Evaluation of abnormal uterine bleeding

Diseases

Summary

Abnormal uterine bleeding (AUB) is any symptomatic variation from normal menstruation in terms of regularity, frequency, volume, or duration.[1] It may be acute, chronic, or intermenstrual.

AUB affects up to 30% of women of reproductive age.[2]

Causes include leiomyomata (fibroids), adenomyosis, endocervical and endometrial polyps, malignancy, endometrial hyperplasia, ovulatory or endometrial dysfunction, coagulopathy, and iatrogenic causes.

Initial evaluation includes a medical, surgical, and gynecological history, and pelvic examination. Further investigations may include blood tests and ultrasound.

Citations

Key Articles

American College of Obstetricians and Gynecologists. ACOG committee opinion no. 557: management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Apr 2013 [internet publication].[Abstract][Full Text]
American College of Obstetricians and Gynecologists. Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Jul 2012 [internet publication].
National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication].[Full Text]
American College of Radiology. ACR appropriateness criteria abnormal uterine bleeding. 2020 [internet publication].[Full Text]

Referenced Articles

1. Munro MG, Critchley HOD, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011 Apr;113(1):3-13.[Abstract][Full Text]
2. Shapley M, Jordan K, Croft PR. An epidemiological survey of symptoms of menstrual loss in the community. Br J Gen Pract. 2004 May;54(502):359-63.[Abstract][Full Text]
3. Yuksel S, Tuna G, Celik HG, et al. Endometrial polyps: is the prediction of spontaneous regression possible? Obstet Gynecol Sci. 2021 Jan;64(1):114-21.[Abstract][Full Text]
4. Clark TJ, Stevenson H. Endometrial Polyps and Abnormal Uterine Bleeding (AUB-P): What is the relationship, how are they diagnosed and how are they treated? Best Pract Res Clin Obstet Gynaecol. 2017 Apr;40:89-104.[Abstract]
5. Dreisler E, Stampe Sorensen S, Ibsen PH, et al. Prevalence of endometrial polyps and abnormal uterine bleeding in a Danish population aged 20-74 years. Ultrasound Obstet Gynecol. 2009 Jan;33(1):102-8.[Abstract][Full Text]
6. Baiocchi G, Manci N, Pazzaglia M, et al. Malignancy in endometrial polyps: a 12-year experience. Am J Obstet Gynecol. 2009 Nov;201(5):462.e1-4.[Abstract]
7. Taran FA, Stewart EA, Brucker S. Adenomyosis: epidemiology, risk factors, clinical phenotype and surgical and interventional alternatives to hysterectomy. Geburtshilfe Frauenheilkd. 2013 Sep;73(9):924-31.[Abstract][Full Text]
8. Pontis A, D'Alterio MN, Pirarba S, et al. Adenomyosis: a systematic review of medical treatment. Gynecol Endocrinol. 2016 Sep;32(9):696-700.[Abstract]
9. Gordts S, Grimbizis G, Campo R. Symptoms and classification of uterine adenomyosis, including the place of hysteroscopy in diagnosis. Fertil Steril. 2018 Mar;109(3):380-8.[Abstract][Full Text]
10. Baird DD, Dunson DB, Hill MC, et al. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003 Jan;188(1):100-7.[Abstract]
11. Giuliani E, As-Sanie S, Marsh EE. Epidemiology and management of uterine fibroids. Int J Gynaecol Obstet. 2020 Apr;149(1):3-9.[Abstract][Full Text]
12. Whitaker L, Critchley HO. Abnormal uterine bleeding. Best Pract Res Clin Obstet Gynaecol. 2016 Jul;34:54-65.[Abstract][Full Text]
13. Shankar M, Lee CA, Sabin CA, et al. von Willebrand disease in women with menorrhagia: a systematic review. BJOG. 2004 Jul;111(7):734-40.[Abstract]
14. Gleeson NC. Cyclic changes in endometrial tissue plasminogen activator and plasminogen activator inhibitor type 1 in women with normal menstruation and essential menorrhagia. Am J Obstet Gynecol. 1994 Jul;171(1):178-83.[Abstract]
15. Smith SK, Abel MH, Kelly RW, et al. A role for prostacyclin (PGi2) in excessive menstrual bleeding. Lancet. 1981 Mar 7;1(8219):522-4.[Abstract]
16. Samuelson Bannow BT, Chi V, Sochacki P, et al. Heavy menstrual bleeding in women on oral anticoagulants. Thromb Res. 2021 Jan;197:114-9.[Abstract][Full Text]
17. Medicines and Healthcare products Regulatory Agency. Direct-acting oral anticoagulants (DOACs): reminder of bleeding risk, including availability of reversal agents. Jun 2020 [internet publication].[Full Text]
18. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 557: management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Apr 2013 [internet publication].[Abstract][Full Text]
19. Gayet-Ageron A, Prieto-Merino D, Ker K, et al; Antifibrinolytic Trials Collaboration. Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients. Lancet. 2018 Jan 13;391(10116):125-32.[Abstract][Full Text]
20. American College of Obstetricians and Gynecologists. ACOG committee opinion, number 785: screening and management of bleeding disorders in adolescents with heavy menstrual bleeding. Sep 2019 (reaffirmed 2023) [internet publication].[Abstract][Full Text]
21. National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management. Aug 2023 [internet publication].[Full Text]
22. Cappellini MD, Musallam KM, Taher AT. Iron deficiency anaemia revisited. J Intern Med. 2020 Feb;287(2):153-70.[Abstract][Full Text]
23. American College of Obstetricians and Gynecologists. Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Jul 2012 [internet publication].
24. Munro MG, Critchley HOD, Fraser IS, et al. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018 Dec;143(3):393-408.[Abstract][Full Text]
25. National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. May 2021 [internet publication].[Full Text]
26. Dancz CE, Kadam P, Li C, et al. The relationship between uterine leiomyomata and pelvic floor symptoms. Int Urogynecol J. 2014 Feb;25(2):241-8.[Abstract][Full Text]
27. Xin J, Lai HP, Lin SK, et al. Bladder leiomyoma presenting as dyspareunia: case report and literature review. Medicine (Baltimore). 2016 Jul;95(28):e3971.[Abstract][Full Text]
28. Kouides PA, Conard J, Peyvandi F, et al. Hemostasis and menstruation: appropriate investigation for underlying disorders of hemostasis in women with excessive menstrual bleeding. Fertil Steril. 2005 Nov;84(5):1345-51.[Abstract][Full Text]
29. Nutescu EA, Shapiro NL, Ibrahim S, et al. Warfarin and its interactions with foods, herbs and other dietary supplements. Expert Opin Drug Saf. 2006 May;5(3):433-51.[Abstract]
30. Lien LL, Lien EJ. Hormone therapy and phytoestrogens. J Clin Pharm Ther. 1996 Apr;21(2):101-11.[Abstract]
31. Evans D, Goldstein S, Loewy A, et al. No. 385-Indications for Pelvic Examination. J Obstet Gynaecol Can. 2019 Aug;41(8):1221-34.[Abstract][Full Text]
32. Azziz R, Hincapie LA, Knochenhauer ES, et al. Screening for 21-hydroxylase-deficient nonclassic adrenal hyperplasia among hyperandrogenic women: a prospective study. Fertil Steril. 1999 Nov;72(5):915-25.[Abstract][Full Text]
33. International PCOS Network. International evidence-based guideline for the assessment and management of polycystic ovary syndrome. 2018 [internet publication].[Full Text]
34. Azziz R, Carmina E, Dewailly D, et al. Positions statement: criteria for defining polycystic ovary syndrome as a predominantly hyperandrogenic syndrome: an Androgen Excess Society guideline. J Clin Endocrinol Metab. 2006 Nov;91(11):4237-45.[Abstract][Full Text]
35. James PD, Connell NT, Ameer B, et al. ASH ISTH NHF WFH 2021 guidelines on the diagnosis of von Willebrand disease. Blood Adv. 2021 Jan 12;5(1):280-300.[Abstract][Full Text]
36. American College of Radiology. ACR appropriateness criteria abnormal uterine bleeding. 2020 [internet publication].[Full Text]
37. Mendelson EB, Bohm-Velez M, Joseph N, et al. Gynecologic imaging: comparison of transabdominal and transvaginal sonography. Radiology. 1988 Feb;166(2):321-4.[Abstract][Full Text]
38. Leibman AJ, Kruse B, McSweeney MB. Transvaginal sonography: comparison with transabdominal sonography in the diagnosis of pelvic masses. AJR Am J Roentgenol. 1988 Jul;151(1):89-92.[Abstract][Full Text]
39. Fedele L, Bianchi S, Dorta M, et al. Transvaginal ultrasonography versus hysteroscopy in the diagnosis of uterine submucous myomas. Obstet Gynecol. 1991;77:745-748.[Abstract]
40. Valentin L. Imaging techniques in the management of abnormal vaginal bleeding in non-pregnant women before and after menopause. Best Pract Res Clin Obstet Gynaecol. 2014 Jul;28(5):637-54.[Abstract]
41. Pennant ME, Mehta R, Moody P, et al. Premenopausal abnormal uterine bleeding and risk of endometrial cancer. BJOG. 2017 Feb;124(3):404-11.[Abstract][Full Text]
42. Yoon SW, Lee C, Cha SH, et al. Patient selection guidelines in MR-guided focused ultrasound surgery of uterine fibroids: a pictorial guide to relevant findings in screening pelvic MRI. Eur Radiol. 2008 Dec;18(12):2997-3006.[Abstract]