Abnormal Uterine Bleeding

AUB applies to nongravid reproductive-aged patients with bleeding abnormal in regularity, frequency, duration, or volume. A normal cycle interval is 24 to 38 days, duration is 2 to 7 days, and estimated blood loss is 5 to 80 mL; deviations should prompt a structured AUB assessment rather than use of obsolete terms such as dysfunctional uterine bleeding. Wiley+1WileyFIGO Systems 1 and 2 - Obstetrics and GynecologyPubMedAbnormal Uterine Bleeding - StatPearls - NCBI Bookshelf - NIH

At the initial encounter, determine whether bleeding is uterine rather than cervical, vaginal, vulvar, urinary, or rectal. Speculum examination should identify cervical lesions, vaginitis, trauma, foreign body, ulceration, atrophy, prolapse-related erosion, or genital neoplasia; these entities require cause-specific evaluation rather than a uterine bleeding algorithm. PubMed+1PubMedVaginal Bleeding - StatPearls - NCBI BookshelfPubMedAnovulatory Bleeding - StatPearls - NCBI Bookshelf

Document cycle timing, duration, volume, intermenstrual or postcoital bleeding, medication exposure, and reproductive goals. Irregular, unpredictable, heavy, or prolonged bleeding favors ovulatory dysfunction, whereas predictable cyclic heavy or prolonged bleeding after exclusion of other causes supports endometrial dysfunction. PubMed+1PubMedDiagnosis and Management of Formerly Called “Dysfunctional Uterine Bleeding” According to PALM-COEIN FIGO Classification and the New GuidelinesPubMedAnovulatory Bleeding - StatPearls - NCBI Bookshelf In perimenopause, intervals shorter than 21 days are more common early in the transition and intervals longer than 36 days later in the transition, but physiologic transition does not eliminate the need to evaluate hyperplasia or cancer risk. PubMedPubMedManagement of the Perimenopause - PMC - NIH

In perimenopausal AUB, hormonal transition can mimic or conceal pathologic bleeding; use PALM-COEIN and pursue evaluation for hyperplasia or cancer when clinical context warrants. FIGO-associated literature identifies endometrial tissue testing as a first-line approach in perimenopausal AUB, particularly before hormonal treatment when a premalignant or malignant endometrial process must be excluded. PubMed+1PubMedManagement of the Perimenopause - PMC - NIHPubMedFIGO’s PALM–COEIN Classification of Abnormal Uterine Bleeding: A Clinico-histopathological Correlation in Indian Setting

For postmenopausal bleeding, transvaginal ultrasound can triage endometrial evaluation. An endometrial thickness of 4 mm or less is associated with a malignancy risk of approximately 1 in 917; pooled data cited in this review found 3 cancers among 2,752 patients with bleeding and an endometrial echo of 4 mm or less. ScienceDirectScienceDirectThe role of transvaginal ultrasound or endometrial biopsy in the evaluation of the menopausal endometrium - ScienceDirect A technically unreliable or nonvisualized endometrial echo should not be treated as a negative test; saline infusion sonohysterography can clarify the cavity. ScienceDirectScienceDirectThe role of transvaginal ultrasound or endometrial biopsy in the evaluation of the menopausal endometrium - ScienceDirect

Outpatient endometrial biopsy is useful when an adequate specimen is obtained, particularly for ruling in endometrial cancer: pooled positive and negative likelihood ratios were 66.48 and 0.14, respectively. ScienceDirectScienceDirectTriage of abnormal postmenopausal bleeding: A comparison of endometrial biopsy and transvaginal sonohysterography versus fractional curettage with hysteroscopy A benign or negative blind biopsy does not end the evaluation of persistent AUB, because focal lesions may be missed; proceed to cavity-focused imaging or hysteroscopy when bleeding continues or imaging suggests focal pathology. ScienceDirect+2ScienceDirectTriage of abnormal postmenopausal bleeding: A comparison of endometrial biopsy and transvaginal sonohysterography versus fractional curettage with hysteroscopyScienceDirectA comparison between ultrasonography and hysteroscopy in the diagnosis of uterine pathology - ScienceDirectScienceDirectThe accuracy of endometrial biopsy and saline sonohysterography in the determination of the cause of abnormal uterine bleeding - ScienceDirect

Transvaginal ultrasound is the initial anatomic test for suspected PALM causes, but a suspected lesion on ultrasound should prompt a test that better defines the cavity when management depends on focal versus diffuse disease. Diagnostic hysteroscopy improves diagnostic accuracy for uterine pathology beyond ultrasound in selected patients with AUB or suspicious sonographic findings. ScienceDirectScienceDirectA comparison between ultrasonography and hysteroscopy in the diagnosis of uterine pathology - ScienceDirect

Saline infusion sonohysterography provides real-time transvaginal imaging during sterile saline instillation and is particularly useful for differentiating focal from diffuse endometrial and subendometrial lesions. It is more accurate than transvaginal sonography for submucosal fibroids and endometrial polyps and can clarify endometrial or periendometrial processes. pubs rsna+1pubs rsnaSonohysterographic Findings of Endometrial and Subendometrial ConditionsRadioGraphicsScienceDirectSaline infusion sonohysterography (SIS) - ScienceDirect

Where pathology must be established, the combination of saline infusion sonohysterography and endometrial biopsy offers a high-sensitivity office approach. In a prospective cohort completing definitive reference testing, the combined strategy had 97.0% sensitivity and 94.3% negative predictive value for abnormal pathologic findings, although specificity was 70.2%. ScienceDirectScienceDirectThe accuracy of endometrial biopsy and saline sonohysterography in the determination of the cause of abnormal uterine bleeding - ScienceDirect A positive or persistent focal finding still requires a directed procedural plan rather than reassurance from a nonspecific test result. ScienceDirect+1ScienceDirectA comparison between ultrasonography and hysteroscopy in the diagnosis of uterine pathology - ScienceDirectScienceDirectThe accuracy of endometrial biopsy and saline sonohysterography in the determination of the cause of abnormal uterine bleeding - ScienceDirect

AUB-O results from absent ovulation and consequent lack of progesterone exposure. Continuous unopposed estrogen stimulation produces an endometrium that is proliferative, fragile, vascular, and insufficiently supported by stroma, yielding irregular, often heavy or prolonged bleeding. PubMed+1PubMedDiagnosis and Management of Formerly Called “Dysfunctional Uterine Bleeding” According to PALM-COEIN FIGO Classification and the New GuidelinesPubMedAnovulatory Bleeding - StatPearls - NCBI Bookshelf The next step is to identify the driver of anovulation, including puberty, perimenopause, polycystic ovary syndrome, or thyroid disease, while excluding pregnancy, structural disease, and other PALM-COEIN causes. PubMed+1PubMedVaginal Bleeding - StatPearls - NCBI BookshelfPubMedAnovulatory Bleeding - StatPearls - NCBI Bookshelf

AUB-E is an exclusion diagnosis. The usual pattern is predictable, apparently ovulatory cycles with heavy or prolonged bleeding after exclusion of structural lesions, ovulatory dysfunction, and coagulopathy. Proposed mechanisms include altered local vasoconstrictors, accelerated endometrial clot lysis, and altered prostaglandin balance; infection or inflammation may also contribute. PubMedPubMedDiagnosis and Management of Formerly Called “Dysfunctional Uterine Bleeding” According to PALM-COEIN FIGO Classification and the New Guidelines A noncyclic pattern should redirect evaluation toward AUB-O, iatrogenic bleeding, structural pathology, or a nonuterine source. PubMed+2PubMedDiagnosis and Management of Formerly Called “Dysfunctional Uterine Bleeding” According to PALM-COEIN FIGO Classification and the New GuidelinesPubMedVaginal Bleeding - StatPearls - NCBI BookshelfPubMedAnovulatory Bleeding - StatPearls - NCBI Bookshelf

AUB-C requires deliberate recognition because coagulopathy is a distinct FIGO category and changes both procedural planning and medication choices. PubMed+1PubMedAbnormal Uterine Bleeding - StatPearls - NCBI Bookshelf - NIHPubMedVaginal Bleeding - StatPearls - NCBI Bookshelf Review the personal and family bleeding history, anticoagulant exposure, and prior hemostatic challenges; if concerning, arrange targeted laboratory evaluation and coordinate management before endometrial procedures or surgery.

For idiopathic heavy menstrual bleeding in a hemodynamically stable patient, medical therapy is generally first-line. PubMedPubMedTranexamic acid for the treatment of heavy menstrual bleeding: efficacy and safety - PubMed Oral tranexamic acid reduces menstrual blood loss by 26% to 60%; the reviewed regimen is 3.9 to 4 g/day for 4 to 5 days beginning on the first day of menses. PubMedPubMedTranexamic acid for the treatment of heavy menstrual bleeding: efficacy and safety - PubMed Do not use tranexamic acid with active thromboembolic disease; in the United States, a history of thrombosis or thromboembolism or an intrinsic thrombosis risk is also considered a contraindication. PubMedPubMedTranexamic acid for the treatment of heavy menstrual bleeding: efficacy and safety - PubMed

The levonorgestrel-releasing intrauterine system reduces menstrual blood loss more than tranexamic acid in heavy menstrual bleeding. PubMedPubMedTranexamic acid for the treatment of heavy menstrual bleeding: efficacy and safety - PubMed Select uterine-directed hormonal therapy only after completing the appropriate assessment for endometrial neoplasia or hyperplasia when the patient’s age, bleeding pattern, or clinical context makes tissue evaluation necessary. PubMedPubMedFIGO’s PALM–COEIN Classification of Abnormal Uterine Bleeding: A Clinico-histopathological Correlation in Indian Setting

When an intracavitary lesion is identified, hysteroscopy provides a diagnostic and potentially therapeutic route because it can improve recognition of uterine pathology and permits visually directed evaluation. ScienceDirect+1ScienceDirectA comparison between ultrasonography and hysteroscopy in the diagnosis of uterine pathology - ScienceDirectWileyDiagnostic hysteroscopy in abnormal uterine bleeding: a ... For persistent heavy AUB in patients who have completed childbearing, endometrial ablation is a minimally invasive option only after the underlying cause has been evaluated; it destroys the functional endometrium to reduce subsequent menstrual blood loss. PubMedPubMedEndometrial Ablation - StatPearls - NCBI Bookshelf Hysterectomy is definitive surgical management and has high patient satisfaction, but it is not fertility-sparing. PubMed+1PubMedClinical bleeding patterns and management techniques of abnormal uterine bleeding at a teaching and referral hospital in Western KenyaPubMedEndometrial Ablation - StatPearls - NCBI Bookshelf

Reassess the bleeding pattern, CBC when blood loss has been clinically significant, treatment adherence, and adverse effects after initiating medical therapy. Continued intermenstrual, irregular, or heavy bleeding should trigger diagnostic reconsideration rather than repeated empiric treatment, especially if anovulatory bleeding was presumed without definitive exclusion of endometrial pathology. PubMed+2PubMedDiagnosis and Management of Formerly Called “Dysfunctional Uterine Bleeding” According to PALM-COEIN FIGO Classification and the New GuidelinesPubMedFIGO’s PALM–COEIN Classification of Abnormal Uterine Bleeding: A Clinico-histopathological Correlation in Indian SettingPubMedAnovulatory Bleeding - StatPearls - NCBI Bookshelf

Escalate to saline infusion sonohysterography or hysteroscopy when transvaginal ultrasound does not adequately visualize the endometrium, a focal lesion is suspected, outpatient biopsy is inadequate, or bleeding persists after a negative biopsy. ScienceDirect+3ScienceDirectTriage of abnormal postmenopausal bleeding: A comparison of endometrial biopsy and transvaginal sonohysterography versus fractional curettage with hysteroscopyScienceDirectA comparison between ultrasonography and hysteroscopy in the diagnosis of uterine pathology - ScienceDirectScienceDirectSaline infusion sonohysterography (SIS) - ScienceDirectScienceDirectThe role of transvaginal ultrasound or endometrial biopsy in the evaluation of the menopausal endometrium - ScienceDirect This approach addresses the principal blind-sampling limitation: a focal lesion may remain untreated or unsampled despite a nondiagnostic or benign global specimen. ScienceDirect+1ScienceDirectTriage of abnormal postmenopausal bleeding: A comparison of endometrial biopsy and transvaginal sonohysterography versus fractional curettage with hysteroscopyScienceDirectThe role of transvaginal ultrasound or endometrial biopsy in the evaluation of the menopausal endometrium - ScienceDirect

For patients proceeding to ablation or hysterectomy, confirm that the diagnostic workup has accounted for PALM-COEIN causes and that reproductive plans are documented. Endometrial ablation should follow, not substitute for, evaluation of the underlying AUB cause. PubMedPubMedEndometrial Ablation - StatPearls - NCBI Bookshelf