Resident Editor: Anne Montgomery, MD

Faculty Editor: Meg Autry, MD

Background

• Abnormal uterine bleeding refers to menstrual flow outside of normal volume, duration, regularity, or frequency. AUB is a common complaint and accounts for 1/3 of all outpatient gynecology visits.
• Normal menstruation: 21-35 day cycle with approx. 5 days of bleeding
• AUB is typically described as either heavy menstrual bleeding (bleeding along with a regular cycle) and/or intermenstrual bleeding (bleeding between cycles) and is most commonly classified according to the PALM-COEIN system:

• Causes of ovulatory dysfunction can be both physiologic and pathologic: 
  • Physiologic: adolescence, perimenopause, pregnancy/lactation
  • Pathologic: hyperandrogenic anovulation (eg. PCOS), hypothalamic dysfunction (eg. anorexia), hyperprolactinemia, thyroid disease, pituitary disease, premature ovarian failure, side effects from chemo/radiation, medications

Evaluation

Primary questions 

• Is the patient pregnant? 
• Is the uterus the source of bleeding?
• Is the patient pre- or post-menopausal?

History

• Menstrual history: onset, frequency, regularity, duration, volume
• Associated symptoms: dysmenorrhea, dyspareunia, vaginal discharge, bowel/bladder issues, galactorrhea, heat/cold intolerance, hirsutism, hot flashes
• Obstetric and surgical history: pregnancy history, prior c-section(s)
• Other medical histories: personal/family history of a bleeding disorder, thyroid disease, infertility
• Medications, including contraceptives and anti-coagulation

Physical – Vital signs, weight/habitus, hirsutism, skin exam for signs of a bleeding disorder, pelvic exam (including speculum exam to look for vaginal or cervical lesions and bimanual exam to establish size and contour of the uterus)

Labs and other testing

• Pregnancy test, CBC[g1], TSH; consider PT/PTT if concerned for bleeding disorder
• Pap smear +/- chlamydia testing (for at-risk patients)
• Transvaginal ultrasound to evaluate for structural lesions -> saline sono
• Endometrial biopsy if >45yo, hx of longstanding unopposed estrogen (BMI>30, chronic anovulation), or if unresponsive to medical therapy

Management of AUB:

• Acute, moderate to heaving bleeding: Provera 20mg TID x7 days, monophasic combined OCP (35mcg Ethinyl estradiol) TID x7 days, or tranexamic acid 1300mg TID until bleeding stops (maximum 5 days).
• Acute bleeding with abnormal vital signs or severe symptoms: Send directly to ED; may require urgent/emergent surgical curettage or IV estrogen therapy.
• Recurrent AUB due to ovulatory dysfunction:
• Women of child-bearing age: Continuous combined OCPs, cyclic combined OCPs (or ongoing continuous use), levonorgestrel IUD, progestin-only therapy, tranexamic acid during menses.
• Completed childbearing: Hormonal methods as above versus endometrial ablation vs hysterectomy.
• Perimenopausal Bleeding: If EMB negative low-dose combined OCPs or progesterone-only methods.
• AUB due to a structural cause: Refer to Gynecology.

References

Committee on Practice Bulletins – Gynecology. Diagnosis of abnormal uterine bleeding in reproductive-aged women. Practice bulletin no. 128. Obstet Gynecol 2012; 120:197-206. 

Committee on Gynecologic Practice. Management of acute abnormal uterine bleeding associated with ovulatory dysfunction. Committee opinion no. 557. Obstet Gynecol 2013;121:891-6.

Committee on Practice Bulletins – Gynecology. Management of abnormal uterine bleeding in nonpregnant reproductive-aged women. Practice bulletin no. 136. Obstet Gynecol 2013;122:176-85.

Kaunitz A, et al. Approach to abnormal uterine bleeding in nonpregnant reproductive-age women. UpToDate Online. Nov 28, 2017. Accessed April 15, 2018.

Wise MR, Gill P, Lensen S, et al. Body mass index trumps age in decision for endometrial biopsy: cohort study of symptomatic premenopausal women. Am J Obstet Gyneol 2016;215:598.e1-8.