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Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women

  • Practice Bulletin PB
  • Number 128
  • July 2012

ABSTRACT: Menstrual flow outside of normal volume, duration, regularity, or frequency is considered abnormal uterine bleeding (AUB). One third of outpatient visits to the gynecologist are for AUB, and it accounts for more than 70% of all gynecologic consults in the perimenopausal and postmenopausal years 1. Many new diagnostic modalities are available to assist the clinician in evaluating the woman with alterations in her normal menstrual patterns. The purpose of this document is to provide evidence-based management guidelines for the evaluation of the reproductive-aged patient with AUB. A secondary purpose is to introduce a new classification system for AUB. This document does not address pregnancy-related bleeding or postmenopausal bleeding.

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Figures & Tables

Fig. 1. Basic PALM–COEIN classification system for the causes of abnormal uterine bleeding in nonpregnant women of reproductive age. This system, approved by the International Federation of Gynecology and Obstetrics, uses the term AUB paired with descriptive terms that describe associated bleeding patterns (HMB or IMB), or a qualifying letter (or letters), or both to indicate its etiology (or etiologies). Modified from Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO classification system (PALM–COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. FIGO Working Group on Menstrual Disorders. Int J Gynaecol Obstet 2011;113:3–13. [PubMed] [Full Text]

Fig. 1. Basic PALM–COEIN classification system for the causes of abnormal uterine bleeding in nonpregnant women of reproductive age. This system, approved by the International Federation of Gynecology and Obstetrics, uses the term AUB paired with descriptive terms that describe associated bleeding patterns (HMB or IMB), or a qualifying letter (or letters), or both to indicate its etiology (or etiologies). Modified from Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO classification system (PALM–COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. FIGO Working Group on Menstrual Disorders. Int J Gynaecol Obstet 2011;113:3–13. [PubMed] [Full Text]

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Fig. 2. Uterine evaluation. The uterine evaluation is, in part, guided by the medial history and other elements of the clinical situation, such as patient age, presence of an apparent chronic ovulatory disorder, or presence of other risk factors for endometrial hyperplasia or malignancy. For those at increased risk, endometrial biopsy is probably warranted. If there is a risk of structural anomaly, particularly if previous medical therapy has been unsuccessful, evaluation of the uterus should include imaging, at least with a screening transvaginal ultrasonography. Unless the ultrasound image indicates a normal endometrial cavity, it will be necessary to use either or both hysteroscopy and sonohysterography to determine whether target lesions are present. Such an approach is also desirable if endometrial sampling has not provided an adequate specimen. Uncommonly, these measures are inconclusive or, in the instance of virginal girls and women, not feasible outside of an anesthetized environment. In these instances, magnetic resonance imaging may be of value, if available. Abbreviations: AUB, abnormal uterine bleeding; AUB-P, polyp; AUB-A, adenomyosis; AUB-L SM , leiomyoma submucosal; AUB-M, malignancy and hyperplasia; AUB-O, ovulatory dysfunction; AUB-E, endometrial; CA, carcinoma; MRI, magnetic resonance imaging; SIS, sonohysterography; TVUS, transvaginal ultrasonography. Reprinted from Munro MG. Abnormal Uterine Bleeding. Cambridge: Cambridge University Press; 2010.

Fig. 2. Uterine evaluation. The uterine evaluation is, in part, guided by the medial history and other elements of the clinical situation, such as patient age, presence of an apparent chronic ovulatory disorder, or presence of other risk factors for endometrial hyperplasia or malignancy. For those at increased risk, endometrial biopsy is probably warranted. If there is a risk of structural anomaly, particularly if previous medical therapy has been unsuccessful, evaluation of the uterus should include imaging, at least with a screening transvaginal ultrasonography. Unless the ultrasound image indicates a normal endometrial cavity, it will be necessary to use either or both hysteroscopy and sonohysterography to determine whether target lesions are present. Such an approach is also desirable if endometrial sampling has not provided an adequate specimen. Uncommonly, these measures are inconclusive or, in the instance of virginal girls and women, not feasible outside of an anesthetized environment. In these instances, magnetic resonance imaging may be of value, if available. Abbreviations: AUB, abnormal uterine bleeding; AUB-P, polyp; AUB-A, adenomyosis; AUB-L SM , leiomyoma submucosal; AUB-M, malignancy and hyperplasia; AUB-O, ovulatory dysfunction; AUB-E, endometrial; CA, carcinoma; MRI, magnetic resonance imaging; SIS, sonohysterography; TVUS, transvaginal ultrasonography. Reprinted from Munro MG. Abnormal Uterine Bleeding. Cambridge: Cambridge University Press; 2010.

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