe anemia, hypotension, renal dysfunction, hypovolemic shock, and, in rare instances, death if prompt and effective treatment and supportive care are not initiated. [⁹] Early diagnosis AUB meaning and effective management are crucial to prevent these potential complications.

Consultations for Abnormal Uterine Bleeding

Early consultation with obstetrics and gynecology specialists is recommended for proper evaluation and management of AUB. Depending on the identified etiology of AUB, consultations with other specialties may be necessary to optimize patient care. For suspected coagulopathies, consultation with hematology/oncology is warranted. Interventional radiology consultation is needed for procedures such as uterine artery embolization. If malignancy is suspected or confirmed, gynecologic oncology and hematology/oncology specialists should be involved in treatment planning and management. Interprofessional consultation is often key to comprehensive diagnosis AUB meaning and management, especially in complex cases.

Deterrence and Patient Education for Abnormal Uterine Bleeding

Patient counseling and preventive strategies for AUB should focus on education, proactive planning, and comprehensive support. Primary care clinicians should initiate discussions with patients about menstrual cycles, regularity, fertility desires, contraception, and sexual health. Patients with AUB should be educated about the importance of open communication with their healthcare providers. Regular clinic visits are essential for addressing specific concerns, monitoring symptoms, and optimizing management strategies. Supportive therapies, including lifestyle modifications, stress management techniques, and psychological support, can be valuable in reducing anxiety and improving quality of life for women experiencing AUB.

For individuals with known bleeding disorders, especially adolescents, early counseling is essential to prepare for the challenges associated with menarche and heavy menstrual bleeding. Discussions should include strategies for managing heavy bleeding, menstrual hygiene practices in school and public settings, and recognizing common causes of bleeding, such as accidental trauma. A collaborative approach involving gynecologists, hematologists, and social workers can help create individualized care plans, empowering patients and their families to effectively manage these concerns. Interprofessional clinics, when available, offer a convenient and integrated setting for such comprehensive care. [⁹] Effective patient education and proactive counseling are vital components of managing AUB and improving patient outcomes, ensuring patients understand their diagnosis AUB meaning and management options.

Enhancing Healthcare Team Outcomes in Abnormal Uterine Bleeding Management

Effective management of AUB requires a collaborative, interprofessional healthcare team approach to ensure patient-centered care, optimal clinical outcomes, and enhanced patient safety. Seamless coordination among physicians, advanced practice providers, nurses, pharmacists, and other healthcare professionals is crucial in the comprehensive evaluation and treatment of women with AUB. Primary care clinicians, including family medicine and internal medicine physicians, often play a pivotal role in the initial identification of AUB. Prompt consultation with obstetrics and gynecology specialists is essential to initiate appropriate diagnostic and management pathways. Comprehensive patient care involves detailed discussions about treatment options, carefully considering the underlying etiology (informed by accurate diagnosis AUB meaning), the patient’s desire for future fertility, and preferences for medical versus surgical management.

Physicians and pharmacists share a critical responsibility to thoroughly educate patients about the potential adverse effects of medical treatments, promoting informed decision-making and enhancing adherence to prescribed therapies. Nurses and advanced practice providers contribute significantly to patient education, provide essential emotional support, and help patients navigate the complexities of their care journey. Open, consistent, and respectful interprofessional communication ensures that all team members are aligned in their approach, minimizing medical errors, enhancing the quality of care provided, and improving overall team performance. By effectively integrating the diverse expertise of each discipline within the healthcare team, professionals can comprehensively address AUB, prioritize patient safety, achieve better clinical and reproductive outcomes, and optimize the overall patient experience. A collaborative approach ensures that the diagnosis AUB meaning informs a holistic and effective management plan.

Review Questions

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References

(Note: References from the original article are included as per instructions.)

1.Munro MG, Critchley HOD, Fraser IS., FIGO Menstrual Disorders Committee. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018 Dec;143(3):393-408. [PubMed: 30198563]

2.Wouk N, Helton M. Abnormal Uterine Bleeding in Premenopausal Women. Am Fam Physician. 2019 Apr 01;99(7):435-443. [PubMed: 30932448]

3.Leal CRV, Vannuccini S, Jain V, Dolmans MM, Di Spiezio Sardo A, Al-Hendy A, Reis FM. Abnormal uterine bleeding: The well-known and the hidden face. J Endometr Uterine Disord. 2024 Jun;6 [PMC free article: PMC11101194] [PubMed: 38764520]

4.Marnach ML, Laughlin-Tommaso SK. Evaluation and Management of Abnormal Uterine Bleeding. Mayo Clin Proc. 2019 Feb;94(2):326-335. [PubMed: 30711128]

5.ACOG committee opinion no. 557: Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol. 2013 Apr;121(4):891-896. [PubMed: 23635706]

6.Jain V, Munro MG, Critchley HOD. Contemporary evaluation of women and girls with abnormal uterine bleeding: FIGO Systems 1 and 2. Int J Gynaecol Obstet. 2023 Aug;162 Suppl 2(Suppl 2):29-42. [PMC free article: PMC10952771] [PubMed: 37538019]

7.Liu Z, Doan QV, Blumenthal P, Dubois RW. A systematic review evaluating health-related quality of life, work impairment, and health-care costs and utilization in abnormal uterine bleeding. Value Health. 2007 May-Jun;10(3):183-94. [PubMed: 17532811]

8.Cheong Y, Cameron IT, Critchley HOD. Abnormal uterine bleeding. Br Med Bull. 2017 Sep 01;123(1):103-114. [PubMed: 28910998]

9.ACOG Committee Opinion No. 785, Screening and Management of Bleeding Disorders in Adolescents With Heavy Menstrual Bleeding: Correction. Obstet Gynecol. 2023 Jan 01;141(1):228. [PubMed: 36701629]

10.Whitaker L, Critchley HO. Abnormal uterine bleeding. Best Pract Res Clin Obstet Gynaecol. 2016 Jul;34:54-65. [PMC free article: PMC4970656] [PubMed: 26803558]

11.Screening and Management of Bleeding Disorders in Adolescents With Heavy Menstrual Bleeding: ACOG COMMITTEE OPINION, Number 785. Obstet Gynecol. 2019 Sep;134(3):e71-e83. [PubMed: 31441825]

12.Expert Panel on GYN and OB Imaging. Robbins JB, Sadowski EA, Maturen KE, Akin EA, Ascher SM, Brook OR, Cassella CR, Dassel M, Henrichsen TL, Learman LA, Patlas MN, Saphier C, Wasnik AP, Glanc P. ACR Appropriateness Criteria® Abnormal Uterine Bleeding. J Am Coll Radiol. 2020 Nov;17(11S):S336-S345. [PubMed: 33153547]

13.Vitale SG, Della Corte L, Ciebiera M, Carugno J, Riemma G, Lasmar RB, Lasmar BP, Kahramanoglu I, Urman B, Mikuš M, De Angelis C, Török P, Angioni S. Hysteroscopic Endometrial Ablation: From Indications to Instrumentation and Techniques-A Call to Action. Diagnostics (Basel). 2023 Jan 17;13(3) [PMC free article: PMC9914843] [PubMed: 36766443]

14.Committee on Practice Bulletins—Gynecology. Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012 Jul;120(1):197-206. [PubMed: 22914421]

Disclosure: Emily Davis declares no relevant financial relationships with ineligible companies.

Disclosure: Paul Sparzak declares no relevant financial relationships with ineligible companies.