Abnormal Uterine Bleeding

AUB: Basics & PALM-COEIN - Decoding the Drip

• AUB: Abnormal Uterine Bleeding - deviation from normal menstrual cycle (frequency, regularity, duration, volume).
  • Normal: Cycle 21-35 days, duration ≤7 days, volume 5-80 mL.
• Key Patterns:
  • Heavy Menstrual Bleeding (HMB): >80 mL/cycle or >7 days, or impacting QoL.
  • Intermenstrual Bleeding (IMB): Bleeding between menses.
• PALM-COEIN (FIGO Classification): 📌
  • PALM (Structural):
    • Polyp (AUB-P)
    • Adenomyosis (AUB-A)
    • Leiomyoma (AUB-L)
    • Malignancy/Hyperplasia (AUB-M)
  • COEIN (Non-Structural):
    • Coagulopathy (AUB-C)
    • Ovulatory Dysfunction (AUB-O)
    • Endometrial (AUB-E)
    • Iatrogenic (AUB-I)
    • Not Yet Classified (AUB-N)

⭐ AUB-O (Ovulatory dysfunction) is the most common cause of AUB, particularly at extremes of reproductive age.

AUB: Etiology In-Depth - Cause Code Crackdown

PALM (Structural)

• Polyp: Endometrial/cervical. Intermenstrual/postcoital bleeding.
• Adenomyosis: Endometrial tissue in myometrium. HMB, dysmenorrhea, tender bulky uterus.
• Leiomyoma: Fibroids. Submucosal type most often causes AUB.
• Malignancy/Hyperplasia: Endometrial cancer (esp. PMB). Biopsy >45 yrs or risk factors.

COEIN (Non-Structural)

• Coagulopathy: Von Willebrand disease (commonest). Screen if HMB from menarche/family Hx.
• Ovulatory Dysfunction: PCOS, thyroid, stress → unopposed estrogen → irregular, heavy bleeding.
• Endometrial: Local factors (e.g., endometritis). Diagnosis of exclusion.
• Iatrogenic: Hormonal contraception (breakthrough), anticoagulants, copper IUDs.
• Not Classified: Rare (AVMs, C-section scar defect/isthmocele).

⭐ Up to 20% of adolescents with severe AUB have a coagulopathy, often Von Willebrand disease.

AUB: Diagnostic Approach - Sleuthing the Source

• History: Menstrual (LMP, cycle, flow, IPB, PCB), medical, family Hx (bleeding disorders, cancer).
• Examination: General (pallor, BMI, thyroid), P/A, P/S & P/V (source, uterine size, adnexa).
• Investigations (guided by PALM-COEIN framework):
  • Labs: CBC, β-hCG, TSH. Coagulation profile if indicated.
  • Imaging: TVS (1st line). SIS for better endometrial view.
  • Endometrial Sampling: Biopsy if >45 yrs, risk factors (obesity, PCOS), persistent AUB, failed Rx.
  • Hysteroscopy: Gold standard for intrauterine pathology.

![Heavy Menstrual Bleeding: Diagnosis Pathway](https://ylbwdadhbcjolwylidja.supabase.co/storage/v1/object/public/notes/L1/Obstetrics_and_Gynecology_Gynecological_Disorders_Abnormal_Uterine_Bleeding/614b298b-95eb-4810-9b16-502889ea84c0.jpg)
> ⭐ Endometrial sampling is crucial for women >**45** years with AUB to exclude endometrial hyperplasia or carcinoma.

AUB: Management Strategies - Taming the Tide

• Acute AUB:
  • Assess hemodynamic stability: IV fluids, urgent blood transfusion if Hb < 7 g/dL.
  • Medical (rapid control):
    • High-dose IV Estrogen (CEE 25 mg q4-6h).
    • High-dose Progestins (MPA 20 mg TID).
    • Tranexamic acid (1.3 g PO / 10 mg/kg IV TID, max 600mg/dose).
    • High-dose OCPs (tapering regimen).
  • Surgical (if medical fails/CI): D&C, hysteroscopy.
• Chronic AUB (PALM-COEIN guided):
  • Medical (long-term management):
    • Non-hormonal: NSAIDs (during menses), Tranexamic acid.
    • Hormonal: OCPs, Progestins (oral, depot, LNG-IUS), GnRH analogs (short-term).
  • Surgical (cause-specific/refractory): Endometrial ablation, Myomectomy, Polypectomy, Hysterectomy.

⭐ LNG-IUS is first-line for AUB-O and AUB-E in many cases, reducing blood loss by up to 90%.

High‑Yield Points - ⚡ Biggest Takeaways

• PALM-COEIN is the primary AUB classification system, guiding diagnosis and management.
• Endometrial sampling is vital for women >45 years or with risk factors for malignancy.
• Ovulatory dysfunction (AUB-O), often linked to PCOS, is a frequent cause.
• Structural lesions (polyps, adenomyosis, leiomyomas) are best identified via ultrasound or hysteroscopy.
• Medical therapy (hormonal, tranexamic acid) is the initial approach for most AUB.
• Heavy Menstrual Bleeding (HMB) is defined as blood loss >80 mL per cycle or lasting >7 days.
• Suspect coagulopathy in adolescents with severe HMB, especially if present since menarche.