Harvey's Garden

Abnormal uterine bleeding

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aliasesAUB

2 min read

Abnormal uterine bleeding (AUB) is a broad term that describes irregularities in the menstrual cycle involving frequency, regularity, duration, and volume of flow outside of pregnancy

Epidemiology

Etiology

  • Intermenstrual bleeding
    • Polyp: normal pelvic exam
  • Heavy menstrual bleeding
    • Adenomyosis: mobile, globular, boggy uterus
    • Leiomyoma: enlarged, mobile uterus with irregular contour
    • Coagulopathy: normal pelvic exam
    • Endometrial dysfunction: normal pelvic exam
  • Irregular menstrual bleeding
    • Ovulatory dysfunction: normal pelvic exam c
  • Postmenopausal bleeding
    • Malignancy & hyperplasia: normal pelvic exam
  • Structural causes: polyps, adenomyosis, leiomyomas, and malignancy and hyperplasia (PALM)
  • Nonstructural causes: coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified (COEIN)

Pathophysiology

Clinical features

Diagnostics

  • Initial Step: β-hCG in all females of childbearing age to rule out pregnancy-related bleeding (ectopic, spontaneous abortion, gestational trophoblastic disease).
  • Initial Imaging: Transvaginal Ultrasound (TVUS).
    • Assesses endometrial stripe thickness (EST), structural cavity lesions (fibroids, polyps), and myometrial architecture.
    • Postmenopausal: EST ≤4 mm rules out endometrial CA (high NPV). EST >4 mm requires tissue sampling.
  • Confirmatory / Gold Standard (Tissue Diagnostic):
    • Endometrial Biopsy (EMB) Indications:
      • Age ≥45 years presenting w/ AUB.
      • Age <45 years w/ AUB + risk factors for unopposed estrogen (obesity, PCOS, failed medical management, Lynch syndrome).
      • Postmenopausal woman w/ bleeding and EST >4 mm (or persistent bleeding w/ normal TVUS).
    • Hysteroscopy w/ targeted biopsy: Gold standard for evaluating intracavitary lesions (submucosal fibroids, polyps).
    • Saline Infusion Sonohysterography (SIS): TVUS w/ intrauterine saline injection; distinguishes focal polyps vs diffuse hyperplasia/fibroids.
  • Key Labs: CBC (severity of anemia), TSH, Prolactin, Coagulation profile (PT/PTT, vWD panel if heavy bleeding since menarche), Pap smear (rule out cervical pathology).E

Treatment

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