ABNORMAL UTERINE BLEEDING

Understanding Abnormal Uterine Bleeding (AUB): 

Introduction

Abnormal Uterine Bleeding (AUB) is one of the most common gynecological complaints encountered in clinical practice. It affects women of all age groups, from adolescence to menopause, and can significantly impact quality of life. Understanding the modern classification and evaluation of AUB is essential for every medical and Ayurveda student.

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What is Abnormal Uterine Bleeding (AUB)?

AUB refers to any bleeding from the uterus that differs from the normal menstrual pattern in terms of:

- Frequency of menstruation

- Regularity of cycles

- Duration of bleeding

- Amount of blood loss

Normal Menstrual Parameters

Parameter| Normal Range

Frequency| Every 24–38 days

Regularity| Variation ≤7–9 days

Duration| Up to 8 days

Blood Loss| Usually less than 80 mL/cycle

Any deviation from these parameters is considered abnormal uterine bleeding.

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From DUB to AUB: Why Was the Terminology Changed?

Earlier Term: Dysfunctional Uterine Bleeding (DUB)

Traditionally, abnormal bleeding without any identifiable structural or systemic cause was called Dysfunctional Uterine Bleeding (DUB).

However, the term had several limitations:

- It was vague and descriptive.

- It did not explain the actual cause.

- Different clinicians interpreted it differently.

Current Term: Abnormal Uterine Bleeding (AUB)

To standardize terminology worldwide, the International Federation of Gynecology and Obstetrics (FIGO) introduced the term AUB in 2011.

Today, the term DUB is no longer recommended and has been replaced by the FIGO PALM-COEIN classification system.

PALM-COEIN Classification of AUB

The FIGO classification divides causes of AUB into two major groups:

PALM – Structural Causes

These causes can usually be identified by imaging or histopathology.

P – Polyp

Localized overgrowths of endometrial tissue that may cause irregular bleeding.

A – Adenomyosis

Presence of endometrial tissue within the uterine muscle causing heavy and painful periods.

L – Leiomyoma (Fibroid)

Benign tumors of the uterus that may produce heavy menstrual bleeding.

M – Malignancy and Hyperplasia

Precancerous or cancerous changes of the endometrium.

COEIN – Non-Structural Causes

These causes are usually not detected by imaging.

C – Coagulopathy

Bleeding disorders such as von Willebrand disease.

O – Ovulatory Dysfunction

Irregular or absent ovulation leading to abnormal bleeding.

E – Endometrial Causes

Abnormal local endometrial function despite normal ovulation.

I – Iatrogenic

Bleeding caused by medications or medical devices.

N – Not Yet Classified

Rare causes that do not fit into other categories.

Which is the Most Common Cause?

The most common cause of AUB is:

AUB-O (Ovulatory Dysfunction)

It is particularly common in:

- Adolescents

- Perimenopausal women (>45 years)

- Women with PCOS

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How Does AUB-O Occur?

Understanding the mechanism is easy if we follow the hormonal sequence:

Anovulation → No corpus luteum formation → No progesterone production → Continuous estrogen stimulation of endometrium → Excessive endometrial growth → Irregular shedding → Abnormal bleeding

Clinical Importance

Repeated episodes may lead to:

- Endometrial hyperplasia

- Increased risk of endometrial carcinoma

Therefore, proper evaluation is important.

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Clinical Evaluation of AUB

Step 1: Detailed History

Ask about:

- Cycle length

- Duration of bleeding

- Amount of blood loss

- Passage of clots

- Intermenstrual bleeding

- Associated pain

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Step 2: Exclude Pregnancy First

A pregnancy test should be performed in all reproductive-age women presenting with abnormal bleeding.

Remember: Pregnancy-related bleeding must always be ruled out before proceeding further.

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Step 3: Laboratory Investigations

Basic Tests

- Complete Blood Count (CBC)

- Serum Ferritin

- Pregnancy Test

Hormonal Tests

- Thyroid Stimulating Hormone (TSH)

- Serum Prolactin

- Serum Progesterone

- Testosterone and DHEAS (if PCOS suspected)

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Step 4: Imaging

Transvaginal Ultrasound (TVUS)

TVUS is the first-line imaging investigation for evaluating AUB.

It helps detect:

- Polyps

- Fibroids

- Adenomyosis

- Endometrial abnormalities

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Step 5: Endometrial Biopsy

Indications

Perform endometrial sampling in:

- Women aged ≥45 years

- Women with obesity, diabetes, or PCOS

- Persistent or recurrent bleeding

- Suspected endometrial pathology

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Management of AUB

Management depends upon the underlying cause and severity of symptoms.

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Non-Hormonal Treatment

Tranexamic Acid

- Reduces menstrual blood loss

- Useful in heavy menstrual bleeding

NSAIDs

- Reduce bleeding and menstrual pain

- Helpful in ovulatory cycles

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Hormonal Treatment

Combined Oral Contraceptive Pills (COCs)

Useful in:

- Ovulatory dysfunction

- Adolescents

- Perimenopausal women

Progesterone Therapy

Especially useful in:

- Anovulatory bleeding

- Endometrial hyperplasia prevention

Levonorgestrel-Releasing Intrauterine Device (LNG-IUD)

One of the most effective long-term treatments for heavy menstrual bleeding.

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Surgical Management

When medical treatment fails or structural lesions are present, surgery may be required.

Hysteroscopy

Useful for diagnosis and treatment of intrauterine pathology.

Myomectomy

Removal of fibroids while preserving the uterus.

Endometrial Ablation

Destroys the endometrial lining to reduce bleeding.

Hysterectomy

Definitive treatment for women who have completed childbearing.

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Acute AUB: A Gynecological Emergency

Severe bleeding requires immediate management.

Initial Steps

1. Assess hemodynamic stability.

2. Start IV fluids if necessary.

3. Arrange blood transfusion when indicated.

4. Exclude pregnancy.

Medical Management

- High-dose combined oral contraceptives

- High-dose progesterone therapy

- Intravenous estrogen (selected cases)

- Tranexamic acid

Prompt treatment can prevent severe anemia and shock.

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Easy Mnemonic for PALM-COEIN

PALM = Structural Causes

"Things you can see"

- P – Polyp

- A – Adenomyosis

- L – Leiomyoma

- M – Malignancy/Hyperplasia

COEIN = Non-Structural Causes

"Things you cannot easily see"

- C – Coagulopathy

- O – Ovulatory Dysfunction

- E – Endometrial

- I – Iatrogenic

- N – Not Yet Classified

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Important Examination Pearls

✔ DUB is an obsolete term; use AUB.

✔ PALM causes are structural and detectable on imaging.

✔ COEIN causes are non-structural.

✔ AUB-O is the most common cause of abnormal uterine bleeding.

✔ Pregnancy must always be excluded first.

✔ Transvaginal ultrasound is the first-line imaging modality.

✔ Endometrial biopsy is recommended in women aged 45 years and above with AUB.

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Clinical Example

A 45-year-old woman presents with irregular bleeding every 10–15 days for six months. She passes clots and has no uterine abnormality on ultrasound.

Most Likely Diagnosis:

AUB-O (Ovulatory Dysfunction)

This is a common presentation in the perimenopausal period due to irregular ovulation.

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Conclusion

Abnormal Uterine Bleeding is a symptom rather than a diagnosis. The FIGO PALM-COEIN classification provides a systematic approach to identifying the cause and guiding management. For students, understanding this classification, the basic evaluation steps, and common treatment options is essential for both examinations and clinical practice.