The document discusses abnormal uterine bleeding, providing definitions and classifications including the PALM-COEIN system. It covers the evaluation, differential diagnosis, and management of abnormal uterine bleeding, both acute and chronic. The evaluation involves history, exam, labs, imaging and other tests to determine the cause, while management depends on whether it is acute or chronic and may involve medical options like hormones or surgery depending on the situation.

1. ABNORMAL UTERINE
BLEEDING
DR KD DELE
DEPT. OF FAMILY MEDICINE
DORA NGINZA HOSPITAL

2. INTRODUCTION

3. Introduction:
Abnormal
Uterine Bleeding
Most common complaint in Gynecological
and Family practice.
It accounts for 70% of all Gynaecologic
Consults.
Affects 1/3 of women at some stage in their
life.
Key to management include:
•establishing cause
•instituting appropriate therapy

4. Normal Uterine Bleeding
Age of patient: reproductive-aged women (from menarche to menopause)
Frequency / Cycle Length: 21 days to 35 days interval
Duration of Flow: 2 days to 8 days; usually 4-6 days
Flow: Average of 35 ml although 10ml – 80ml is considered normal.
(1 normally soaked regular pad / tampon holds +/- 5mls of blood.
However, depending on the brand, a pad can hold between 5 and 15 ml of
blood)

5. Menstrual
Assessment
Chart

6. Volume of
blood flow
assessed by
number of pads
/ tampons used

7. Normal Uterine Bleeding
 Menarche:
• 9-16 years (mean 12,8) usually 2,3 years after 1st sign of breast development.
 Reproductive years:
• Cycle length 23-39 days (mean 30).
• Duration of menstrual bleeding 2-8 days (mean 5).
• Normal blood loss 10-55ml (=/< 80mls)
 Menopause:
• 48-55 years (mean 51,3); 40 – 48 = early menopause

8. Normal Menstrual Cycle
• Menstruation is a cyclic physiological phenomena
• Starting at the age of Menarche (10-12years) till establishment of
Menopause (45-55 yrs.).
• It is regulated by hypothalmo-pituitary- ovarian hormones secreted in
pulsatile and cyclic pattern.
• Also influenced by endometrial response to the Oestrogen & Progesterone
hormones and coagulation cascade.

10. Regulation By
Hypothalmo-
pituitary- Ovarian
Hormones

11. Phases of Menstrual Cycle
• Follicular
• Begins with Menses ends with luteinizing (LH) hormone surge
• Ovulation (30-36 hours)
• Begins with LH surge and ends with ovulation
• Luteal (14 days)
• Begins with the end of the LH surge and ends with onset of menses

13. Phases of
Menstrual
Cycle

14. Arrest of Menstrual bleeding
Haemostasis by
platelet plug and
clot formation:
important in the
functional
endometrium
Prostaglandin
dependent
vasoconstriction
important in the
basalis layer
Tissue Repair
the raw area of remaining
basal endometrium is
completely epithelized
under Estrogen effect

15. I’m on my
period….

16. ABNORMAL UTERINE BLEEDING

17. Abnormal Uterine Bleeding
• What is abnormal uterine bleeding?
• Bleeding from the uterine corpus that is abnormal in regularity,
volume, frequency or duration, and occurs in absence of pregnancy
• 3 Main Factors: Volume, Duration and Frequency
ACOG: American Congress of Obstetricians and Gynecologists, 2013

18. AUB: OLDER CLASSIFICATION

19. AUB vs DUB: Why Talk About It?
• Prior definitions had some gray areas.
• “Dysfunctional uterine bleeding” is a term used synonymously with AUB in
literature…
• But unlike AUB, DUB is a diagnosis of exclusion for which no cause was
identifiable
• FIGO in 2011 eliminated misleading terms
• Articles also unanimously recommend discontinuing use of the term DUB.
FIGO: International Federation of Gynecology and Obstetrics, 2011

20. Some Older classification/Clinical Types
• Dysfunctional Uterine Bleeding: uterine bleeding, diagnosis of exclusion
• Menorrhagia: heavy menstrual bleeding (>80 mL)
• Metrorrhagia: bleeding between periods – irregular intervals, excessive
flow and duration
• Polymenorrhea: bleeding that occurs more often than every 21 days
• Oligomenorrhea: bleeding that occurs at intervals longer than every 35
days

21. Some Older classification/Clinical Types
• Amenorrhea: no menstruation. primary (if no menses by age of 16 years)
and secondary (if no menses for at least 3 months after menarche has
occurred).
• Oligomenorrhoea: normal menstrual duration and intensity but decreased
frequency. lengthened cycle >39 days. usually associated with anovulation
• Post-menopausal bleeding: vaginal bleeding in a woman who has reached
menopausal age OR had 6 months of amenorrhea preceding the episode of
vaginal bleeding.

22. Old Definitions
Polymenorrhoea:
Menstruation with normal duration
and flow, but shorted cycle with intervals < 25 days
Menorrhagia/ Hypermenorrhoea:
Heavy cyclical bleeding - increased duration and/or increased flow
Metrorrhagia: acyclical, irregular or continuous
Uterine bleeding independent of menstrual pattern
Menometrorrhagia:
•Increased flow during menstruation and between menstrual periods
Dysfunctional Uterine Bleeding

23. AUB: FIGO CLASSIFICATION
PALM-COEIN

24. PALM-COEINClassification
• A new classification system known is by acronym “PALM-COIEIN”
• It classifies by bleeding pattern & aetiology.
• It was introduced by FIGO in 2011, to create universal nomenclature system to
describe uterine bleeding abnormalities in reproductive-aged women
• ACOG also supported adopting PALM-COEIN classification/nomenclature to
standardize terminology used to describe AUB
FIGO: International Federation of Gynecology and Obstetrics; ACOG: American Congress of Obst & Gyne

25. • Keywords: Menstrual Disorders, Menorrhagia, Heavy Uterine Bleeding, Classification

26. FIGO Classifications cont.
• Abnormal Uterine Bleeding (AUB): quantity, regularity and/or timing
• Acute AUB: episode of heavy bleeding that is sufficient amount to require
immediate intervention to prevent further blood loss
• Chronic AUB: AUB present for most of previous 6 months
• Acute AUB can be spontaneous or in context of chronic AUB

27. FIGO Classifications cont.
• Intermenstrual bleeding (IMB): bleeding between clearly defined cycles
• Heavy menstrual bleeding (HMB): excessive menstrual blood loss affecting
quality of life – physical, emotional, social, material
• Objective HMB: blood loss > 80ml/ cycle. 60% of these women will have
evidence of iron deficiency anaemia.
• Subjective HMB: 50% of women presenting with heavy menses will have
measured blood loss within normal limits but must still be considered
abnormal, and investigated accordingly.

28. AUB: FIGO CLASSIFICATION
PALM-COEIN

29. PALM-COEIN Classification; FIGO: International Federation of Gynecology and Obstetrics, 2011

30. PALM-COEINClassification
Structural Imaging, Histology Or Both
• Polyp
• Adenomyosis
• Leiomyoma
• Malignancy and hyperplasia
Unrelated To Structural Abnormalities
• Coagulopathy
• Ovulatory disorders
• Endometrium
• Iatrogenic
• Not classified

31. FIGO
CLASSIFICATION

32. PALM COEIN

33. Distribution
of study
population
based on
PALM-COEIN
classification
PALM-COEIN FIGO Classification for diagnosis of Abnormal Uterine Bleeding: Practical Utility of same at Tertiary Care
Centre in North India. Priyanka Goel, Samta Bali Rathore. Published 2016

34. AUB: Differential Diagnoses
• Cervix: Polyp, cervicitis, ectropion, dysplasia, invasive carcinomas
• Uterus: FIBROIDS (1/3 of patients);
• Uterus: endometritis, endometrial polyp, endometriosis, adenomyosis,
adenocarcinoma
• Ovary: Anovulatory cycles, Ovarian failure, Polycystic ovaries, Obesity
• Ovarian Tumours: germ cell tumours, sex cord (stromal) tumours
• Iatrogenic: Hormonal Contraceptives, IUCD, Hormone replacement therapy,
Phytoestrogens, ginseng, SSRIs

35. AUB: Differential Diagnoses, cont.
• Prolactinomas
• Thyroid disease
• Coagulation defects: ITP; von Willebrand’s Disease (inherited disorder)
• Hepatic and renal failures
• Trauma
• Foreign bodies
• Pregnancy related complications: ectopic pregnancy, inevitable abortions, GTD

36. Common Differential by Age
13-18 19-39 40-Menopause
Anovulation
OCP
Pelvic infection
Coagulopathy
Tumor
(the most common cause
among Adolescents is
persistent anovulation due to
immaturity/dysregulation of
the H-P-ovarian axis)
Pregnancy
Structural Lesions (leiomyoma,
polyp)
Anovulatory cycles (PCOS)
OCP
Endometrial hyperplasia
Endometrial cancer (less common)
Anovulatory bleeding
Endometrial hyperplasia and
carcinomas
Endometrial atrophy
Leiomyoma

37. AGE GROUP AETIOLOGY TREATMENT
Prepubertal child
(< 10 years)
• Precocious puberty
• Non-menstrual bleeding
e.g.
• foreign bodies, tumours
• Iatrogenic (taking
mother’s OCP)
• assess secondary sexual
characteristics
• proper exam to exclude local
causes
• direct treatment at cause
Adolescent anovulatory (AUB) usually • exclude a pathological cause
• treat cause if found
• if DUB(AUB) and mild, reassure,
counsel, haematinics, menstrual
calendar
• if DUB(AUB) and severe, admit,
FBC, exclude blood dyscrasias,
blood transfusion, COC/cyclical
progestogens, haematinics

38. AGE GROUP AETIOLOGY TREATMENT
Reproductive
female
• Benign polyps
• Fibroids
• PID
• Abnormal pregnancy
• Ovulatory DUB (AUB)
• Examination
• Pregnancy test
• Pap smear
• Ultrasound
• Hysteroscopy
• Endometrial sampling
• Direct treatment of
underlying cause
• If tests normal, COC
• If bleeding continues,
exclude blood dyscrasias,
thyroid abnormalities.

39. AGE GROUP AETIOLOGY TREATMENT
Perimenopausal
Female
• Anovulatory DUB
(AUB)
• Organic disease
• Exam
• Pap Smear
• Endometrial sampling
• Hysteroscopy, D&C
• Treat particular cause
• If DUB(AUB), may settle after D&C
• If endometrial hyperplasia after DD&C
and is complex/atypical 
hysterectomy
• If simple hyperplasia progestogens
• If problem recurs  hysterectomy
Postmenopausal
Female
• Vaginal atrophy
• Cervical ca
• Endometrial ca
• HRT
• Topical oestrogen
• Hysterectomy & bilateral
oophorectomy
• Chemo-radiation
• Palliation

40. DIAGNOSIS

41. Assessment of Patient with Acute AUB
• General Approach:
i. Assess rapidly the clinical picture to determine patient’s acuity
ii. Determine most likely cause of bleeding
iii. Choosing the most appropriate treatment for the patient

42. History: Focus
• 1. guided by palm-coein system
• 2. focus on details of current bleeding episodes – length, duration, amount,
presence of clots, and related symptoms e.g. dizziness
• 3. past menstrual and gynaecological history; pap smears, recent surgery,
previous medical treatment for gynaecological disorders.
• 4. Sexual history and contraceptive hormone use.
• 5. medical history, medications: warfarin, heparin, NSAID, OCP, ginseng
• 6. Personal/family history of bleeding disorders family history

43. Physical Examination: Focus
• 1. sign of acute blood loss e.g. Vital signs, evidence of hypovolemic shock
• 2. findings suggesting the aetiology – “palm coein” e.g. obesity and hirsutism in
PCOS; cold/heat intolerance and proptosis in thyroid dysfunction; petechiae in
bleeding disorder; splenomegaly - haematological disorders
• 3. confirm it is bleeding from genital tracts (and not other places – pelvic
examination, speculum and bimanual
• 4. differentiate between acute and chronic AUB e.g. admit, refer or discharge

44. Labs: Acute AUB
• Pregnancy test (b-hcg)
• FBC, UEC
• Group and cross match blood
• Coagulation study – e.g. PTT/INR; when indicated – vW-factor assay, ristocetin
cofactor assay, Factor VIII etc.
• TSH, LFT, Nutritional/iron studies, renal, adrenal function in most patients

45. Labs: Chronic AUB
• Pap Smear / Cervical cytology
• Hormonal Assay – FSH/LH, Prolactin levels,
• Nutritional/iron studies
• Gonorrhea/Chlamydia in high risk patients
• Retroviral screen
• Endometrial biopsy / endometrial sampling in an older patient

46. Imaging
• Pelvic Ultrasound
• TVUS: (transvaginal US is the primary imaging of uterus for evaluation of AUB)
• Sono-hysterography (aka saline infusion sonohysterography)
• Hysteroscopy
• MRI

47. Evaluation cont.
Others:
• Cytopathology:
• Pap smear,
• Cervical biopsy,
• Endometrial biopsy
• Surgical
• D&C hysteroscopy

48. Uterine Evaluation

49. MANAGEMENT

50. Management: General Considerations
• 1. Medical management should be initial treatment for most patients
• 2. Need for surgery (including type of surgery) is based on various factors:
• stability of patient
• severity of bleed
• contraindications to med management,
• underlying cause
• desire for future fertility
• 3. Long term maintenance therapy after acute bleed is controlled

51. Initial Approach
• Determine if AUB acute vs. chronic
• If acute AUB, are there signs of hypovolemia/hemodynamic instability?
• If yes, resuscitate:
• IV access with 1 to 2 large bore IV;
• Crystalloids vs colloids
• Prepare for blood transfusion +/- clotting factor replacement

52. • Once stable, evaluate etiology (PALM-COEIN)
• Determine Treatment

54. Medical Management: Hormonal
• First line medical therapy for AUB (for patients not known with bleeding
disorders)
Treatment options:
• 1. Combined oral contraceptive pills – different combination
• 2. Progesterone therapy
• (medroxyprogesterone acetate – Cyclic Provera 2.5-10mg daily for 10-14 days /
Continuous Provera 2.5-10mg daily / DepoProvera® 150mg IM every 3 months /
Levonorgestrel IUCD 5 years / Implants )

55. Medical Management: Hormonal cont.
• 3. Conjugated oestrogen (e.g. IV estrogen 25mg qid or Premarin 1.25 po qid
x 24hrs)
• 4. Progestin: Local – Mirena (IUCD), 20mcg levonorgestrel daily 5years
• 5. Progestin: Implantable – Implanon (etonogestrel,3rd generation
progestin), daily for 3years
• 6. GnRH analogue
• 7. Danazol

56. Medical
Management:
Hormonal
cont.

57. Medical Management: Hormonal cont.
Note: Long term therapy: levonorgesterel IUD, OCPs,
progestin (PO or IM);
Unopposed oestrogen should not be used long term
OCPs are generally considered effective in
management of both ovulatory and Anovulatory AUB

58. Medical Management: Antifibrinolytics
• They are used as inhibitors of fibrinolysis without significant increase in GIT
side effects
• They reduce virtually all cases bleeding by 40-60%
• Examples: Tranexamic acid (Cyclokapron) and aminocaproic acid
• Tranexamic acid 1g QID x 4 days cycle for ovulatory DUB
• MOA – prevent plasminogen activation and decrease fibrinolysis, so
decreasing bleeding

59. Medical Management: NSAIDs
• Cyclo-oxygenase inhibitors (NSAIDS)
• Mode of action unclear, ?Vasoconstriction, ?suppress prostaglandin
synthesis
• Examples:
• Trials usually used Mefanamic acid (Ponstan) 250-500mg 2-4x daily,
• Also naproxen and ibuprofen

60. Medical Management: Summary
Fe (Iron)
therapy
01
Anti-
fibrinoly
tics
02
Cyclo-
oxygena
se
inhibitor
s/
NSAIDS
03
Progesti
n
04
Continuo
us / cyclic
05
Local
06
Implanta
ble
07
Oestrog
ens plus
progesti
n
08
Androge
ns
09
GNRH
agonists
and
antagoni
sts
10

61. Surgical Management
• . Need for surgery (including type of surgery) is based on various factors:
• stability of patient
• severity of bleed
• contraindications to medical management,
• patient not responding to medical management
• underlying cause
• desire for future fertility

62. Surgical Management Options
Dilatation &
Curettage
Endometrial
Ablation
Uterine Artery
Embolization
Hysterectomy
Others include:
•hysteroscopy with D&C
•polypectomy
•myomectomy

63. References
Committee Opinion no 557: management of acute abnormal uterine
bleeding in nonpregnant reproductive-aged women. Obstet Gynecol.
2013 Apr;121(4):891-6. doi: 10.1097/01.AOG.0000428646.67925.9a
Malcolm G. Munro, Hilary O.D. Critchley, Michael S. Broder, Ian S.
Fraser (2011). FIGO classification system (PALM-COEIN) for causes of
abnormal uterine bleeding in nongravid women of reproductive age.
International Journal of Gynecology and Obstetrics 113 (2011) 3–13

64. THANK YOU!

65. CASE STUDY:
THE LIFE OF THEMBI

66. QUESTION 1
Thembi is a 8 year old girl. Her mother brings her to the ED because she
has noticed blood on her pant.
What are the potential causes?
• Foreign Bodies – most common
• Sexual Abuse
• Tumors – uncommon
• Early menarche

67. How to assess her?
• History :
• caregiver, onset, duration, medication (coc)
• Examination:
• Secondary sexual characteristics, bruises in and around the perineum

68. Investigation
• EUA – using nasal speculum
• Vaginal Swabs
• Rape Kit if suspicion of abuse

69. QUESTION 2
Thembi, now 17yrs old P0 presents with the complaint of heavy, irregular
periods since her menarche at 16yrs of age.
She has recently started sexual activity and she is not on contraceptives.
How do we assess her?
• Urinary/Blood β-HCG (i.e. urine/Blood pregnancy test)

70. Pregnancy Test Positive
• threatened miscarriage
• inevitable miscarriage
• incomplete miscarriage
• ectopic pregnancy
• induced termination of pregnancy
• gestational trophoblastic disease
• antepartum haemorrhage

71. Pregnancy Test Negative
• genital tract pathology
• congenital uterine abnormalities
• trauma
• infection e.g. PID
• endometriosis/adenomyosis
• benign neoplasms e.g. polyps, fibroids, endometrial hyperplasia
• malignant neoplasms e.g.. carcinomas, sarcomas

72. Pregnancy Test Negative, cont.
• Iatrogenic: hormones; anticoagulants - needs a more complete history
• endocrine causes: Hypothyroidism; adrenal disorders
• systemic disorders: Hepatic; Renal; obesity
• blood dyscrasias: Van Willebrand’s; thrombocytopenia etc.

73. Consideration
• For Thembi, take into consideration
• her young age,
• hasn’t completed her family,
• expectant and medical management are most appropriate –
• i.e. hematinic and hormone therapy (COC, cyclical progestogens)
should be used 1st.

74. QUESTION 3
• Suppose Thembi is a 36-year-old P1G1.
• She is sexually active with HMB and post-coital bleeding.

75. What are the potential causes of the problem?
• Most likely to be pregnancy related OR
• Genital tract pathology
• Other likely causes:
• Cervical – dysplasia, cervicitis, malignancy
• Endometrial – endometritis, hyperplasia, polyps, fibroids.

76. QUESTION 3 cont.
After thorough history, examination, and investigation, Thembi was
found to have CINI
• She was then referred to GOPD for further repeat test in 6 months,
assessment and staging.
• P.S.: in our environment premalignant and malignant cervical disease
have high prevalence.

77. QUESTION 4
• Thembi is a 65yrs old female, 10yrs postmenopausal not on HRT
presenting with complain of 3 days history of PV bleeding.

78. What to consider here?
• Cancer until proven otherwise:
• Cervical ca; Endometrial ca
Others
• Systemic:
• Hematological; Hepatic
• Local:
• Infection e.g. viral, bacterial, fungal;
• Vaginal atrophy;
• Trauma
• Iatrogenic: Hormone; warfarin

79. Assessment:
• History
• Examination: general, focused
• Investigation: speculum, PAP, endometrial sampling, trans-vaginal
ultrasound, DD&C

80. Management:
• Hemodynamic stability
• Treat underlying cause: topical estrogen, antifungal, correct abnormal
INR and PTT.
• If ca. cervix or endometrial  staging with CXR, AUS, CT abdomen 
treat accordingly