Vaginal bleeding - abnormal uterine bleeding
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Abnormal Uterine Bleeding (AUB)
Definition
AUB is bleeding from the uterine corpus that is abnormal in regularity, volume, frequency, or duration in the absence of pregnancy, present for at least 6 months. It is an overarching clinical term that has replaced older, discarded terminology (menorrhagia, metrorrhagia, dysfunctional uterine bleeding, menometrorrhagia, etc.).
Normal menstrual parameters (for comparison):
- Cycle interval: 24–38 days
- Duration: 4.5–8 days
- Blood loss: ≤30 mL; >80 mL is considered abnormal
— Tintinalli's Emergency Medicine, p. 649
FIGO Terminology (Current)
| Term | Definition |
|---|---|
| Heavy menstrual bleeding (HMB) | Excessive bleeding interfering with quality of life (replaces "menorrhagia") |
| Intermenstrual bleeding | Bleeding between normally timed menses (replaces "metrorrhagia") |
| Prolonged menstrual bleeding | Periods exceeding 8 days regularly |
| Irregular menstrual bleeding | Cycle variations >20 days over 1 year |
| Amenorrhea | Absent bleeding >6 months |
| Postmenopausal bleeding | Any bleeding >12 months after cessation of menses |
— Tintinalli's Emergency Medicine, p. 649
Classification: PALM-COEIN
The FIGO PALM-COEIN system classifies AUB causes into structural and nonstructural:
Structural (PALM)
| Cause | Notes | |
|---|---|---|
| P | Polyp | Endometrial/endocervical; benign epithelial proliferations; most common cause of intermenstrual bleeding in women >35; diagnosed by US or hysteroscopy |
| A | Adenomyosis | Endometrial glands within myometrium; causes heavy, painful menses |
| L | Leiomyoma | Uterine fibroids; structural cause not typical until mid-30s |
| M | Malignancy & hyperplasia | Endometrial carcinoma, cervical/vaginal tumors; endometrial hyperplasia from unopposed estrogen |
Non-structural (COEIN)
| Cause | Notes | |
|---|---|---|
| C | Coagulopathy | Up to 20% of women with heavy bleeding have an underlying disorder; von Willebrand disease is most common |
| O | Ovulatory dysfunction | Most common non-structural cause; anovulation at extremes of reproductive life |
| E | Endometrial | Primary endometrial disorder |
| I | Iatrogenic | Hormonal contraceptives, anticoagulants, SSRIs, tamoxifen, herbal supplements (e.g., ginseng) |
| N | Not otherwise classified |
— Tintinalli's Emergency Medicine, p. 649
Causes by Age Group
| Age Group | Most Common Causes |
|---|---|
| Prepuberty | Precocious puberty (hypothalamic, pituitary, or ovarian origin) |
| Adolescence (13–19) | Anovulatory cycles (immature HPO axis), coagulation disorders (von Willebrand disease) |
| Reproductive age | Pregnancy complications (threatened/missed abortion, ectopic pregnancy), anatomic lesions (leiomyoma, adenomyosis, polyps, hyperplasia, carcinoma), dysfunctional/anovulatory bleeding, OCP use |
| Perimenopause (mid-to-late 40s) | Anovulatory bleeding (incipient ovarian failure) |
| Postmenopause | Atrophic vaginitis, exogenous hormones, endometrial malignancy |
~20% of AUB occurs in adolescents; ~50% occurs in perimenopausal women. Overall, ~75% of AUB cases have no demonstrable organic cause and are due to anovulation (estrogen withdrawal or estrogen breakthrough bleeding).
— Goldman-Cecil Medicine; Robbins Pathology, p. 609
Pathophysiology of Anovulatory Bleeding
In anovulatory women, estrogen stimulates the endometrium unopposed by progesterone. The endometrium proliferates, becomes thickened, and sheds irregularly. Common causes of anovulation include:
- Hypothalamic/pituitary disturbances (e.g., prolactin-secreting tumors suppressing GnRH → ↓LH, ↓FSH)
- Polycystic ovary syndrome (PCOS) — most common in reproductive-age anovulatory AUB
- Granulosa cell tumors (functioning ovarian tumors producing estrogen)
- Obesity, malnutrition, chronic systemic illness (metabolic causes)
- Perimenopausal ovarian failure
A less common cause is luteal phase defect (insufficient progesterone from the corpus luteum).
Estrogen excess from any cause (obesity, exogenous estrogens without progestin, ovarian lesions) can lead to endometrial hyperplasia — an important precursor to endometrial carcinoma.
— Robbins Pathology, p. 609; Goldman-Cecil Medicine
Diagnosis
History
- Bleeding pattern (amount, duration, frequency, acuity)
- Assess severity: pad/tampon use (each absorbs ~20–30 mL), presence of clots
- Family/personal history of bleeding disorders
- Medications (hormonal contraceptives, anticoagulants, SSRIs, herbals)
- Reproductive and sexual history
Screen for coagulopathy if: heavy bleeding since menarche, postpartum hemorrhage, surgical/dental bleeding, + ≥2 of: bruising 1–2×/month, epistaxis 1–2×/month, gum bleeding, family history.
Physical Examination
- Hemodynamic stability first
- General: hirsutism, obesity → endocrinologic; petechiae, purpura → hematologic
- Pelvic exam: perineum, vulva, urethra, vaginal canal, cervix, bimanual assessment
Investigations
- Urine/serum β-hCG (exclude pregnancy)
- CBC, platelet count (assess anemia, thrombocytopenia)
- Coagulation studies including von Willebrand screening
- Thyroid function tests, fasting glucose
- Pelvic ultrasound — first-line imaging; detects polyps, fibroids, endometrial thickness
- Endometrial biopsy: mandatory in all women >35 years and in younger women with prolonged anovulatory bleeding or risk factors for endometrial carcinoma
Anovulatory AUB is a diagnosis of exclusion.
— Goldman-Cecil Medicine; Tintinalli's Emergency Medicine
Management
Acute/Profuse Bleeding (Hemodynamically Stable)
- Combined oral contraceptive pill (off-label): 1 pill every 6 hours for 5–7 days → bleeding should cease within 24 hours; warn patient of heavy withdrawal bleed 2–4 days after stopping
- Tranexamic acid (antifibrinolytic): effective for heavy menstrual bleeding
- Blood transfusion if profound anemia
- If unresponsive to medical therapy → surgical intervention
Chronic AUB — Medical Options
| Agent | Indication |
|---|---|
| NSAIDs | Ovulatory AUB; reduce prostaglandin-mediated blood loss |
| Combined oral contraceptives | Anovulatory and ovulatory AUB |
| Progestin (alone or combined) | Anovulatory AUB; PCOS |
| Levonorgestrel IUD (LNG-IUS) | Ovulatory AUB, dysmenorrhea; highly effective |
| Tranexamic acid | Heavy menstrual bleeding |
| GnRH agonists | Leiomyoma-related AUB; short-term pre-surgical use |
Surgical Options
- Endometrial ablation: effective; ~29% ultimately require hysterectomy by 5 years
- Uterine artery embolization (UAE): for symptomatic fibroids; ~31% ultimately require hysterectomy
- Hysterectomy: reserved for failure/intolerance of medical therapy and patient not desiring fertility preservation; endometrial sampling must be performed before hysterectomy
- Polypectomy / myomectomy: for structural lesions (polyps, fibroids)
Dilation and curettage (D&C) alone is not an effective means of controlling bleeding and is not necessary before hysterectomy.
— Berek & Novak's Gynecology; Goldman-Cecil Medicine
Special Considerations
- Postmenopausal bleeding: always warrants evaluation — most important cause to exclude is endometrial carcinoma
- Pregnancy must always be excluded before any workup or treatment in reproductive-age women
- Diethylstilbestrol (DES) exposure in utero: associated with clear cell adenocarcinoma of vagina/cervix and congenital uterine/cervical anomalies — though incidence of malignancy is extremely low
- Systemic disease: diabetes, hypo/hyperthyroidism, Cushing syndrome, Addison disease, leukemia, renal disease can all present with AUB
Sources: Tintinalli's Emergency Medicine; Robbins & Kumar Basic Pathology (Robbins Pathology); Goldman-Cecil Medicine; Berek & Novak's Gynecology
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