Abnormal uterine Bleeding

AUB

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Assessment & Management

Evaluation includes a detailed history, examination, and appropriate investigations (blood tests, imaging, or endometrial sampling). Treatment is tailored to the underlying cause, severity, and patient preferences, with the aim of controlling bleeding and improving quality of life.

Classification

Modern classification (FIGO) improves clarity and includes:

  • Descriptive terms:

    • Heavy menstrual bleeding (HMB)

    • Intermenstrual bleeding

    • Breakthrough bleeding (on hormonal therapy)

  • Causes (PALM-COEIN):

    • Structural: Polyp, adenomyosis, fibroids (leiomyoma), malignancy/hyperplasia

    • Non-structural: Coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, other

  • Types

  • Acute AUB: Sudden, heavy bleeding requiring urgent management

  • Chronic AUB: Irregular bleeding present for most of the past 6 months

Abnormal Uterine Bleeding (AUB)

A normal cycle occurs every 24–38 days, lasts 2–7 days, with a blood loss of 5–80 mL. Any deviation from these parameters is considered AUB.

Abnormal uterine bleeding (AUB) refers to any variation in menstrual cycle frequency, regularity, duration, or volume in non-pregnant women of reproductive age. Up to one-third of women experience AUB, particularly around menarche and perimenopause.

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Classification of AUB

PALM-COEIN

The FIGO PALM-COEIN system categorises causes of abnormal uterine bleeding into structural and non-structural groups to guide diagnosis and management.

Structural Causes (PALM)

  • Polyp (P): Benign growths that may cause intermenstrual bleeding

  • Adenomyosis (A): Endometrial tissue within the uterine muscle, causing heavy, painful periods

  • Leiomyoma (L): Fibroids that may lead to heavy or prolonged bleeding

  • Malignancy/Hyperplasia (M): Abnormal or cancerous changes of the endometrium, often with irregular bleeding

Non-Structural Causes (COEIN)

  • Coagulopathy (C): Bleeding disorders (e.g. von Willebrand disease)

  • Ovulatory dysfunction (O): Irregular ovulation (e.g. PCOS, thyroid disorders)

  • Endometrial (E): Disorders affecting the lining’s ability to control bleeding

  • Iatrogenic (I): Medication- or treatment-related (e.g. hormonal therapy, anticoagulants)

  • Not otherwise classified (N): Less common causes (e.g. vascular abnormalities)

AUB is often multifactorial, requiring a tailored, patient-specific approach combining clinical assessment, imaging, and laboratory evaluation.