Abnormal Uterine BleedingEdit

Abnormal uterine bleeding (AUB) is a common gynecologic symptom characterized by bleeding from the uterus that deviates from a typical pattern for a given woman. It is best understood as a symptom set rather than a single disease, and it arises from a range of structural and non-structural factors. AUB can have substantial effects on health and daily life, including iron-deficiency anemia, fatigue, and reduced productivity, and it prompts a wide spectrum of medical and, when appropriate, surgical interventions. The modern framework for classifying AUB is the PALM-COEIN system, which distinguishes structural causes from non-structural ones and is widely used in clinical guidelines and educational resources PALM-COEIN.

The presentation of AUB varies by age and individual risk factors. Adolescents and young adults may experience menorrhagia (heavy menstrual bleeding) or irregular cycles as the hypothalamic-pituitary-ovarian axis matures. Perimenopausal individuals frequently report irregular bleeding patterns tied to evolving ovarian function. Other common contributors across ages include uterine fibroids (leiomyomas), polyps, adenomyosis, coagulation disorders, thyroid disease, obesity, and certain medications or medical therapies. While bleeding patterns are central to diagnosis, clinicians also screen for anemia and assess overall health, pregnancy status, and signs of more serious pathology when indicated. See discussions of menorrhagia, metrorrhagia, and iron-deficiency anemia for related concepts.

Classification and definitions

AUB is organized in many guidelines around the PALM-COEIN framework. This approach groups causes into two overarching categories:

  • Structural causes (the “PALM” portion):

    • Polyp endometrial polyp
    • Adenomyosis
    • Leiomyoma (fibroids)
    • Malignancy and hyperplasia (endometrial cancer and endometrial hyperplasia)
  • Non-structural causes (the “COEIN” portion):

    • Coagulopathy
    • Ovulatory dysfunction
    • Endometrial causes not related to structural change
    • Iatrogenic factors (e.g., medications, medical devices)
    • Not yet classified

This framework helps clinicians target investigations and therapies efficiently. For readers who want a broader overview of these categories, see PalM-COEIN and related entries on each specific condition such as endometrial hyperplasia, adenomyosis, and uterine fibroids.

Presentation and evaluation

Patients with AUB may report various patterns, including: - Heavy or prolonged menses (menorrhagia) - Bleeding between expected menses (intermenstrual bleeding) - Bleeding after sex (postcoital bleeding) - Postmenopausal bleeding, which demands prompt evaluation for serious pathology

A careful history focuses on bleeding pattern, impact on quality of life, pregnancy status, medication use (including anticoagulants and antiplatelet agents), and prior uterine surgery. A physical exam, including a pelvic exam, helps identify obvious structural causes or signs of systemic disease.

Guideline-directed evaluation typically includes: - Pregnancy testing when relevant - Complete blood count to assess anemia - Iron studies if iron deficiency is suspected - Thyroid function tests and screening for other endocrine issues - Coagulation studies if a bleeding disorder is suspected - Transvaginal ultrasound to assess structural causes such as polyps, fibroids, or adenomyosis - Endometrial sampling (biopsy) or hysteroscopic evaluation in cases with postmenopausal bleeding or high suspicion of endometrial pathology - Endocrine or bleeding-d disorder workups when indicated by history or exam

Key diagnostic tools include imaging and tissue sampling. For readers seeking detailed descriptions, see transvaginal ultrasound, endometrial biopsy, and hysteroscopy.

Management and treatment options

The management of AUB is individualized, balancing bleeding severity, patient age, fertility desires, comorbidities, and risk tolerance. The overarching goals are to reduce bleeding, prevent anemia, improve quality of life, and treat underlying causes when possible.

  • Non-surgical medical management

    • Nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce menstrual blood loss and pain.
    • Antifibrinolytic therapy, such as tranexamic acid, helps reduce bleeding in many patients.
    • Hormonal therapies, including combined estrogen-progestin regimens or progestin-only regimens, can regulate cycles and decrease bleeding.
    • The levonorgestrel-releasing intrauterine system (LNG-IUD) is a highly effective, long-acting option for many people with AUB due to various etiologies.
    • Iron supplementation or dietary interventions address concomitant iron-deficiency anemia.
    • Fertility considerations guide choices between short-acting therapies and long-acting, reversible options.
  • Surgical and procedural options

    • Endometrial ablation can reduce or stop bleeding for many people who do not wish to maintain fertility.
    • Hysterectomy remains a definitive treatment for those who have completed childbearing or who have other uterine pathology not amenable to conservative therapy.
    • Uterine artery embolization and selective vascular procedures may be considered in some fibroid-related AUB cases.
  • Disease-specific and staged approaches

    • Treatment should be tailored to structural causes identified under PALM-COEIN (e.g., polyp removal, fibroid-directed strategies, or addressing adenomyosis) and concomitant conditions like coagulopathies or thyroid disease.
    • Ongoing monitoring and reassessment are important, as bleeding patterns can evolve with age and comorbidity.

Any discussion of management in this topic should note the importance of shared decision-making. The best approach often depends on whether the patient wants to preserve fertility, tolerate a non-surgical course, or pursue definitive surgical management.

Controversies and debates

As with many areas of medicine, opinions differ on the balance between conservative management, the risks and benefits of procedures, and how to allocate healthcare resources. From a pragmatic, cost-conscious perspective, several themes recur:

  • Diagnostic pathways and overtesting: Some clinicians advocate for stepwise evaluation that emphasizes noninvasive testing first, reserving invasive procedures for cases with red flags or persistent symptoms. Others argue that prompt, thorough assessment can prevent complications from undiagnosed pathology. The right balance is often guided by age, bleeding pattern, and risk factors for cancer or anemia.

  • Screening and cancer risk in postmenopausal bleeding: There is ongoing discussion about how aggressively to pursue endometrial sampling in postmenopausal bleeding, especially in women with low-risk features. Evidence supports prompt evaluation for postmenopausal bleeding, but resource allocation and patient preference influence how pathways are implemented in practice.

  • Medical therapy versus surgery: There is debate over when to escalate from medical management to surgical approaches, particularly in fibroid-related AUB. Proponents of conservative therapy emphasize symptom control, fertility preservation, and avoidance of surgical risks; supporters of earlier surgical intervention point to definitive resolution and long-term cost considerations, especially for recurrent or refractory cases.

  • Access to care and policy implications: Access disparities affect timely diagnosis and treatment. Advocates for patient-centered care argue for broad access to both medical and surgical options, while others emphasize responsible stewardship of limited resources and the role of evidence-based guidelines to prevent unnecessary interventions.

  • Woke criticisms and medical practice: Critics of policy-oriented social debates around health care argue that sound medical practice should be guided by evidence, clinical judgment, and patient values rather than ideological campaigns. In this view, the focus should be on improving diagnostic accuracy, reducing unnecessary tests, and offering treatments that maximize safety and efficacy, while avoiding overreach or politicization of clinical decisions. Supporters of this perspective contend that patient outcomes improve when care decisions are anchored in high-quality evidence and individualized risk assessment, rather than bureaucratic mandates or identity-based narratives. When evaluating guidelines and practice patterns, many clinicians prioritize the best available data, transparency about uncertainties, and shared decision-making with patients.

See also