1. Approach to Abnormal Uterine Bleeding
Brent E. Seibel, MD
Chief, Benign Gynecology
Medical Director, UF Health North Jacksonville
Associate Professor of Obstetrics and Gynecology
University of Florida College of Medicine-Jacksonville

2. Disclosures
I have no conflicts to disclose

3. Objectives
Describe nomenclature, work up and management of abnormal uterine bleeding
Illustrate treatment plan options for the PCP

4. Resources
Committee on Practice Bulletins-Gynecology. Practice Bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol 2012; 120:197
Munro MG, Critchley HO, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011; 113:3
UpToDateR : Approach to abnormal uterine bleeding in nonpregnant reproductive-age women.

5. Introduction Abnormal uterine bleeding (AUB)
Menstrual bleeding of abnormal quantity, duration, or schedule
AUB terminology more descriptive than menorrhagia, metrorrhagia, etc.
Accounts for 1/3 outpatient visits to gynecologists
Wide variety of local and systemic diseases or medications
Annual prevalence of 53 per 1000 women
Common etiologies
Structural, anovulation, disorders of hemostasis or neoplasia

6. Abnormal Uterine Bleeding
Heavy Menstrual Bleeding (AUB-HMB)
Intermenstrual Menstrual Bleeding (AUB-IMB)
PALM: Structural
Polyp (AUB-P)
Adenomyosis (AUB-A)
Leiomyoma (AUB-L)
Malignancy and
Hyperplasia (AUB-M)
COEIN: Non-Structural
Coagulopathy (AUB-C)
Ovulatory Dysfunction (AUB-O)
Endometrial (AUB-E)
Iatrogenic (AUB-I)
Not Yet Classfied (AUB-N)

7. PALM: Structural
Polyps

8. PALM: Structural
Adenomyosis

9. PALM: Structural
Leiomomas

10. PALM: Structural
Malignancy and
Hyperplasia

11. COEIN: Non-structural
Coagulopathy
Inherited and acquired
May occur in up to 20% of patients with HMB
Indications for evaluation
HMB since menarche
Postpartum hemorrhage, excessive surgical bleeding or bleeding with dental work, or any two of the following
Bruising 1-2 times per month
Epitaxis 1-2 times per month
Frequent gum bleeding
Family history of bleeding symptoms

12. COEIN: Non-structural
Ovulatory Dysfunction
(From amenorrhea and oligomenorrhea to frequent irregular menses)
Hypothalimic hypogonadotropic hypogonadism
Thyroid dysfunction
Hyperprolactinemia
Hyperandrogenemia/PCOS
Premature ovarian insufficiency
Idiopathic anovulation
Chronic illness

13. COEIN: Non-structural
Endometrial Abnormalities
Abnormal endometrial angiogenesis
Prostaglandin production
Vasoconstriction
Increased fibrinolysis

14. COEIN: Non-structural
Iatrogenic
Contraceptives
OCPs, patch or ring
Depo Provera (DMPA)
Contraceptive implant (Nexplanon)
Intrauterine device (IUD)
Other medications
Antipsychotics
Anticoagulants
other

15. Evaluation: History Age of menarche Menstrual bleeding pattern
Severity of bleeding
Pain
Medical history
Surgical history
Family history
Bleeding disorders, PCOS, diabetes, cancer

16. Evaluation: Medications
Anticoagulants
Hormonal medications
NSAIDS
Antipsychotics
Supplements

17. Evaluation: Physical Exam
Weight extremes
Skin
Acanthosis nigrans
Hirsuitism
Acne
Pallor
Petechiae or echymosis
Thyroid
Abdomen
Pelvic

18. Evaluation: Labs Pregnancy test STD testing if indicated Pap smear CBC
TSH

19. Evaluation: Labs Bleeding disorder Hyperandrogenism/PCOS PT/PTT/INR
Platelet function
Fibrinogen
Hyperandrogenism/PCOS
Testosterone
DHEAS
17-OHP
HgbA1C, lipids, CMP

20. Evaluation: Labs
Amenorrhea/Oligomenorrhea
Prolactin
FSH/LH
Estradiol

21. Evaluation: Imaging Transvaginal ultrasound
Saline Infusion Sonohysterogram (SIS)
Excellent for cavity assessment
MRI
Fibroid mapping
Mullerian anomalies
Adenomyosis

22. Evaluation: Tissue Sampling
Endometrial biopsy
Women > age 45 with AUB
Women < age 45 with chronic anovulation
Obese
PCOS
Unopposed estrogens
Hysteroscopy
D&C

23. Treatment: Medical Combined oral contraceptives Progesterone therapy
Intramuscular
Levonorgestrel intrauterine system (IUD)
Tranexamic acid
NSAIDs

24. Treatment: Surgical Dilation and Curettage (D&C) Hysteroscopy
Diagnostic
Operative (polypectomy, myomectomy)
Endometrial ablation
Uterine artery embolization (UAE)
Myomectomy
Hysterectomy

25. Adolescent with AUB (HMB or IMB)
History and physical exam
*Pelvic ultrasound
Peripubertal anovulatory bleeding
Bleeding disorder
Expectant management
Treatment with OCPs or cyclic MPA
Refer
Ped/Ad Gyn or
Hematology

26. Reproductive Age with AUB-HMB
History, Physical exam and labs
*Pelvic ultrasound
Abnormal pelvic exam
Normal pelvic exam
Success!
No further workup
Pelvic ultrasound
Treat abnormality
Treat:
OCPs
Progesterone
LngIUD
Tranexamic acid
NSAIDs
Pelvic ultrasound
Refer to GYN

27. Reproductive Age with AUB-IMB
History, Physical exam and labs
*Pelvic ultrasound
Short-term IMB
Long-standing IMB
Expectant management or
Treatment:
OCPs
Progesterone
Pelvic ultrasound (TVS)
Cavity evaluation*
GYN referral
EmBx*
Treatment failure
TVS/Cavity evaluation
GYN referral
Success!
No further workup

28. Summary AUB a common condition among reproductive age women
Evaluation and initial management by PCP
Differentiate between structural and non- structural causes
PALM – COEIN terminology

29. Thank you!
Questions?