Abnormal uterine bleeding (AUB) is bleeding from the uterus that is longer than usual or that occurs at an irregular time. Bleeding may be heavier or lighter than usual and occur often or randomly. AUB can occur: As spotting or bleeding between your periods.

1. PALESTINE POLYTECHNIC UNIVERSITY
Faculty of Medicine and Health Sciences
MohmmadRjab Seder

2. o Define AUB.
o Get a brief overview of normal uterine bleeding (menstruation).
o Distinguish the AUB from other similar terms.
o Describe etiologies of AUB.
o Classification of AUB.
o Patterns of AUB.
o Assessing AUB?
o Diagnosis (Examination + Lab tests)
o Management.
Learning Objectives

3. o The periodic blood that flows as a discharge from the woman’s
uterus.
o Normal uterine bleeding is also called menorrhea.
o The process by which menorrhea occurs is called menstruation.
o The time of the cycle during which menstruation occurs is referred to
as menses.
What is Normal Uterine Bleeding?

4. o Females of reproductive age.
o Shading of the endometrium.
o Controlled by the endocrine system (HPO Axis).
Menstruation – Brief Overview

5. Menstruation – Brief Overview
Normal
Menses
Frequency
24-35 days
Duration
2-8 days
Avg blood
loss
(30-40 ml)
Pad count
not reliable
to quantify
blood loss
Symptoms
associated
with
menstrual
cycle
Heavy
blood loss
is >80
ml/cycle
↑ Cervical mucus secretions at
mid-cycle
Premenstrual symptoms (cramps,
breast tenderness, bloating,
appetite/mood changes)

6. o Abnormal uterine bleeding (AUB): variation in normal bleeding
patterns.
o Frequency
o Regularity
o Duration
o Volume
o Frequent condition in Gynecology.
o The commonest menstrual problem during perimenopause.
o AUB may be acute or chronic (> 6months).
o Acute??
What is AUB?

7. o Menorrhagia: prolonged or heavy menstrual bleeding at regular
intervals.
o Metrorrhagia: bleeding between normal menses (irregular intervals).
o Menometrorrhagia = Menorrhagia + Metrorrhagia
= Heavy bleeding between normal menses
o Polymenorrhea: frequent menstrual bleeding.
o Oligomenorrhea: uterine bleeding at intervals > 35 days.
o Hypomenorrhea: abnormally low bleeding (< 30mL/menstrual cycle).
Related Terms

8. Age group:
o Premenarchal
o Postmenopausal
o Reproductive
o Pregnant
o Non-pregnant
o Abnormal Uterine Bleeding (AUB)
o Dysfunctional Uterine Bleeding (DUB)
Vaginal Bleeding

9. Effects of AUB on different aspects

10. How to Measure Blood Loss?
To calculate actual menstrual blood loss, multiply
the number of hygiene products used during
period by 5 ml (in case of regular size products) or
10 ml (for extra-absorbent products). Multiply this
number by 0.36 (WHY?) to get the approximate
amount of blood you lost during your period.

11. oA woman used 9 extra-absorbent pads during her
period. What is the average blood loss during a
typical menstrual cycle?
A. 90 mL
B. 66 mL
C. 40 mL
D. 33 mL
Question
✔

12. Advantages and disadvantages of
methods to measure menstrual
blood loss
Click Here

13. Etiologies | PALM-COEIN Scheme

14. PALM-COEIN Scheme
Each letter indicates
one of the etiologies of
bleeding:
PALM
Assessed by inspection,
imaging and histopathology.
COEIN
Needs further workup
PALM-COEIN Classification System

15. Distribution of Cases as Per Clinical
Diagnosis
Chinese women aged 15 to 55 years
Indian women aged 40 years till menopause

16. Usual Causes of AUB Vary by
Female Age

17. Patterns of AUB

18. o Endometrial polyps.
o Usually BENIGN.
o Characteristics:
o Usually light.
o Intermenstrual.
o Diagnosis:
o Transvaginal ultrasonography (TVUS)
o Hysteroscopy
o Histologic examination (WHY??)
o Management:
o Hysteroscopy
PALM-COEIN | Polyps

19. o Endometrial tissue grows into the muscular wall of the uterus.
(tissue develops ectopically)
o BENIGN.
o Characteristics:
o Dysmenorrhea.
o Heavy menstrual bleeding.
o Chronic pain.
o Enlarged uterus.
o Respond to hormonal changes throughout the cycle.
o Diagnosis:
o Hysterectomy (histopathological analysis of uterus)
o Management:
o Hysterectomy
o Contraceptives.
PALM-COEIN |Adenomyosis

20. o Uterine fibroids
o BENIGH growths of the uterus
(myometrium) that often appear during
childbearing years.
o Most common pelvic tumor (Repr. Age F.)
o Characteristics:
o Diagnosis:
o Management:
PALM-COEIN |Leiomyoma

21. o Malignancy and Hyperplasia
o Characteristics:
o Diagnosis:
PALM-COEIN |Malignancy

22. o 15% of AUB cases have coagulopathies.
o von willebrand disease is the most common
hereditary coagulation abnormality.
o Family history.
o Labs:
o CBC
o PT
o PTT
o vWF antigen.
PALM-COEIN |Coagulopathy
If 1, 2 or 3 is ascertained, it indicates
positive screen, and further referral
for appropriate investigation should
be considered.

23. o Excessively heavy, prolonged, or frequent bleeding.
o Anovulatory AUB
o unpredictable times
o unpredictable patterns
o Ovulatory AUB
o excessive bleeding during regular menstrual cycles
o Diagnosis:
o Exclusion of other potential causes
o CBC, pregnancy test, and hormone measurement (eg, TSH, prolactin)
o transvaginal ultrasonography.
o hysteroscopy
o Management:
o Hormonal therapy: e.g. OCTs, GnRH agonists
o NSAIDs
o Tranexamic acid
PALM-COEIN |Ovulatory disorder

25. o Endometrial dysfunction.
o AUB that occurs in the context of a structurally normal uterus with
regular menstrual cycles without evidence of coagulopathy is likely
to have an underlying endometrial cause.
o Lack of clinically available specific tests or biomarkers means.
o Diagnosis:
o careful history taking and exclusion of other contributors.
PALM-COEIN |Endometrial

26. o Exogenous therapy than may lead to unscheduled endometrial
bleeding
o Typically associated with continuous oestrogen or progestin therapy.
o IUD → low-grade endometritis → AUB.
PALM-COEIN |Iatrogenic

27. o Rare or poorly defined pathologies that do not easily fit within the
other categories.
o Examples:
o arteriovenous malformations.
o endometrial pseudoaneurysms.
o myometrial hypertrophy.
o chronic endometritis.
PALM-COEIN |Not yet classified

28. o Initial assessment – History and physical examination.
o Laboratory tests – pregnancy test, tests for infections, blood tests.
o Tests to determine ovulatory status – ovulation?
o Endometrial assessment.
o Endometrial biopsy.
o Transvaginal ultrasound.
o Hysteroscopy.
o Saline infusion sonography (sonohysterography).
AUB Evaluation

29. Specific treatment options for individual PALM-COEIN causes of AUB.
Management

30. The medical management of abnormal uterine bleeding in
reproductive-aged women
Click Here
Management – Further Reading

31. o Benetti-Pinto, C., Rosa-e-Silva, A., Yela, D., & Soares Júnior, J. (2017). Abnormal Uterine Bleeding. In Revista
Brasileira de Ginecologia e Obstetrícia / RBGO Gynecology and Obstetrics (Vol. 39, Issue 07, pp. 358–368).
Georg Thieme Verlag KG. https://doi.org/10.1055/s-0037-1603807
o Mishra, D., & Sultan, S. (2016). FIGO’s PALM–COEIN Classification of Abnormal Uterine Bleeding: A Clinico-
histopathological Correlation in Indian Setting. In The Journal of Obstetrics and Gynecology of India (Vol. 67,
Issue 2, pp. 119–125). Springer Science and Business Media LLC. https://doi.org/10.1007/s13224-016-0925-8
o Whitaker, L., & Critchley, H. O. D. (2016). Abnormal uterine bleeding. In Best Practice &amp; Research Clinical
Obstetrics &amp; Gynaecology (Vol. 34, pp. 54–65). Elsevier BV.
https://doi.org/10.1016/j.bpobgyn.2015.11.012
o Kaplan Medical. (2018). USMLE Step 2 CK Lecture Notes 2019: 5-book set. Kaplan Publishing.
o Kenny, L., & Bickerstaff, H. (Eds.). (2017). Gynaecology by ten teachers, 20th edition (20th ed.). CRC Press.
o Osmosis
o Up to date
References

32. Thank You