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  • Accurate diagnosis of abnormal uterine bleeding (AUB) depends on appropriate categorization and diagnostic tests.

  • Pregnancy should always be ruled out as a cause of AUB in reproductive age women.

  • The evaluation of AUB depends on the age and risk factors of the patient.

General Considerations

Normal menstrual bleeding lasts an average of 5 days (range, 2–7 days), with a mean blood loss of 40 mL per cycle. Menorrhagia is defined as blood loss of over 80 mL per cycle and frequently produces anemia. Metrorrhagia is defined as bleeding between periods. Polymenorrhea is defined as bleeding that occurs more often than every 21 days, and oligomenorrhea is defined as bleeding that occurs less frequently than every 35 days.

A classification system, known by the acronym PALM-COEIN, is used by the International Federation of Gynecology and Obstetrics (FIGO) and does not use the term “dysfunctional uterine bleeding.” Instead, abnormal uterine bleeding (AUB) is the overarching term paired with descriptive terms denoting the bleeding pattern (ie, heavy, light and menstrual, intermenstrual) and by etiology (Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, and Not yet classified) (eTable 18–1). In adolescents, AUB often occurs as a result of persistent anovulation due to the immaturity of the hypothalamic-pituitary-ovarian axis and represents normal physiology. Once regular menses has been established during adolescence, ovulatory AUB (AUB-O) accounts for most cases. AUB in women aged 19–39 years is often a result of pregnancy, structural lesions, anovulatory cycles, use of hormonal contraception, or endometrial hyperplasia.

eTable 18–1.PALM-COEIN classification system for the causes of abnormal uterine bleeding (AUB) in nonpregnant women of reproductive age.

Clinical Findings

A. Symptoms and Signs

The diagnosis usually depends on the following: (1) A careful description of the duration and amount of flow, related pain, and relationship to the last menstrual period (LMP), with the presence of blood clots or the degree of inconvenience caused by the bleeding serving as useful indicators; (2) A history of pertinent illnesses, such as recent systemic infections or hospitalizations, or weight change; (3) A history of medications or herbal remedies that might cause ...

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