This document discusses abnormal uterine bleeding (AUB), providing definitions, terminology, and etiologies. It describes the normal menstrual cycle and defines AUB as bleeding that is abnormal in duration, volume, frequency, or regularity. Common etiologies of AUB are organized using the PALM-COEIN system, including structural issues like polyps, adenomyosis, and leiomyomas. Diagnosis involves taking a history, examining the patient, and running targeted tests. Treatment for acute AUB focuses on stabilization, while chronic AUB may be treated with medical options, procedures, or surgery depending on the individual.

1. Abnormal Uterine Bleeding (AUB)
Up-to-date
(FIGO 2018-NICE 2018-ACOG 2012, ACOG 2013)
Abdelrahman Elqusy
2022

2. Definition
Terminology
Aetiology Of AUB (PALM-COEIN)
Approach for diagnosis
Treatment of Acute and chronic AUB

3. Normal Menstrual flow
Average duration of
menses 4 days (2 – 7)
Average amount 35 ml
(10 -80 ml)
Average duration of
menstrual cycle 28days
(21 – 35 days)

4. Terminology

5. Definition
Abnormal uterine bleeding (AUB) is
 bleeding from the uterus that is longer than usual
or that occurs at an irregular time.
 Uterine bleeding of abnormal quantity, duration, or
schedule

6. Old Terminology
Polymenorrhoea: cyclic bleeding of normal amount
occurs at too frequent interval < 21 days
Oligomenorrhea cyclic bleeding of normal amount
occurs at infrequent interval > 35 days
Menorrhagia: Excessive (>80 ml) & / or prolonged
bleeding (> 7days) occurs at regular intervals at time
of menstruation

7. Metrorrhagia: Acyclic bleeding of normal or reduced amount
occurs at irregular intervals (intermittent or continuous)
Hypomenorrhea : Menstrual flow < 30 ml
Menometrorrhagia: prolonged / or excessive bleeding occurs
at irregular intervals
Breakthrough spotting: mild bleeding occurs intermenstrual
due to hormonal therapy

8. 18 to 25 years: cycle length variance >9 days
26 to 41 years: cycle length variance >7 days
42 to 45 years: cycle length variance >9 days

9. New terminology
Abnormality in Amount
Prolonged menstrual bleeding is defined as menstrual bleeding
consistently lasting >8 days; this is often, but not always,
associated with heavy menstrual bleeding
Heavy Menstrual bleeding (HMB) is >80 mL menstrual blood
loss per cycle
 It should be noted that some patients have had HMB
"normalized" by family members, friends, or health care
providers, and therefore think their heavy volume is "normal.“
 Bleeding volume sufficient to interfere with the woman’s
quality of life

10. Light menstrual bleeding is uncommon and rarely
related to pathology, although it may be a
presenting symptom of cervical stenosis or
intrauterine synechiae
<5 mL is considered "low volume," a metric that
can only be assessed quantitatively with methods
like the alkaline hematin assay

11. Abnormalities in frequency
Frequent menstrual bleeding refers to periods that start at
intervals <24days.
Infrequent menstrual bleeding refers to periods that start at
intervals>38 days.
Absent – Absence of menses is either primary (absence of
menarche by age 15 years)or secondary (absence of
spontaneous menstrual bleeding for six months in a patient
who previously had menstrual bleeding) amenorrhea

12. Intermenstrual bleeding refers to AUB that occurs between well-
defined cyclical menses
1- Cyclical midcycle intermenstrual bleeding
A small amount of bleeding around midcycle associated with the midcycle
drop in circulating estradiol levels that occurs just after ovulation
2- Acyclical intermenstrual bleeding
– Intermenstrual bleeding that is not cyclical or predictable is typically
associated with non-malignant lesions, such as chronic cervicitis /
endometritis or polyps of the cervix or endometrium or intracavitary
uterine fibroids; postcoital bleeding is a frequent symptom

16. New terminology
1. Heavy Menstrual bleeding (HMB)
2. Heavy Prolonged Menstrual bleeding (HPMB)
3. Intermenstrual bleeding (IMB) (Cyclic – Acyclic)
4. Postmenopausal bleeding (PMB)

17. Acute versus chronic AUB
Chronic non-gestational AUB in the reproductive years is defined as
bleeding from the uterine corpus that is abnormal in duration,
volume, frequency, and/or regularity, and has been present for the
majority of the preceding 6 months.
 Acute AUB :
Excessively heavy or prolonged bleeding of uterine origin sufficient
in volume as to require urgent or emergency intervention
Bleeding that is profuse and soaks a large sanitary pad or tampon at
every hour or two and continues for two or more hours

18. Aetiology OF AUB

19. Aetiology OF AUB (FIGO 2012, 2018)
PALM COEIN

21. Diagnosis Nomenclature
Example
Patient with AUB due adenomyosis
P0A1L0M0C0O0E0I0N0

22. Aetiology According Age
New born
Estrogen withdrawal bleeding from maternal blood passage to the
fetus
 Premenarche
1. Foreign body
2. Precocious puberty
3. Vulvovaginitis of children
4. Sarcoma of vagina, cervix
 Perimenarche
1. AUB-O , AUB-E
2. Coagulapathy

23. Childbearing period
1. Complications of pregnancy
2. Traumatic & inflammatory causes
3. benign lesions Myoma , Polyp
4. AUB-O :PCOs
5. Iatrogenic causes; contraception
6. General causes (hemophilia ,ITP, drug-induced)

24. Perimenopausal
1.AUB-O , AUB-E
2.Benign and malignant tumors
3.Traumatic and inflammatory causes
Post menopausal
1.Atrophic endometritis
2.Malignant causes
3.HRT

25. AUB-P
 Uterine polyps are growths that occur in the
inner lining (endometrium) of the uterus.
 Uterine polyps are usually Benign, but they may
cause problems with periods (menstruation) or
fertility.
 Usually presented with HMB
 Diagnosed by Transvaginal ultrasound,
Sonohysterography and Hysteroscopy.
 Treatment Hysteroscopic Polypectomy or D&C

26. AUB-A
 Adenomyosis is the presence of ectopic endometrial glands and stroma located within the
myometrium of the uterine wall.
 diffuse or focal involvement of the myometrium.
 C/P pelvic pain, progressive dysmenorrhea, HMB, and tender symmetrically enlarged
uterus
 Investigation
1- U/S : diffusely symmetrically enlarged uterus with cystic areas found within the
myometrial wall (Myometrial cyst).
2- MRI Accurate diagnosis .Diffuse or focal widening of JZ(--Increase junctional zone >12 mm)
 Treatment : LNG-IUS , adenomyomectomy and Hysterectomy

28. AUB-L
 Leiomyoma uteri is a benign smooth muscle growth of the myometrium
 the possible etiology is hyperestrinism estrogen-dependent tumors
 Submucous fibroid usually associated AUB
 Diagnosis ultrasound ,SIS,MRI
 Treatment : Medical or surgical

31. AUB-M
Vulval , Vaginal , Cervical ,Uterine and adnexal
cancer
 Presented Intermenstrual bleeding , postcoital
bleeding and postmenpuasal bleeding

32. AUB-C
Coagulation disorder such as Von willebrand disease, ITP ,
Drug –induced and hemophilia
Indications for screen
 Heavy menstrual bleeding since menarche
 One of the following:
1. Postpartum hemorrhage
2. Surgery-related bleeding
3. Bleeding associated with dental work
Two or more of the following
symptoms:
1. Bruising one to two times per month
2. Epistaxis one to two times per month
3. Frequent gum bleeding
4. Family history of bleeding symptoms

33. AUB-O
Old term : Anovulatory Dysfunctional uterine bleeding ,Metropathia
Hemorragica
Acyclic bleeding
HMB, Intermenstrual bleeding, Oligomenorrhea, Amenorrhea
Pathophysiology :During an anovulatory cycle, the corpus luteum does
not form. Thus, the normal cyclical secretion of progesterone does not
occur, and estrogen stimulates the endometrium unopposed. Without
progesterone, the endometrium continues to proliferate, eventually
outgrowing its blood supply; it then sloughs incompletely and bleeds
irregularly and sometimes profusely or for a long time
(Chronic Proliferative Endometrium)

34. AUB-O
Usually common extremes of age (Perimenarche, Perimenopause)
Cuases of Anovulation
1. Hypothalamic (severe weight loss, stress, drug-induced,
2. Pituitary (Pituitary tumours including prolactinoma, trauma and
inflammation)
3. Ovarian (PCOs)
4. Hypothyroidism ,cushing syndrome

35. AUB-E
Endometrial Dysfunctional uterine bleeding
Cyclic
Causes
1. Abnormalities in platelet plug
2. Inadequate production of VC PGF2-alpha
3. Excessive production of VD PG prostacyclin

36. Forms :
1. HPMB.
2. Frequent menstrual bleeding (Polymenorrhea)
 Short follicular phase (rapid maturation of GF)
 Short luteal phase (rapid degeneration CL)
3. Infrequent menstrual bleeding (Oligomenorrhea)…..persistent
corpus luteum (Halban disease )

37. AUB- I
Iatrogenic
Abnormal uterine bleeding due to medications ….Hormonal
contraception
Usually type of bleeding …..Breakthrough bleeding
Usualy some medication causes hyperprolactinemia as
Antipsychotic drugs
Anticoagulant therapy

38. AUB-N
Not yet classified
1. Uterine arteriovenous malformation
• May be congenital or Acquired
• HPMB
• Doppler ultrasound and CT Angiography may be helpful
• Treatment : uterine artery embolization, Hysterectomy

39. 2. Infection: endometritis , cervicitis
Causes Intermenstrual bleeding
3.Uterine Niche
Postmenstrual spotting
Ultrasound and hystrescopy have a good role for diagnosis
Repair : laparotomy, Laparoscopy, Vaginal and Hysteroscopic

40. Approach for Diagnosis

41. History (ACOG 2013)
Age of menarche and menopause
Menstrual bleeding patterns (Calendar based)
 Severity of bleeding (clots or flooding)
 Pain (severity and treatment)
Medical conditions (thyroid , hyperprolactinemia)
Surgical history
Contraception
Use of medications
 Symptoms and signs of possible bleeding disorder

42. History suggest Heavy Menstrual Bleeding
HMB
1. Passing one blood clot > 1 inch in diameter
2. Changing pads more frequent than every 3 hours
3. Pictoreal blood loss assessment score > 100
4. Flooding or gush sensation
5. Leakage from Protection
6. Diagnosed with anaemia

44. Menstrual calender

46. Physical Examination
 General physical
 Vital signs : tachycardia , pale
 Obese ,Acne ,Hirsuitism …..PCOs
 Bruises ,Echymosis ….bleeding disorder
 Enalrged thyroid gland
 Breast show galactorrhea
 Pelvic Examination
 External
 Speculum with Pap test, if needed*
 Bimanual

47. Laboratory Tests
1. Pregnancy test (blood or urine)
2. Complete blood count , serum ferritin
3. Targeted screening for bleeding disorders (when indicated)† :
Prothrombine time and concetration, platelet function test,
Vonwillebrand factor
4. Thyroid-stimulating hormone level
5. Serum Prolactin level
6. FSH , LH
7. Chlamydia trachomatis

48. ACOG 2013

49. Indications of Targeted screening for bleeding disorders
(ACOG 2013)
Heavy menstrual bleeding since menarche
One of the following:
1. Postpartum hemorrhage
2. Surgery-related bleeding
3. Bleeding associated with dental work
Two or more of the following symptoms:
1. Bruising one to two times per month
2. Epistaxis one to two times per month
3. Frequent gum bleeding
4. Family history of bleeding symptoms

50. NICE 2018
 Do not routinely carry out a serum ferritin test for women with HMB
 Do not carry out female hormone testing for women with HMB.
 Do not carry out thyroid hormone testing for women with HMB unless
other signs and symptoms of thyroid disease are present.
 Testing for coagulation disorders (for example, von Willebrand's disease)
should be considered for women who:
1. have had HMB since their periods started and
2. have a personal or family history suggesting a coagulation disorder

51. Available Diagnostic or Imaging Tests (when indicated)
1. Saline infusion sonohysterography
2. Transvaginal ultrasonography
3. Magnetic resonance imaging
4. Hysteroscopy
NICE 2018

52. ACOG 2013

53. Available Tissue Sampling Methods (when indicated)
typically performed for select patients with HMB with risk
factors, or suspicion, for uterine malignancy
1. Office endometrial biopsy
2. Hysteroscopy directed endometrial sampling (office or
operating room

55. High risk for Endometrial malignancy
1. Increasing age
2. Unopposed estrogen therapy
3. Tamoxifen therapy
4. Early menarche
5. Late menopause (after age 55)
6. Nulliparity
7. Polycystic ovary syndrome (chronic anovulation)
8. Obesity
9. Lynch syndrome (hereditary nonpolyposiscolorectal cancer)
10. Family history of endometrial, ovarian, breast, orcolon cancer

56. Treatment of Acute and
chronic AUB

58. Treatment of Acute severe HMB
ACOG 2013

59. Establish hemodynamic stability
Exclude pregnancy
Identify the source of bleeding
Evaluate the volume of blood loss
Medical management should be the initial treatment for most
patients, if clinically appropriate. Options include
1. IV conjugated equine estrogen,
2. Multi-dose regimens of Ocs
3. Oral progestins
4. Tranexamic acid.
Decisions should be based on the patient’s medical history and
contraindications to therapies.

62. Patients at high risk for thrombosis
 Estrogen therapy and tranexamic acid are contraindicated in
patients at a high risk of thrombosis
Once the acute bleeding episode has been controlled,
transitioning the patient to long-term maintenance therapy is
recommended.

63. Role of intrauterine tamponade
Intrauterine tamponade may be used in conjunction with administration
of blood products to stabilize the patient while more definitive therapy
Surgical options include
1. Dilation and curettage (D&C),
2. Endometrial ablation,
3. Uterine artery embolization
4. Hysterectomy.
The choice of surgical modality (eg, D&C versus hysterectomy) is
based on mentioned factors plus the patient’s desire for future fertility

64. Specific treatments,
Hysteroscopy with D&C, polypectomy, or myomectomy, may
be required if structural abnormalities are suspected as the
cause of acute AUB
Endometrial ablation,
• should be considered only if other treatments have been
ineffective or are contraindicated, and it should be performed
• only when a woman does not have plans for future
childbearing
• when the possibility of endometrial or uterine cancer has
been reliably ruled out as the cause of the acute AUB

65. ACOG 2022
Hemodynamically unstable patients acute uterine
bleeding :Initial stabilization includes obtaining vascular
access and blood product replacement. 'Stabilizing the
patient‘ above.For most patients, we suggest uterine
curettage rather than medical therapy
Uterine curettage can be performed rapidly and is both
diagnostic and therapeutic(cessation or decreased
bleeding is expected in less than one hour).
NB : Patients with a suspected uterine arteriovenous malformation
may be managed differently.

66. Intrauterine tamponade may be used in conjunction
with administration of blood products while more
definitive therapy (eg, transfer to a high-acuity setting,
preparation for uterine curettage, arrival of a surgeon)
is implemented, or after completion of uterine
curettage should bleeding continue.
ACOG 2022

67. ACOG 2022
For patients with persistent bleeding after uterine
curettage or prevention of recurrent bleeding, or for
those in whom a waiting period of three or more hours is
not likely to result in the need for additional blood
product transfusion or medical complications, we suggest
intravenous conjugated equine estrogens (CEE) alone
rather than othe rmedical or surgical therapy

68. ACOG 2022
For hemodynamically stable patients with acute
uterine bleeding we suggest high-dose combined
oral contraceptives (OCs) rather than treatment
with high-dose oral estrogens alone, progestins, or
tranexamic acid

69. ACOG 2022
For patients in whom medical therapy is contraindicated
or unsuccessful, we suggest endometrial ablation rather
than uterine curettage or uterine artery embolization
(UAE). However, ablation should only be performed in
patients in whom malignancy has been excluded and in
those who have completed childbearing. For patients who
have not completed childbearing, uterine curettage is
preferred

70. Treatment of Chronic uterine bleeding

71. Non-hormonal treatments for abnormal uterine bleeding
due to ovulatory dysfunction have fewer risks and adverse
effects than hormone therapy and can be given
intermittently, when bleeding occurs. They are used mainly
to treat women who desire pregnancy, who wish to avoid
hormone therapy, or who have heavy regular bleeding
(menorrhagia). Choices include
1. Nonsteroidal anti-inflammatory drugs (NSAIDs), which
reduce bleeding by 25 to 35% and relieve dysmenorrhea
by reducing prostaglandin levels
2. Tranexamic acid, which inhibits plasminogen activator,
reducing menstrual blood loss by 40 to 60%

72. B- Hormone therapy
(eg, oral contraceptives, progestogens, a long-acting progestin-
releasing intrauterine device [IUD]) is often tried first in women
who want contraception or who are perimenopausal.
This therapy does the following:
Suppresses endometrial development
Reestablishes predictable bleeding patterns
Decreases menstrual flow
Hormone therapy is usually given until bleeding has been
controlled for a few months.

73. Oral contraceptives (OCs) are commonly given.
OCs, used cyclically or continuously, can control abnormal uterine bleeding due
to ovulatory dysfunction:
 Decrease menstrual blood loss by 40 to 50%
 Decrease breast tenderness and dysmenorrhea
 Decrease risk of uterine and ovarian cancer
 Combination formulations consisting of an estrogen and a progestin or a
progestin alone may be used. Risks of an OC depend on the type of OC,
dose, duration of use, and patient factors.

74.  If patients using cyclic progestins or progesterone wish to prevent
pregnancy, contraception should be used. Contraceptive options
include
1. levonorgestrel-releasing IUD: It is effective in up to 97% by 6
months, provides contraception, and relieves dysmenorrhea.
2. Depot medroxyprogesterone acetate injections: They cause
amenorrhea and provide contraception but may cause irregular
spotting and reversible bone loss.

75. A progestogen can be used alone in the following cases:
1. Estrogen is contraindicated (eg, for patients with cardiovascular risk
factors or prior deep vein thrombosis).
2. Estrogen is declined by the patient.
3. Combination OCs are ineffective after about 3 months of use.
Withdrawal bleeding may be more predictable with cyclic progestin
therapy
1. (medroxyprogesterone acetate 10 mg/day orally or norethindrone
acetate 2.5 to 5 mg/day orally) given for 21 days a month than with a
combination OC.
2. Cyclic natural (micronized) progesterone 200 mg/day for 21 days a month

76. Other treatments that are occasionally used to treat abnormal
uterine bleeding due to ovulatory dysfunction include
1. Danazol:
 It reduces menstrual blood loss (by causing endometrial atrophy)
but has many androgenic adverse effects, which may be lessened by
using lower doses or a vaginal formulation.
 To be effective, danazol must be taken continuously, usually for
about 3 months.
 It is usually used only when other forms of therapy are
contraindicated.

77. 2. Gonadotropin-releasing hormone (GnRH) agonists:
 These drugs suppress ovarian hormone production and cause
amenorrhea; they are used to shrink fibroids or the endometrium
preoperatively.
 However, their hypoestrogenic adverse effects (eg, osteoporosis)
limit their use to 6 months; they are often used concurrently with
low-dose hormone therapy.
3. Ergot derivatives
are not recommended for treatment of abnormal uterine bleeding due
to ovulatory dysfunction because they are rarely effective.

78. If pregnancy is desired and bleeding is not heavy, ovulation
induction with clomiphene (50 mg orally on days 5 through 9 of
the menstrual cycle) can be tried.

79. Hysteroscopy with dilation and curettage (D & C)
 may be therapeutic as well as diagnostic;
 it may be the treatment of choice when anovulatory bleeding is
severe or when hormone therapy is ineffective.
 Structural causes such as polyps or fibroids may be identified or
removed during hysteroscopy.
 This procedure may decrease bleeding but, in some women,
causes amenorrhea due to endometrial scarring (Asherman
syndrome).

80. Endometrial ablation
(eg, laser, rollerball, resectoscopic, thermal, or freezing)
may help control bleeding in 60 to 80%.
Ablation is less invasive than hysterectomy, and the
recovery time is shorter. .
 Endometrial ablation does not prevent pregnancy.
Pregnancy rates may be as high as 5% after ablation.
Ablation causes scarring which may make sampling the
endometrium difficult later.

81. Hysterectomy, abdominal or vaginal,
 may be recommended for patients who decline hormone
therapy or who, despite other treatments, have
symptomatic anemia or poor quality of life caused by
persistent, irregular bleeding.