Abnormal Uterine Bleeding

Laurie A.P. Mitan

Beth I. Schwartz

Abnormal uterine bleeding (AUB) is a common menstrual problem during adolescence. When severe, it can result in life-threatening anemia. Even when mild, it is usually both a concern and a nuisance for the adolescent or young adult. In 2011, the International Federation of Gynecology and Obstetrics recommended discontinuation of the popular term dysfunctional uterine bleeding and the use of a new classification system for causes of AUB in nonpregnant women known by the acronym PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified)¹,² (Table 48.1). The etiology of AUB is quite different in the adolescent and young adult (AYA) compared to that of the older adult. Uterine fibroids and malignancy are the leading diagnoses in the older adult, but are rare in women under age 39. This chapter will focus mainly on AUB that falls into the COEIN subtypes, with ovulatory dysfunction being the leading cause in AYAs.

DEFINITIONS

Normal menstrual cycles occur every 21 to 40 days, with 2 to 8 days of bleeding and 20 to 80 mL of blood loss per cycle.

TABLE 48.1 AUB Classification System for Nonpregnant Women of Reproductive Age, Known by the Acronym PALM-COEIN

PALM: Structural Etiologies	COEIN: Nonstructural Etiologies
Polyp (AUB-P)	Coagulopathy (AUB-C)
Adenomyosis (AUB-A)	Ovulatory (AUB-O)
Leiomyoma (AUB-L)	Endometrial (AUB-E)
Malignancy and hyperplasia (AUB-M)	Iatrogenic (AUB-I)
	Not yet classified (AUB-N)
Modified from Munro MG, Critchley HOD, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynecol Obstet 2011;113:3-13.

Up to 80% of menstrual cycles are anovulatory in the first year after menarche. Cycles become ovulatory on average by 20 months after menarche.
Menorrhagia, prolonged or heavy uterine bleeding that occurs at regular intervals, is now known as AUB/heavy menstrual bleeding.¹
Metrorrhagia, uterine bleeding that occurs at irregular intervals, is now referred to as AUB/intermenstrual bleeding.¹
Oligomenorrhea is uterine bleeding that occurs at prolonged intervals of 41 days to 3 months, but is of normal flow, duration, and quantity, and is discussed in Chapter 49.

EVALUATION

The evaluation of any patient with bleeding begins with an assessment of hemodynamic stability. The next objective is to determine the site of bleeding (e.g., gastrointestinal, urinary, vaginal, cervical, or uterine). Once the site of bleeding is found to be uterine, the evaluation focuses on determination of its cause.

History

The history should be obtained from the adolescent or young adult and, if possible, the parent or guardian. The sexual history should be obtained from the patient alone.

Menstrual history: Age at menarche, cycle regularity, cycle duration, flow by number of pads or tampons over a 24-hour period, need to double up products or change products overnight, “gushing” or “flooding” sensation, frequency of bleeding through products, interference with daily activities including absences from school or work, dysmenorrhea, symptoms of anemia.³
Sexual history: Age at coitarche, use of condoms, contraception, pregnancies, deliveries, miscarriages, abortions, past sexually transmitted infections (STIs)/pelvic inflammatory disease, number of partners, new partner, vaginal discharge, known exposure to an STI. A history of sexual abuse, genital trauma, or foreign body is also essential to ascertain.
History of systemic illness, anemia, iron deficiency, frequent nose bleeds, easy bleeding or bruising, excessive bleeding after surgery or dental procedures, history of blood transfusions, recent changes in weight, eating, exercise, stress, or medications
Endocrine history: Symptoms suggestive of hypothyroidism (e.g., fatigue, weight gain), hyperthyroidism (e.g., palpitations, weight loss), or hyperandrogenism (e.g., hirsutism, severe acne), and exogenous hormone use
Family history: AUB, bleeding diathesis, infertility, diabetes mellitus
Medications: Recent use of hormone contraception, antipsychotics, or anticonvulsants

Physical Examination

Vital signs should include date of last menstrual period, height, weight, body mass index, and blood pressure and heart rate in supine, sitting, and standing positions to detect orthostatic changes. Thorough physical exam should note sexual maturity rating of breasts and pubic hair, as well as presence or absence of galactorrhea. Pelvic examination should be considered in sexually active patients to screen for STIs. However, it is unnecessary in virginal teens whose clinical presentation is otherwise consistent with anovulatory bleeding.

Laboratory Tests

Laboratory testing may not be necessary in the adolescent with mild anovulatory bleeding associated with physiological immaturity. Depending on the history and physical examination, other patients may require some of the following laboratory evaluation¹: