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Abnormal Uterine Bleeding Overview
Abnormal uterine bleeding refers to any deviation from the normal menstrual pattern in non‑pregnant women of reproductive age that persists for at least six months. This definition…
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A 28‑year‑old woman presents with heavy menstrual bleeding (HMB) and a uterine size that feels globular on examination. Which PALM‑COEIN category is most likely responsible for her symptoms?
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Which of the following statements about the diagnostic accuracy of Pipelle endometrial sampling is correct?
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A 16‑year‑old adolescent presents with heavy menstrual bleeding since menarche and frequent epistaxis. According to the screening criteria, which of the following findings would most strongly support referral to a hematologist?
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Which of the following is the gold‑standard method for diagnosing adenomyosis?
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A 42‑year‑old woman with obesity and polycystic ovary syndrome presents with prolonged heavy menstrual bleeding. According to the guidelines, which of the following is the most appropriate next step?
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Which PALM‑COEIN category corresponds to bleeding caused by an iatrogenic factor such as a hormonal contraceptive device?
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A patient with a 3‑cm submucosal leiomyoma is symptomatic with heavy menstrual bleeding. According to the treatment recommendations, which surgical option is preferred?
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Which of the following laboratory findings would most strongly suggest a von Willebrand disease in a teenager with heavy menstrual bleeding?
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According to the FIGO 2007 normal menstrual parameters, what is the maximum acceptable menstrual blood volume that does not qualify as heavy menstrual bleeding?
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A 35‑year‑old woman with a history of hypertension presents with intermenstrual spotting while using a combined oral contraceptive. Which of the following management steps is most appropriate?
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Which of the following best characterizes the difference between AUB‑O and AUB‑E according to the classification?
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A woman with a 4‑cm intramural leiomyoma reports heavy menstrual bleeding but desires future fertility. According to the treatment algorithm, which option should be considered first?
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Which of the following statements about the prevalence of adenomyosis is accurate?
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A 30‑year‑old woman with a known von Willebrand disease presents with heavy menstrual bleeding. Which of the following pharmacologic agents is most appropriate for acute management of her bleeding?
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Which of the following best explains why a levonorgestrel‑releasing intrauterine system (LNG‑IUS) is considered a first‑line therapy for chronic AUB‑E?
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A 45‑year‑old woman with persistent intermenstrual bleeding undergoes endometrial sampling that returns a diagnosis of atypical hyperplasia. According to the management guidelines, what is the recommended definitive treatment?
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Which of the following clinical features most strongly suggests a coagulopathy as the cause of heavy menstrual bleeding in an adolescent?
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In the PALM‑COEIN classification, which letter corresponds to malignancy or hyperplasia as a structural cause?
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A woman with a known uterine fibroid (leiomyoma) reports a sudden increase in menstrual blood loss after starting a combined oral contraceptive. Which of the following mechanisms best explains this observation?
Abnormal Uterine Bleeding (AUB): Definition and Overview
Abnormal uterine bleeding refers to any deviation from the normal menstrual pattern in non‑pregnant women of reproductive age that persists for at least six months. This definition emphasizes three key elements:
- Non‑pregnant – bleeding that occurs while a woman is not pregnant.
- Reproductive‑age – typically 15‑49 years.
- Duration – a pattern that lasts six months or longer.
Understanding this baseline helps clinicians differentiate physiologic variations from pathologic processes that require further evaluation.
PALM‑COEIN Classification System
The PALM‑COEIN framework categorises the causes of AUB into structural (PALM) and non‑structural (COEIN) groups. Each letter stands for a distinct aetiology:
- P – Polyp (AUB‑P)
- A – Adenomyosis (AUB‑A)
- L – Leiomyoma (fibroid) (AUB‑L)
- M – Malignancy & hyperplasia (AUB‑M)
- C – Coagulopathy (AUB‑C)
- O – Ovulatory dysfunction (AUB‑O)
- I – Iatrogenic (AUB‑I)
- E – Endometrial (AUB‑E)
- N – Not otherwise classified (AUB‑N)
Memorising the mnemonic "PALM‑COEIN" helps quickly identify whether a patient’s bleeding is likely due to a structural lesion (e.g., fibroids) or a functional/iatrogenic factor.
Common Structural Causes
Leiomyoma (Fibroids) – AUB‑L
Fibroids are the most frequent structural cause of heavy menstrual bleeding (HMB). A classic presentation includes a globular‑shaped uterus on bimanual examination and a history of prolonged, heavy flow.
- Key clue: uterine enlargement or a palpable mass.
- Management tip: sub‑mucosal fibroids ≤4 cm are best treated with hysteroscopic myomectomy, preserving fertility.
Adenomyosis – AUB‑A
Adenomyosis involves the invasion of endometrial glands into the myometrium. While imaging (ultrasound, MRI) can suggest the diagnosis, the gold‑standard remains histopathological examination of a hysterectomy specimen.
- Gold‑standard: histology from a hysterectomy.
- Clinical hint: a uniformly enlarged, tender uterus with dysmenorrhea.
Non‑Structural Causes
Coagulopathy – AUB‑C
Bleeding disorders, such as von Willebrand disease, often present in adolescents with heavy menstrual bleeding plus mucocutaneous bleeding (e.g., epistaxis, bruising). Referral to a hematologist is warranted when two or more bleeding signs coexist.
- Referral rule: "Dos Síntomas = Derivar" – two or more bleeding manifestations trigger hematology evaluation.
Iatrogenic – AUB‑I
Hormonal contraceptive devices, intrauterine systems, and other medications can alter endometrial stability, leading to irregular bleeding. This category underscores the importance of reviewing a patient’s medication history.
- Mnemonic: I for Iatrogenic – think “Insert device → AUB‑I”.
Diagnostic Tools
Pipelle Endometrial Sampling
The Pipelle is a minimally invasive office‑based device used to obtain endometrial tissue. Its diagnostic performance is notable:
- Sensitivity for endometrial cancer ≈ 91 %.
- Sensitivity for endometrial hyperplasia ≈ 81 %.
- Specificity is high but not absolute.
When a patient presents with risk factors such as obesity, polycystic ovary syndrome (PCOS), or prolonged HMB, an endometrial biopsy with Pipelle is the recommended first step before initiating therapy.
Imaging Modalities
While ultrasound (including Doppler) and magnetic resonance imaging (MRI) are valuable for characterising fibroids, polyps, and adenomyosis, they cannot replace histology for definitive diagnosis of adenomyosis or malignancy.
Management Strategies
Fibroid‑Related Heavy Bleeding
For a sub‑mucosal leiomyoma ≤4 cm causing HMB, hysteroscopic myomectomy is the preferred surgical option. This technique removes the lesion through the uterine cavity, preserving uterine integrity and fertility potential.
- Why not hysterectomy? Hysterectomy is reserved for larger, multiple, or refractory fibroids when fertility preservation is not a priority.
- Alternative therapies: uterine artery embolisation or medical management (e.g., levonorgestrel‑releasing IUD) are considered when hysteroscopic access is not feasible.
Endometrial Evaluation Before Treatment
In women with obesity, PCOS, or prolonged HMB, the guidelines stress obtaining an endometrial biopsy before any therapeutic intervention. This step rules out hyperplasia or carcinoma, conditions that require specific management.
- Clinical tip: OBESIDAD → OBLIGATORIA Biopsia – obesity mandates a biopsy.
Key Take‑Home Points
- Definition: AUB is any menstrual irregularity lasting ≥6 months in non‑pregnant, reproductive‑age women.
- PALM‑COEIN: Use the mnemonic to quickly classify structural vs. non‑structural causes.
- Fibroids (AUB‑L): Heavy bleeding with a globular uterus → consider hysteroscopic myomectomy for lesions ≤4 cm.
- Adenomyosis (AUB‑A): Definitive diagnosis requires histopathology from a hysterectomy specimen.
- Coagulopathy (AUB‑C): Two or more bleeding signs → refer to hematology.
- Iatrogenic (AUB‑I): Hormonal devices are classic triggers; review medication history.
- Pipelle biopsy: Sensitivity ≈ 91 % for cancer, 81 % for hyperplasia – the first step in high‑risk patients.
- Imaging: Helpful for lesion localisation but not the gold‑standard for adenomyosis or malignancy.
By integrating these concepts, clinicians can efficiently evaluate, classify, and manage abnormal uterine bleeding, ensuring that patients receive evidence‑based care tailored to their specific aetiology.
