Abnormal Uterine Bleeding
Evidence-Based Clinical Guidelines and Management
Clinical Practice
Evidence-Based
Professor Mykhailo Medvediev
Based on International Guidelines and Evidence-Based Medicine
Learning Objectives
1
Terminology
Understand standardized FIGO terminology for abnormal uterine bleeding patterns
2
Evaluation
Master systematic diagnostic approach for reproductive-age patients
3
Management
Apply evidence-based treatment strategies for different bleeding patterns
4
Special Populations
Recognize unique considerations for adolescents and high-risk patients

This presentation synthesizes current international guidelines including ACOG, FIGO, and NICE recommendations
Reference: Munro MG, et al. Int J Gynaecol Obstet 2018;143:393
Definition and Scope
What is AUB?
Abnormal uterine bleeding encompasses menstrual bleeding of abnormal quantity, duration, or schedule in non-pregnant reproductive-age women.
AUB is one of the most common gynecologic concerns, affecting quality of life and potentially indicating serious underlying conditions.
Clinical Impact
  • Affects 10-30% of reproductive-age women
  • Leading cause of gynecologic consultations
  • Can result in anemia and iron deficiency
  • May indicate endometrial hyperplasia or cancer
  • Significant impact on quality of life
Reference: ACOG Practice Bulletin No. 128. Obstet Gynecol 2012;120:197
FIGO Classification System
Two Complementary Systems
System 1
Nomenclature and Definitions
Standardized terminology for normal and abnormal uterine bleeding patterns
System 2
PALM-COEIN Classification
Systematic categorization of causes of abnormal uterine bleeding
The International Federation of Gynecology and Obstetrics (FIGO) developed these systems to standardize communication among clinicians and researchers worldwide.
Reference: Munro MG, Critchley HOD, Fraser IS. Int J Gynaecol Obstet 2018;143:393
Normal Menstrual Parameters
Frequency
24-38 days
Interval from first day of one cycle to first day of next
Duration
≤8 days
Number of days of menstrual flow
Regularity
Variation ≤9 days
Cycle-to-cycle variation (ages 18-25, 42-45)
Variation ≤7 days (ages 26-41)
Volume
5-80 mL per cycle
Patient perception and quality of life impact are key
Reference: Munro MG, et al. Int J Gynaecol Obstet 2018;143:393
Abnormal Bleeding Patterns
Frequency Abnormalities
Frequent
Cycles <24 days apart
Infrequent
Cycles >38 days apart
Absent
Amenorrhea for ≥6 months
Other Abnormalities
Irregular Bleeding
Cycle length variance >9 days (ages 18-25, 42-45) or >7 days (ages 26-41)
Prolonged Bleeding
Menstrual bleeding consistently lasting >8 days
Heavy Menstrual Bleeding
Volume that interferes with physical, social, emotional, or material quality of life
Intermenstrual Bleeding
Bleeding between well-defined cyclical menses
Reference: Munro MG, et al. Int J Gynaecol Obstet 2018;143:393
PALM-COEIN Classification
Structural Causes (PALM)
Polyp
Endometrial polyps protruding into uterine cavity
Adenomyosis
Endometrial tissue within myometrium
Leiomyoma
Uterine fibroids (submucosal most likely to cause AUB)
Malignancy
Endometrial hyperplasia or carcinoma
Reference: Munro MG, et al. FIGO classification system. Int J Gynaecol Obstet 2011;113:3
PALM-COEIN Classification
Non-Structural Causes (COEIN)
Coagulopathy
Von Willebrand disease, platelet disorders, anticoagulant therapy
Ovulatory dysfunction
Anovulation, PCOS, thyroid disorders, hyperprolactinemia
Endometrial
Primary endometrial disorders of hemostasis
Iatrogenic
Hormonal contraceptives, IUDs, anticoagulants
Not classified
Cesarean scar defects, AVMs, chronic endometritis
Reference: Munro MG, et al. FIGO classification system. Int J Gynaecol Obstet 2011;113:3
Initial Evaluation: History
Essential Components
01
Bleeding Pattern
Frequency, duration, volume, regularity, intermenstrual bleeding
02
Menstrual History
Age at menarche, last menstrual period, previous patterns
03
Sexual History
Pregnancy risk, STI risk, contraceptive use
04
Medical History
Bleeding disorders, thyroid disease, medications, chronic conditions
05
Surgical History
Prior cesarean births, uterine procedures, cervical procedures

Key Questions: Quantify bleeding using validated tools. Ask about clots >2.5 cm, bleeding through clothes, nighttime pad changes, and impact on daily activities.
Reference: ACOG Practice Bulletin No. 128. Obstet Gynecol 2012;120:197
Assessing Menstrual Blood Loss
Clinical Assessment Tools
Patient-Reported Indicators
  • Passing blood clots >2.5 cm (1 inch) in diameter
  • Bleeding through clothes despite protection
  • Needing to change protection during the night
  • Needing to use double protection
  • Changing saturated pad/tampon every 1-2 hours
  • Bleeding lasting >7 days
Quality of Life Impact
Heavy menstrual bleeding is defined as volume that interferes with physical, social, emotional, or material quality of life.
Objective Measures
Pictorial Blood Loss Assessment Chart (PBAC)
Score >100 suggests blood loss >80 mL/cycle
Alkaline Hematin Method
Gold standard for research: >80 mL = HMB
Reference: Higham JM, et al. Br J Obstet Gynaecol 1990;97:734
Physical Examination
1
General Assessment
Vital signs, BMI, signs of anemia (pallor, tachycardia), thyroid examination, signs of hyperandrogenism
2
Abdominal Examination
Masses, tenderness, hepatosplenomegaly, ascites
3
Pelvic Examination
External genitalia, vaginal inspection, cervical assessment, bimanual examination
4
Key Findings
Uterine size/contour, adnexal masses, cervical lesions, active bleeding source, discharge
Reference: ACOG Practice Bulletin No. 128. Obstet Gynecol 2012;120:197
Laboratory Evaluation
Initial Testing for All Patients
Pregnancy Test
Urine or serum hCG - mandatory for all reproductive-age patients
Complete Blood Count
Assess for anemia, thrombocytopenia
Additional Testing Based on Clinical Suspicion
Endocrine Evaluation
  • TSH (thyroid dysfunction)
  • Prolactin (hyperprolactinemia)
  • FSH (premature ovarian insufficiency)
  • Androgens (PCOS, hyperandrogenism)
Coagulation Studies
  • PT/INR (if on warfarin)
  • von Willebrand panel (if HMB)
  • Platelet function studies
  • Factor levels (if indicated)
Reference: ACOG Committee Opinion No. 580. Obstet Gynecol 2013;122:1368
Bleeding Disorders Screening
When to Screen for Coagulopathy
Heavy Menstrual Bleeding Since Menarche
Suggests inherited bleeding disorder
Personal History
Postpartum hemorrhage, surgery-related bleeding, dental procedure bleeding
Family History
Diagnosed bleeding disorder in family members
Clinical Signs
Easy bruising, frequent nosebleeds, gum bleeding, prolonged bleeding from minor cuts

Important: Von Willebrand disease affects approximately 1% of the general population but is found in 13-20% of women with heavy menstrual bleeding.
Reference: ACOG Committee Opinion No. 580. Obstet Gynecol 2013;122:1368
Imaging: First-Line Approach
Transvaginal Ultrasound
Indications
  • Suspected structural abnormality
  • Palpable uterine mass or irregularity
  • Heavy or prolonged bleeding
  • Failed medical management
  • Risk factors for endometrial cancer
Advantages
  • Non-invasive, well-tolerated
  • Excellent visualization of uterus and adnexa
  • Can assess endometrial thickness
  • Identifies fibroids, polyps, adenomyosis
  • Cost-effective first-line imaging
Key Findings
Uterine size and contour
Endometrial thickness (variable in reproductive age)
Intracavitary lesions (polyps, submucosal fibroids)
Myometrial abnormalities (fibroids, adenomyosis)
Adnexal masses
Reference: ACR Appropriateness Criteria. J Am Coll Radiol 2020;17:S336
Advanced Imaging Techniques

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Saline Infusion Sonography (SIS)
Sterile saline instilled into endometrial cavity during transvaginal ultrasound
Best for: Detecting endometrial polyps, submucosal fibroids, intrauterine adhesions
Hysteroscopy
Direct visualization of endometrial cavity with camera
Best for: Diagnosis and treatment of intracavitary lesions, targeted biopsy
MRI Pelvis
Detailed soft tissue imaging without radiation
Best for: Adenomyosis, large fibroids, preoperative planning, complex cases
Reference: Farquhar C, et al. Acta Obstet Gynecol Scand 2003;82:493
Endometrial Sampling: Indications
Age-Based Approach
Age ≥45 Years
Any abnormal bleeding pattern: frequent, heavy, prolonged, or intermenstrual
Age <45 Years
Persistent bleeding (≥6 months) PLUS risk factors for endometrial cancer
Any Age
Obesity (BMI ≥30), chronic anovulation, failed medical management, Lynch syndrome
Risk Factors for Endometrial Cancer
  • Obesity (BMI ≥30 kg/m²)
  • Chronic anovulation/PCOS
  • Unopposed estrogen exposure
  • Tamoxifen therapy
  • Lynch syndrome
  • Cowden syndrome
  • Diabetes mellitus
  • Nulliparity
Reference: ACOG Practice Bulletin No. 128. Obstet Gynecol 2012;120:197
Endometrial Sampling Methods
Office Endometrial Biopsy
Preferred initial method - Pipelle or similar device
Advantages: Office-based, no anesthesia, cost-effective, well-tolerated
Sensitivity: 91% for endometrial cancer, 81% for hyperplasia
Hysteroscopy with Directed Biopsy
When office biopsy inadequate or failed
Advantages: Direct visualization, targeted sampling, can treat lesions
Indications: Focal lesions, persistent bleeding, inadequate office sample
Dilation and Curettage (D&C)
Reserved for specific situations
Indications: Acute heavy bleeding requiring intervention, failed other methods
Note: Less sensitive than hysteroscopy for focal lesions
Reference: Clark TJ, et al. Lancet 2002;359:1776
Management Overview
Treatment Goals
Control Bleeding
Reduce volume and duration of menstrual flow
Improve Quality of Life
Restore normal activities and well-being
Prevent Complications
Avoid anemia, endometrial hyperplasia
Treat Underlying Cause
Address structural or systemic etiologies

Treatment should be individualized based on bleeding pattern, severity, underlying etiology, patient preferences, contraceptive needs, and desire for future fertility.
Reference: NICE Guideline NG88. Heavy menstrual bleeding, 2018
Medical Management: First-Line Options
Hormonal Therapies
Combined Oral Contraceptives
Mechanism: Endometrial atrophy, cycle regulation
Efficacy: 35-69% reduction in menstrual blood loss
Advantages: Contraception, cycle control, widely available
LNG-IUD (52 mg)
Mechanism: Local endometrial suppression
Efficacy: 71-95% reduction in menstrual blood loss
Advantages: Most effective medical therapy, long-acting, contraception
Oral Progestins
Mechanism: Endometrial stabilization and atrophy
Options: Cyclic or continuous norethindrone acetate, MPA
Advantages: No estrogen, flexible dosing
Reference: Matteson KA, et al. Obstet Gynecol 2013;121:632
Medical Management: Non-Hormonal Options
Tranexamic Acid
Mechanism: Antifibrinolytic - inhibits plasminogen activation
Dosing: 1300 mg PO three times daily during menses (up to 5 days)
Efficacy: 26-54% reduction in menstrual blood loss
Advantages:
  • No hormonal effects
  • Taken only during menses
  • Effective for bleeding disorders
Contraindications:
  • Active thrombosis
  • History of VTE (relative)
  • Renal impairment
NSAIDs
Mechanism: Reduce prostaglandin synthesis, promote vasoconstriction
Options:
  • Ibuprofen 600 mg 2-4x daily
  • Naproxen 500 mg twice daily
  • Mefenamic acid 500 mg 3x daily
Efficacy: 10-52% reduction in menstrual blood loss
Advantages:
  • Also treats dysmenorrhea
  • Taken only during menses
  • Inexpensive, widely available
Contraindications:
  • Bleeding disorders
  • Anticoagulant therapy
  • GI ulcers, renal disease
Reference: Lukes AS, et al. Obstet Gynecol 2010;116:865
Comparative Effectiveness
Medical Treatments for Heavy Menstrual Bleeding
The LNG-IUD demonstrates superior efficacy compared to other medical treatments, with the highest reduction in menstrual blood loss and improvement in quality of life measures.
Reference: Bofill Rodriguez M, et al. Cochrane Database Syst Rev 2022;5:CD013180
Surgical Management Options
Hysteroscopic Procedures
Polypectomy, myomectomy for submucosal fibroids, adhesiolysis
Advantages: Minimally invasive, preserves fertility, targeted treatment
Endometrial Ablation
Destruction of endometrial lining (various techniques)
Indications: Completed childbearing, failed medical management
Success rate: 80-90% satisfaction, 20-30% amenorrhea
Hysterectomy
Definitive treatment - removal of uterus
Indications: Failed other treatments, structural pathology, patient preference
Approaches: Vaginal, laparoscopic, or abdominal
Reference: Lethaby A, et al. Cochrane Database Syst Rev 2013:CD001501
Treatment Selection Algorithm

Key Principles: Start with least invasive options, consider patient preferences and contraceptive needs, address underlying etiology when possible, escalate to surgical management if medical therapy fails.
Reference: NICE Guideline NG88. Heavy menstrual bleeding, 2018
Special Population: Adolescents
Unique Considerations
Etiology
Anovulation is the most common cause due to immature hypothalamic-pituitary-ovarian axis
Bleeding disorders are more common than in adults (13-20% vs 1%)
Evaluation
  • Detailed bleeding history since menarche
  • Screen for bleeding disorders if HMB
  • Avoid invasive procedures when possible
  • Consider impact on school and activities
Management Approach
Mild bleeding: Observation, menstrual calendar
Moderate bleeding: Combined OCs or progestins
Severe bleeding: High-dose hormonal therapy, possible hospitalization
Long-Term Monitoring
  • Most resolve with HPO axis maturation
  • Monitor for development of regular cycles
  • Screen for PCOS if persistent anovulation
  • Ensure adequate iron supplementation
Reference: ACOG Committee Opinion No. 651. Obstet Gynecol 2015;126:e143
Adolescent Management: Severity-Based
1
2
3
4
1
Mild Bleeding
Observation, menstrual diary, iron supplementation if needed
2
Moderate Bleeding
Combined OCs (30-35 mcg EE) or oral progestins, consider contraceptive needs
3
Severe Bleeding (Hgb <10 g/dL)
High-dose combined OCs with taper, consider hospitalization if Hgb <7 or unstable
4
Life-Threatening Bleeding
Hospitalization, IV estrogen, hemostatic agents, possible transfusion, hematology consult

Important: Obtain bleeding disorder labs before administering estrogen or blood products. Exogenous estrogen can normalize von Willebrand factor levels and mask diagnosis.
Reference: ACOG Committee Opinion No. 785. Obstet Gynecol 2019;134:e71
Acute Heavy Bleeding Management
Hemodynamically Stable Patients
1
High-Dose Combined OCs
Monophasic 30-35 mcg EE: 1 pill every 4-6 hours until bleeding stops (usually 24-48h), then taper
2
Add Antiemetic
Ondansetron 4-8 mg or promethazine 12.5-25 mg before each hormone dose
3
Consider Tranexamic Acid
1300 mg PO three times daily (if no VTE contraindications)
4
Iron Supplementation
Oral or IV iron to treat anemia
Hemodynamically Unstable Patients
Immediate Actions: Hospitalization, IV access, CBC, type and screen, hemodynamic stabilization
Treatment: IV conjugated estrogen 25 mg every 4-6 hours (max 6 doses), transition to oral hormones once stable
Reference: ACOG Committee Opinion No. 557. Obstet Gynecol 2013;121:891
Contraindications to Estrogen Therapy
Thromboembolism
History of VTE or arterial thrombosis
Cardiovascular
Ischemic heart disease, stroke, complicated valvular disease
Migraine with Aura
At any age
Hepatic Disease
Active liver disease or tumors
Estrogen-Dependent Tumors
Breast cancer, endometrial cancer
Smoking + Age
Age ≥35 years and smoking ≥15 cigarettes/day
Alternative Options: Progestin-only methods (oral, IUD, depot), tranexamic acid, NSAIDs, surgical management
Reference: CDC US Medical Eligibility Criteria 2024. MMWR 2024;73:1
Management of Specific Etiologies
Structural Causes
Endometrial Polyps
Treatment: Hysteroscopic polypectomy
Outcome: High success rate, symptom resolution in 75-100%
Submucosal Fibroids
Treatment: Hysteroscopic myomectomy for type 0-2 fibroids
Alternative: GnRH agonists, uterine artery embolization, myomectomy
Adenomyosis
Medical: LNG-IUD, continuous progestins, GnRH agonists
Surgical: Hysterectomy (definitive), adenomyomectomy (experimental)
Cesarean Scar Defect
Treatment: Hysteroscopic, laparoscopic, or vaginal repair
Indication: Symptomatic postmenstrual spotting
Reference: ACOG Practice Bulletin No. 96. Obstet Gynecol 2008;112:201
Management of Anovulatory Bleeding
Treatment Strategy
Acute Phase
Goal: Stop bleeding and stabilize endometrium
Options:
  • Combined OCs (preferred)
  • High-dose progestins
  • Tranexamic acid (adjunct)
Maintenance Phase
Goal: Prevent recurrence, regulate cycles
Options:
  • Cyclic combined OCs
  • Cyclic progestins (days 1-12 or 14-25)
  • LNG-IUD
  • Treat underlying cause (thyroid, PCOS)
Underlying Causes to Address
Hypothyroidism: Levothyroxine replacement
Hyperprolactinemia: Dopamine agonist (cabergoline, bromocriptine)
PCOS: Weight loss, metformin, combined OCs, cyclic progestins
Hypothalamic dysfunction: Address nutrition, stress, exercise
Long-Term Monitoring
  • Ensure regular withdrawal bleeding (at least every 3 months)
  • Monitor for endometrial hyperplasia risk
  • Consider endometrial sampling if prolonged anovulation
Reference: ACOG Practice Bulletin No. 136. Obstet Gynecol 2013;122:176
Bleeding Disorders: Special Considerations
Von Willebrand Disease
1
Diagnosis
VWF antigen, VWF activity (ristocetin cofactor or GP1bM), Factor VIII, blood type
Repeat testing if initially normal but high suspicion
2
First-Line Treatment
Hormonal: Combined OCs or LNG-IUD (most effective)
Desmopressin (DDAVP): For type 1 VWD, increases VWF and Factor VIII
Tranexamic acid: Adjunctive therapy during menses
3
Severe Cases
VWF concentrate: For severe bleeding or surgical procedures
Hematology consultation: For management guidance

Important: Obtain labs before starting estrogen therapy. Estrogen increases VWF levels and may mask diagnosis. NSAIDs should be avoided as they impair platelet function.
Reference: ACOG Committee Opinion No. 580. Obstet Gynecol 2013;122:1368
Anticoagulation and AUB
Management Approach
Assessment
Approximately 2/3 of women on anticoagulation experience AUB
Key Points:
  • Anticoagulation often exacerbates underlying issue
  • Evaluate for structural causes
  • Check INR if on warfarin (target 2-3)
  • Consider switching anticoagulant if appropriate
Treatment Options
Preferred: LNG-IUD (most effective, no systemic effects)
Alternatives:
  • Tranexamic acid (use with caution)
  • Combined OCs (if no VTE history)
  • Progestin-only methods
Perioperative Management
For surgical treatment of structural lesions:
  • Consult prescribing physician
  • Plan anticoagulation bridging if needed
  • Consider timing of procedure
  • Ensure adequate hemostasis
Contraindications
Avoid estrogen if:
  • History of VTE (relative contraindication)
  • Active thrombosis
  • Multiple VTE risk factors
Tranexamic acid: Use cautiously, monitor closely
Reference: Huq FY, et al. Contraception 2011;84:128
Iron Deficiency Management
Diagnosis and Treatment
50%
Prevalence
Iron deficiency in women with HMB
30%
Anemia Rate
Frank anemia (Hgb <12 g/dL) in HMB patients
80%
Depleted Stores
Women with HMB have low ferritin even without anemia
Diagnostic Criteria
Iron deficiency: Ferritin <30 ng/mL
Iron deficiency anemia: Ferritin <30 ng/mL + Hgb <12 g/dL
Additional tests: Serum iron, TIBC, transferrin saturation
Treatment
Oral iron: 150-200 mg elemental iron daily
IV iron: For severe anemia, intolerance, or malabsorption
Monitor: Hemoglobin and ferritin every 3 months until replete
Reference: ACOG Committee Opinion No. 785. Obstet Gynecol 2019;134:e71
When to Refer
Gynecology Referral
Heavy bleeding, persistent bleeding despite treatment, suspicion of malignancy, need for surgical intervention, inability to perform endometrial sampling or IUD placement
Hematology Referral
Suspected bleeding disorder, abnormal coagulation studies, history of excessive bleeding with procedures, family history of bleeding disorders
Emergency Department
Hemodynamic instability, severe anemia (Hgb <7 g/dL), acute heavy bleeding requiring urgent intervention, symptomatic anemia
Reference: ACOG Practice Bulletin No. 128. Obstet Gynecol 2012;120:197
Follow-Up and Monitoring
Short-Term Follow-Up
01
Initial Visit (2-4 weeks)
Assess treatment response, side effects, bleeding pattern, hemoglobin if anemic
02
3-Month Visit
Evaluate bleeding control, adjust therapy if needed, check hemoglobin and ferritin
03
6-Month Visit
Confirm stable bleeding pattern, assess need for continued therapy, screen for complications
Long-Term Monitoring
Ongoing Hormonal Therapy
  • Annual visits once stable
  • Monitor for side effects
  • Assess continued need for therapy
  • Screen for contraindications
  • Update contraceptive needs
Chronic Anovulation
  • Ensure withdrawal bleeding every 3 months
  • Monitor for endometrial hyperplasia
  • Consider endometrial sampling if >2-3 years untreated
  • Screen for metabolic complications (PCOS)
Reference: ACOG Practice Bulletin No. 136. Obstet Gynecol 2013;122:176
Patient Education: Key Messages
Normal vs Abnormal
"Normal periods occur every 24-38 days, last ≤8 days, and don't significantly interfere with your daily activities. If your periods are different, we should evaluate."
When to Seek Care
"Contact us if you're soaking through pads/tampons every 1-2 hours, passing large clots, bleeding for more than 8 days, or if bleeding interferes with your life."
Treatment Expectations
"Most treatments take 2-3 months to show full effect. Keep a menstrual diary to track your response. Some irregular bleeding is normal when starting hormonal therapy."

Menstrual Diary: Encourage patients to track bleeding patterns using a paper calendar or smartphone app. This provides objective data for treatment decisions.
Reference: NICE Guideline NG88. Heavy menstrual bleeding, 2018
Quality of Life Assessment
Impact of Heavy Menstrual Bleeding
Occupational
Missed work days, reduced productivity, difficulty concentrating, career limitations
Social
Avoiding social activities, embarrassment, isolation, relationship strain
Physical
Fatigue, exercise limitation, sleep disruption, pain, anemia symptoms
Emotional
Anxiety, depression, stress, reduced self-esteem, fear of bleeding through
Economic
Cost of menstrual products, medications, medical visits, lost wages
Relationships
Sexual dysfunction, intimacy issues, family planning concerns
Reference: Warner PE, et al. Am J Obstet Gynecol 2004;190:1216
Shared Decision-Making
Factors to Consider
Effective management requires individualized treatment plans developed through shared decision-making between clinician and patient, considering medical factors, patient values, and life circumstances.
Reference: NICE Guideline NG88. Heavy menstrual bleeding, 2018
Cost-Effectiveness Considerations
Economic Analysis of Treatment Options
The LNG-IUD is the most cost-effective medical treatment over 5 years, despite higher upfront cost. Hysterectomy has highest initial cost but provides definitive cure.
Reference: van den Brink MJ, et al. BJOG 2021;128:2003
Treatment Failure: Next Steps
1
2
3
4
5
1
Reassess Diagnosis
Confirm AUB etiology, rule out missed structural lesions, consider additional imaging
2
Optimize Medical Therapy
Increase dose, switch agents, add adjunctive therapy, ensure adherence
3
Consider Combination Therapy
Hormonal + tranexamic acid, multiple hormonal methods
4
Evaluate for Surgery
Hysteroscopy, endometrial ablation, or hysterectomy based on patient goals
5
Specialist Referral
Gynecology, reproductive endocrinology, or hematology consultation
Reference: ACOG Practice Bulletin No. 128. Obstet Gynecol 2012;120:197
Contraception and AUB Management
Dual Benefits
Methods That Treat AUB
Combined Oral Contraceptives
  • 35-69% reduction in blood loss
  • Highly effective contraception
  • Cycle regulation
LNG-IUD (52 mg)
  • 71-95% reduction in blood loss
  • Most effective contraception
  • Long-acting (5-8 years)
Progestin-Only Pills
  • Moderate reduction in blood loss
  • Effective contraception if taken consistently
  • No estrogen side effects
Methods That May Worsen AUB
Copper IUD
  • Increases menstrual blood loss 20-50%
  • May cause dysmenorrhea
  • Avoid in patients with HMB
Counseling Points
  • Discuss contraceptive needs at every visit
  • Choose methods that address both concerns
  • Explain expected bleeding patterns
  • Set realistic expectations for timing of effect
  • Provide backup contraception during initiation
Reference: CDC US Medical Eligibility Criteria 2024. MMWR 2024;73:1
Fertility Preservation Considerations
Management in Patients Desiring Future Pregnancy
Medical Options
Preferred: Cyclic progestins, tranexamic acid, NSAIDs
Avoid: LNG-IUD (requires removal for conception), depot medroxyprogesterone (delayed return to fertility)
Consider: Combined OCs can be used but may delay conception by 2-3 months after discontinuation
Surgical Options
Fertility-preserving: Hysteroscopic polypectomy, myomectomy
Avoid: Endometrial ablation (contraindicated), hysterectomy (definitive)
Caution: Minimize intrauterine procedures to prevent Asherman syndrome
Preconception Counseling
Optimize iron stores before conception, treat underlying causes (thyroid, PCOS), establish regular cycles, consider ovulation induction if anovulatory
Reference: ACOG Practice Bulletin No. 136. Obstet Gynecol 2013;122:176
Perimenopausal AUB
Special Considerations
Etiology
Anovulation becomes more common as ovarian function declines
Key Points:
  • Irregular cycles are normal during transition
  • Higher risk of endometrial hyperplasia/cancer
  • Structural lesions more common (fibroids, polyps)
  • Bleeding disorders may worsen
Evaluation
Lower threshold for endometrial sampling
  • Age ≥45: sample for any abnormal bleeding
  • Consider FSH if amenorrhea >12 months
  • Rule out pregnancy (still possible)
Management
Medical options:
  • LNG-IUD (preferred if no contraindications)
  • Cyclic progestins
  • Low-dose combined OCs (if no contraindications)
  • Tranexamic acid
Surgical options:
  • Endometrial ablation (if childbearing complete)
  • Hysterectomy (definitive, consider with salpingectomy)
Transition to Menopause
Symptoms often resolve with menopause. Continue treatment until 12 months of amenorrhea confirms menopause.
Reference: ACOG Practice Bulletin No. 141. Obstet Gynecol 2014;123:202
Obesity and AUB
Pathophysiology and Management
Obesity
Increased adipose tissue
Aromatization
Peripheral conversion of androgens to estrogen
Unopposed Estrogen
Continuous endometrial stimulation
Endometrial Changes
Hyperplasia, irregular bleeding
Increased Cancer Risk
4-fold higher risk of endometrial cancer

Management: Lower threshold for endometrial sampling (any age with BMI ≥30), weight loss counseling, ensure regular withdrawal bleeding, consider metformin if PCOS, progestin therapy to oppose estrogen
Reference: Wise MR, et al. Am J Obstet Gynecol 2016;215:598.e1
PCOS and AUB
Diagnosis and Management
Rotterdam Criteria (2 of 3)
  1. Oligo-ovulation or anovulation
  1. Clinical or biochemical hyperandrogenism
  1. Polycystic ovaries on ultrasound
After excluding other causes
Associated Features
  • Irregular or absent menses
  • Hirsutism, acne
  • Obesity (but not required)
  • Insulin resistance
  • Infertility
  • Increased endometrial cancer risk
Management of AUB in PCOS
First-line: Combined OCs
  • Regulate cycles
  • Reduce androgens
  • Protect endometrium
  • Provide contraception
Alternatives:
  • Cyclic progestins (if estrogen contraindicated)
  • LNG-IUD
  • Metformin (adjunct, improves ovulation)
Lifestyle:
  • Weight loss (5-10% improves ovulation)
  • Exercise
  • Dietary modification
Reference: Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Hum Reprod 2004;19:41
Endometrial Hyperplasia Management
Classification and Treatment
1
2
3
1
Hyperplasia Without Atypia
Treatment: Cyclic or continuous progestins, LNG-IUD
Follow-up: Repeat biopsy at 3-6 months
Regression rate: >90%
2
Atypical Hyperplasia
Preferred: Hysterectomy (25-40% concurrent cancer risk)
Fertility-sparing: High-dose progestins with close monitoring
Follow-up: Repeat biopsy every 3 months
3
Endometrial Intraepithelial Neoplasia (EIN)
Treatment: Hysterectomy recommended
Alternative: Progestin therapy only if fertility desired and close follow-up possible

Prevention: Ensure regular withdrawal bleeding (at least every 3 months) in patients with chronic anovulation to prevent hyperplasia development
Reference: ACOG Practice Bulletin No. 234. Obstet Gynecol 2021;138:e32
Medication Side Effects
Common Side Effects and Management
Nausea (High-Dose Estrogen)
Management: Take with food, antiemetics (ondansetron 4-8 mg), temporary dose reduction if possible
Prevention: Start antiemetic 1 hour before hormone dose
Mood Changes (Progestins)
Management: Switch progestin type, reduce dose, consider non-hormonal alternatives
Monitor: Screen for depression, provide support resources
Breast Tenderness (Estrogen)
Management: Usually resolves after 2-3 months, supportive bra, reduce caffeine
Consider: Lower estrogen dose if persistent
Weight Changes
Management: Counsel on diet and exercise, monitor BMI, consider alternative methods
Note: Most weight gain is not directly caused by hormones
Reference: ACOG Practice Bulletin No. 110. Obstet Gynecol 2010;115:206
Breakthrough Bleeding on Hormonal Therapy
Evaluation and Management
1
First 3 Months
Expected: Irregular bleeding common during adjustment period
Management: Reassurance, continue therapy, ensure adherence
Action: No intervention unless heavy or concerning
2
After 3 Months
Evaluate: Medication adherence, drug interactions, missed doses
Consider: Pregnancy test, STI screening, structural lesions
Management: Increase dose, switch formulation, add estrogen (if progestin-only)
3
Persistent After 6 Months
Investigate: Ultrasound, endometrial sampling if indicated
Options: Change method, add tranexamic acid, consider surgical evaluation
Reference: ACOG Committee Opinion No. 557. Obstet Gynecol 2013;121:891
Evidence-Based Guidelines Summary
Key Recommendations
ACOG
Endometrial sampling for age ≥45 or <45 with risk factors; LNG-IUD or combined OCs first-line for HMB
FIGO
Standardized PALM-COEIN classification; structured approach to diagnosis and management
NICE
LNG-IUD first-line for HMB; avoid routine D&C; shared decision-making essential
CDC
Medical eligibility criteria for contraceptive use; VTE risk stratification
References: ACOG Practice Bulletin No. 128, 2012; Munro MG, et al. Int J Gynaecol Obstet 2018;143:393; NICE NG88, 2018; CDC MMWR 2024;73:1
Quality Improvement Metrics
Measuring Success in AUB Management
80%
Treatment Success
Patients reporting improved bleeding and quality of life at 6 months
90%
Appropriate Sampling
Endometrial sampling performed when indicated by guidelines
75%
Anemia Resolution
Hemoglobin >12 g/dL achieved within 6 months of treatment
85%
Patient Satisfaction
Patients satisfied with treatment choice and outcomes
Process Measures
  • Time to diagnosis and treatment initiation
  • Appropriate use of imaging and laboratory tests
  • Documentation of shared decision-making
  • Follow-up visit completion rates
  • Referral patterns and timeliness
Reference: NICE Quality Standard QS47. Heavy menstrual bleeding, 2013
Emerging Therapies
Novel Treatment Approaches
GnRH Antagonists
Elagolix, Relugolix: Oral GnRH antagonists for uterine fibroids and endometriosis
Advantages: Rapid onset, reversible, oral administration
Limitations: Hypoestrogenic effects, bone loss with long-term use, cost
Lower-Dose LNG-IUDs
19.5 mg and 13.5 mg devices: Smaller size, lower hormone dose
Potential: Better tolerability, easier insertion in nulliparous women
Evidence: Efficacy for HMB still being established
Advanced Ablation Techniques
Newer technologies: Improved safety profiles, office-based procedures
Research: Combination with medical therapy, patient selection optimization
Reference: Schlaff WD, et al. Obstet Gynecol 2020;135:30
Global Health Perspective
AUB in Resource-Limited Settings
Challenges
  • Limited access to diagnostic tools (ultrasound, endometrial sampling)
  • Restricted availability of hormonal therapies
  • Cultural barriers to gynecologic care
  • Lack of trained providers
  • High cost of medications and procedures
  • Competing health priorities
Consequences
  • Chronic anemia and iron deficiency
  • Reduced work productivity
  • School absenteeism in adolescents
  • Delayed diagnosis of serious conditions
  • Unnecessary hysterectomies
Practical Solutions
Low-cost interventions:
  • Tranexamic acid (generic, inexpensive)
  • NSAIDs (widely available)
  • Oral progestins (low cost)
  • Iron supplementation
Task-shifting:
  • Train mid-level providers
  • Community health workers for education
  • Telemedicine consultation
Public health approaches:
  • Education on normal menstruation
  • Destigmatization of menstrual health
  • Integration with family planning services
Reference: Haththotuwa R, et al. Semin Reprod Med 2011;29:446
Adolescent-Specific Protocols
Age-Appropriate Management
1
Mild Bleeding (Hgb ≥12 g/dL)
Approach: Observation, menstrual diary, education
Follow-up: 3-6 months, reassess if worsening
2
Moderate Bleeding (Hgb 10-12 g/dL)
Treatment: Combined OCs (30-35 mcg EE) or cyclic progestins
Duration: 6 months minimum, then reassess
3
Severe Bleeding (Hgb <10 g/dL)
Treatment: High-dose combined OCs with taper, iron supplementation
Consider: Hospitalization if Hgb <7 or symptomatic
4
Life-Threatening Bleeding
Immediate: Hospitalization, IV estrogen, hemostatic agents
Evaluate: Bleeding disorder workup, hematology consult
Reference: ACOG Committee Opinion No. 651. Obstet Gynecol 2015;126:e143
Multidisciplinary Care
Team-Based Approach to Complex Cases
Primary Care
Initial evaluation, medical management, coordination
Gynecology
Specialized evaluation, procedures, surgical management
Hematology
Bleeding disorder diagnosis and management
Endocrinology
Hormonal disorders, PCOS, thyroid disease
Radiology
Advanced imaging, interventional procedures
Pathology
Tissue diagnosis, cancer screening
Reference: James AH, et al. Eur J Obstet Gynecol Reprod Biol 2011;158:124
Documentation Best Practices
Essential Elements
Bleeding Characterization
Frequency, duration, volume (using validated tools), pattern, associated symptoms, impact on quality of life
Risk Assessment
Endometrial cancer risk factors, bleeding disorder screening, VTE risk factors, contraindications to therapies
Shared Decision-Making
Treatment options discussed, patient preferences, contraceptive needs, fertility plans, risks and benefits explained
Follow-Up Plan
Expected response timeline, warning signs, when to return, laboratory monitoring schedule
Reference: ACOG Practice Bulletin No. 128. Obstet Gynecol 2012;120:197
Patient Safety Considerations
Preventing Adverse Outcomes
Missed Malignancy
Prevention: Follow age-based endometrial sampling guidelines, maintain high index of suspicion in high-risk patients
Red flags: Postmenopausal bleeding, persistent bleeding despite treatment, obesity with anovulation
Severe Anemia
Prevention: Regular hemoglobin monitoring, aggressive iron supplementation, early intervention for heavy bleeding
Action: Hospitalize if Hgb <7 g/dL or symptomatic, consider transfusion if needed
VTE Risk
Prevention: Screen for risk factors, avoid estrogen in high-risk patients, use lowest effective dose
Education: Teach warning signs (leg pain, chest pain, shortness of breath)
Medication Errors
Prevention: Provide written instructions, confirm understanding, use teach-back method
Follow-up: Early contact to assess adherence and side effects
Reference: ACOG Committee Opinion No. 557. Obstet Gynecol 2013;121:891
Cultural Competence in AUB Care
Addressing Diverse Patient Needs
Cultural Considerations
Menstrual taboos: Some cultures view menstruation as impure or shameful
Religious beliefs: May affect contraceptive choices and treatment preferences
Language barriers: Use professional interpreters, provide translated materials
Health literacy: Assess understanding, use plain language, visual aids
Family dynamics: Involve family members appropriately, respect privacy
Best Practices
  • Ask about cultural beliefs and preferences
  • Avoid assumptions based on appearance
  • Provide culturally appropriate education
  • Respect modesty concerns
  • Offer same-gender providers when possible
  • Be sensitive to trauma history
  • Address socioeconomic barriers to care
  • Partner with community organizations
Reference: Haththotuwa R, et al. Semin Reprod Med 2011;29:446
Telemedicine and AUB
Virtual Care Opportunities
Initial Consultation
History taking, bleeding pattern assessment, risk stratification, treatment planning
Limitations: Cannot perform physical exam or procedures
Medication Management
Prescribe hormonal therapies, adjust doses, manage side effects, provide education
Advantages: Convenient, reduces barriers to care, improves adherence
Follow-Up Care
Monitor treatment response, review lab results, assess need for in-person visit
Efficiency: Reduces unnecessary office visits, improves access
Patient Education
Menstrual health education, shared decision-making, lifestyle counseling
Tools: Screen sharing, digital menstrual diaries, educational videos

When In-Person Visit Required: Physical exam needed, procedures (IUD insertion, endometrial sampling), acute severe bleeding, diagnostic uncertainty
Reference: ACOG Committee Opinion No. 798. Obstet Gynecol 2020;135:e73
Research Priorities
Future Directions in AUB Management
Biomarkers
Identify predictors of treatment response, endometrial cancer risk stratification, non-invasive diagnostic tools
Personalized Medicine
Genetic factors affecting treatment response, pharmacogenomics of hormonal therapies, individualized risk assessment
Novel Therapies
New drug targets, combination therapies, minimally invasive procedures, regenerative medicine approaches
Implementation Science
Improve guideline adherence, reduce disparities in care, optimize care delivery models, patient-centered outcomes
Quality of Life
Validated outcome measures, long-term impact studies, cost-effectiveness analyses, patient preference research
Reference: Munro MG, et al. Int J Gynaecol Obstet 2018;143:393
Key Takeaways for Clinical Practice
01
Systematic Evaluation
Use standardized terminology, exclude pregnancy, assess bleeding pattern and severity, screen for underlying causes
02
Risk Stratification
Age-based endometrial sampling, bleeding disorder screening for HMB, VTE risk assessment before estrogen
03
Individualized Treatment
Consider patient preferences, contraceptive needs, fertility plans, medical comorbidities, start with least invasive options
04
Evidence-Based Management
LNG-IUD or combined OCs first-line for HMB, address underlying causes, monitor response and adjust therapy
05
Appropriate Referral
Gynecology for severe bleeding or surgical needs, hematology for bleeding disorders, multidisciplinary care for complex cases
Reference: ACOG Practice Bulletin No. 128. Obstet Gynecol 2012;120:197
Summary and Conclusions
Evidence-Based Approach to AUB
Core Principles
  • AUB is common and significantly impacts quality of life
  • Systematic evaluation using FIGO classification
  • Exclude pregnancy and serious pathology
  • Age-based risk stratification for endometrial cancer
  • Screen for bleeding disorders in HMB
  • Individualized treatment based on patient factors
Treatment Hierarchy
  1. Medical management (hormonal or non-hormonal)
  1. Minimally invasive procedures (hysteroscopy)
  1. Endometrial ablation (if childbearing complete)
  1. Hysterectomy (definitive treatment)
Best Outcomes Achieved Through
  • Evidence-based guideline adherence
  • Shared decision-making with patients
  • Appropriate use of diagnostic tests
  • Timely specialist referral when needed
  • Multidisciplinary collaboration
  • Regular follow-up and monitoring
  • Patient education and support
Future Directions
Continued research into novel therapies, personalized medicine approaches, improved diagnostic tools, and strategies to reduce disparities in care will further enhance outcomes for patients with AUB.
Professor Mykhailo Medvediev
Key References: Munro MG, et al. Int J Gynaecol Obstet 2018;143:393; ACOG Practice Bulletin No. 128. Obstet Gynecol 2012;120:197; NICE Guideline NG88, 2018