Publication:

Management of abnormal uterine bleeding: good clinical practice recommendations

Abnormal uterine bleeding (AUB) refers to menstrual bleeding that deviates from normal in terms of frequency, regularity, duration, or volume. The PALM-COEIN classification system is the standardized framework for categorizing AUB, encompassing structural causes (polyp, adenomyosis, leiomyoma, malignancy PALM) and non-structural causes (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified COEIN). Initial evaluation includes a comprehensive history and physical examination, with attention to signs suggestive of coagulopathy such as heavy bleeding from menarche, epistaxis, gum bleeding, or a positive family history. Laboratory investigations should include CBC, coagulation profile, thyroid function, and targeted testing for Von Willebrand disease in cases with suspected coagulopathies. Transvaginal ultrasonography is essential for evaluating the uterus, adnexa, and endometrial thickness; 3D-ultrasound or saline infusion sonography may be indicated for intracavitary or myometrial lesions. Medical management is typically first-line, with options including NSAIDs, tranexamic acid, hormonal therapies (COCs, progestins, LNG-IUS), and GnRH analogs depending on etiology, severity, and fertility preferences. Acute heavy bleeding is managed with high-dose oral progestins or COCs, and adjunctive use of tranexamic acid. In coagulopathies (AUB-C), nonhormonal therapies are preferred initially, with hematology consultation advised. Surgical interventions such as hysteroscopic polypectomy or myomectomy are reserved for refractory cases or where structural lesions exist. Hysterectomy is considered definitive for those who fail medical therapy or do not wish to preserve fertility, particularly in cases of malignancy or persistent hyperplasia. In adolescents, conservative medical management is emphasized. AUB requires a tailored, multidisciplinary approach to optimize outcomes and ensure long-term reproductive and overall health.