Updated: 11/29/2021

Abnormal Uterine Bleeding (AUB)

Review Topic
  • Snapshot
    • A 39-year-old woman presents with abnormal heavy menstrual bleeding along with increased pelvic pressure. She denies pain and is not using any hormonal contraception. She uses multiple sanitary pads per day. On pelvic examination, there is an enlarged uterus with asymmetric contours. The uterus is non-tender to palpation. (Uterine leiomyomas)
    • Also known as dysfunctional uterine bleeding (DUB)
    • Abnormal menstrual bleeding with regards to
      • quantity, duration, or schedule
    • The patient must not be pregnant
      • therefore, pregnancy must be ruled out
  • Etiology
    • Causes include
      • structural abnormalities
        • e.g., adenomyosis, uterine fibroids, malignancy, and polyps
      • bleeding disorders and coagulopathies
      • medications
      • anovulation
      • genital infection
      • mnemonic
        • PALM-COEIN
          • Polyps
          • Adenomyosis
          • Leiomyomas
          • Malignancy & hyperplasia
          • Coagulopathy
          • Ovulatory dysfunction
          • Endometrial
          • Iatrogenic (e.g., medications)
          • Not yet classified (e.g., arteriovenous malformations, and chronic endometritis)
    • Pathogenesis
      • mechanism of AUB due to anovulation
        • corpus luteum does not form
        • absence of progesterone
        • unapposed estrogen continues to proliferate the endometrium
          • the endometrium becomes unstable and outgrows its blood supply
            • endometrial sloughing and breakthrough bleeding results
  • Presentation
    • Symptoms
      • variation of normal menstrual cycle
      • symptoms of anemia
        • light-headedness
        • shortness of breath
    • Physical exam
      • dependent on etiology
        • obesity, hirsutism, and acanthosis nigricans can suggests polycystic ovarian syndrome (PCOS)
        • an enlarged pelvic mass may suggest leiomyoma
  • Imaging studies
    • transvaginal ultrasound
      • first-line in adult patients when assessing for structural abnormalities
    • Evaluation is dependent on likely cause of AUB
    • β-hCG
      • to rule out pregnancy
      • can be serum and urine
    • Blood testing
      • complete blood count (CBC)
      • coagulation studies
        • consider in patients with a history of bleeding disorder
      • thyroid-stimulating hormone (TSH)
        • in those with a history concerning for thyroid disease
    • Endometrial biopsy
      • can be considered when
        • > 45 years of age
        • when refractory to treatment
        • < 45 years of age with high risk of endometrial cancer
  • Differential
    • Refer to introduction (PALM-COEIN)
  • Treatment
    • Treat the underlying cause of AUB
    • Treatment
      • in cases of heavy menstrual bleeding (most commonly due to leiomyomas or adenomyosis)
        • hormone therapy
          • estrogen-progestin contraception or levonorgestrel-releasing intrauterine devices are first-line
          • progestin-only treatment is reasonable
        • NSAIDs or tranexamic acid can be used in patients who do not want to be treated with hormone therapy, or have contraindications
          • NSAIDs decrease endometrial prostaglandin synthesis
            • results in decreased blood loss
          • tranexamic acid prevents plasminogen from being converted to plasmin
            • this in turn decreases fibrinolysis
      • in cases of menstrual bleeding due to ovulatory dysfunction
        • reassurance in pediatric patients
          • in a pediatric patient it is a normal finding secondary to an immature hypothalmic-pituitary-ovarian axis
        • hormone therapy
          • estrogen-progestin contraceptives, oral progestin therapy, or levonorgestrel-releasing intrauterine device are first-line
            • oral progestin therapy has a higher failure rate than estrogen-progestin contraceptives
              • use only if contraindications to estrogen-progestin contraceptives or for patient preference
    • Surgical treatment
      • used in cases that are refractory to medical therapy or patient preference
        • heavy menstrual bleeding due to leiomyomas or adenomyomas is an indication for surgery
      • must assess whether patient wants to become pregnant or has completed childbearing
      • myomectomy
        • can be an option in patients who desire future pregnancy
      • endometrial ablation
      • uterine artery embolization
      • hysterectomy
        • definitive therapy
  • Complications
    • May be at increased risk for endometrial cancer or hyperplasia in AUB secondary to anovulation
  • Prognosis
    • Treatment may improve quality of life
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