Abnormal Uterine Bleeding (AUB)- Management

Abnormal Uterine Bleeding (AUB)- Management

It is uterine bleeding after menopause, between menstrual periods, or abnormally heavy and/or prolonged menstrual bleeding. Abnormal uterine bleeding (AUB) is a common condition affecting women and has significant social and economic impact.

The causes of AUB are classified and summarized using the acronym PALM-COEIN:

• P - Polyps

• A - Adenomyosis

• L - Leiomyoma

• M - Malignancy

• C - Coagulopathy

• O - Ovulatory dysfunction

• E - Endometrial causes

• I - Iatrogenic

• N - Not yet classified

Clinical presentation

Polyps

• Contact vaginal bleeding

• Abnormal vaginal discharge

Adenomyosis

• Premenstrual uterine cramps

• Dysmenorrhea

Leiomyoma

• Abdominal mass and distension

• Heavy or prolonged menstrual bleeding

• Pelvic pain or heaviness

• Lower abdominal pain and discomfort

Malignancy

• Presentation depends on type of malignancy

• Abnormal intermenstrual or postmenopausal contact bleeding (cervical cancer)

• Foul smelling bloody or mucoid vaginal discharge

• Weight loss, loss of appetite, early satiety

Coagulopathy

• History of bleeding tendencies

• Heavy and/or prolonged menstruation

Ovulatory dysfunction

• Irregular bleeding, often heavy

• Infertility or subfertility

Endometrial causes

• Heavy or prolonged menstruation

• Irregular menstruation associated with endometrial hyperplasia

Investigations

• Investigate according to the possible cause of AUB based on clinical suspicion

• Complete blood count (CBC)

• Pregnancy test in reproductive age to exclude pregnancy

• Examination under anaesthesia and biopsy in case of malignancy

• Cervical and vaginal swab

• Abdominal pelvic ultrasound, CT scan, MRI, X-ray as indicated

• Liver function tests, renal function tests, electrolytes

• Hysteroscopy, cystoscopy, proctoscopy in case of suspected malignancy

• Biopsy in case of suspected malignancy

• Specific tumour markers in certain suspected malignancies e.g. ovarian tumours

• Testing for coagulation disorders should be considered only in women who have a history of heavy menstrual bleeding beginning at menarche or who have a personal or family history of abnormal bleeding

Pharmacological treatment

Treatment depends on the causative factor:

• Tranexamic acid (PO) 500–1000 mg 6–8 hourly as required until bleeding is controlled

  
  

  OR

• Combined oral contraceptives (PO) useful for anovulatory bleeding

  
  

  OR

• Medroxyprogesterone acetate (PO) 5–10 mg 24 hourly for 10–14 days initially and repeated for 10 days each month thereafter

  
  

  OR

• Norethisterone (PO) 5 mg 24 hourly for 10 days, then 5 mg 12 hourly from days 19 to 26 of the two subsequent cycles to prevent recurrence

Surgical management

AUB due to organic causes may be amenable to surgical intervention. The decision regarding the approach and timing for surgical intervention should depend on final diagnosis, expertise, and available resources.

Referral

Immediately refer to the next level facility capable of appropriate evaluation and management.