Abnormal Uterine Bleeding

Abnormal Uterine Bleeding (AUB)

Overview

Abnormal uterine bleeding (AUB) refers to bleeding from the uterus that is irregular in volume, duration, or timing and not related to normal menstruation. It may be acute (requiring urgent intervention) or chronic.

Common causes are classified by the PALM–COEIN system:

• Structural (PALM): Polyp, Adenomyosis, Leiomyoma (fibroids), Malignancy/hyperplasia.

• Non-structural (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified.

---

Treatment Options

1. Acute Severe Bleeding (Hemodynamically Unstable)

• IV fluids and blood transfusion if necessary.

• High-dose IV estrogen:

  • Conjugated estrogens (Premarin®): 25 mg IV every 4–6 hours for 24 hours.

• High-dose combined oral contraceptives (COCs):

  • Ethinylestradiol 30–35 µg + levonorgestrel 0.15 mg PO, 1 tab TID for 7 days, then taper.

• Tranexamic acid: 1 g IV every 6–8 hours or 1–1.5 g PO TID during bleeding.

---

2. Chronic/Non-Emergency Management

• Hormonal Therapies

  • Levonorgestrel-releasing IUD (Mirena®): 20 µg/day, effective up to 5 years.

  • Combined oral contraceptives (COCs): regulate cycles, reduce flow.

  • Oral progestins:

    • Medroxyprogesterone acetate: 10 mg PO daily for 10–14 days each cycle or continuously.

    • Norethisterone: 5 mg PO TID for 10–14 days.

  • GnRH agonists (e.g., leuprolide 3.75 mg IM monthly): short-term use in fibroid-related AUB.

• Non-Hormonal Therapies

  • Tranexamic acid: 1–1.5 g PO TID during menses.

  • NSAIDs (e.g., mefenamic acid 500 mg PO TID, ibuprofen 400 mg PO TID during menses): reduce prostaglandin-mediated bleeding.

---

3. Surgical Options

• Endometrial ablation: for women who do not desire fertility.

• Myomectomy: for fibroid-related bleeding if fertility is desired.

• Hysterectomy: definitive treatment when conservative measures fail or malignancy suspected.

• Hysteroscopic polypectomy: for endometrial/cervical polyps.

---

Supportive & Monitoring Measures

• Iron supplementation for anemia (e.g., ferrous sulfate 325 mg PO TID).

• Regular hemoglobin and hematocrit checks.

• Pelvic ultrasound, hysteroscopy, or biopsy to identify structural causes.

• Counseling on fertility preservation and contraception.

---

Key Notes

• AUB is a symptom, not a diagnosis — always rule out pregnancy and malignancy.

• In adolescents, most cases are anovulatory bleeding, often managed with reassurance or hormonal therapy.

• In peri- and postmenopausal women, endometrial hyperplasia or malignancy must be excluded.

• Treatment choice depends on age, cause, severity, fertility desires, and comorbidities.