Abnormal uterine bleeding is any bleeding from the uterus that is unusual in amount, timing or duration. The PALM-COEIN system sorts the causes into structural ones such as polyps and fibroids and non-structural ones such as ovulatory dysfunction or bleeding disorders.
Key symptoms
- Heavy periods that soak a pad or tampon every hour
- Bleeding between periods or after sex
- Irregular or missed periods
- Fatigue or shortness of breath from anemia
- Any bleeding after menopause
What you find on exam
- Vital signs to judge blood loss
- Pallor and signs of anemia
- Speculum exam: source of bleeding, cervical lesions
- Signs of thyroid disease, excess androgens or easy bruising
Tests
- Pregnancy test in every patient of reproductive age
- Blood count, ferritin, TSH; coagulation tests if periods have been heavy since the first one
- Transvaginal pelvic ultrasound
- Endometrial biopsy at age 45 or older, or younger with risk factors such as obesity
Treatment basics
- Acute heavy bleeding: IV conjugated estrogen or high-dose oral contraceptives, tranexamic acid
- Hormonal options: combined oral contraceptives, progestins or a levonorgestrel IUD
- NSAIDs such as naproxen during periods
- Iron for anemia; transfusion if unstable
- Procedures for structural causes: polypectomy, myomectomy, ablation or hysterectomy
Red flags
- Heavy bleeding with low blood pressure or fainting
- Bleeding in a pregnant patient
- Postmenopausal bleeding (rule out endometrial cancer)
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.