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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.


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.

The International Federation of Gynecology and Obstetrics (FIGO) introduced the current classification system for abnormal uterine bleeding, and it was then endorsed by the American College of Obstetrics and Gynecology. The new classification system does not use the term “dysfunctional uterine bleeding.” Instead, it uses the term “abnormal uterine bleeding” (AUB) and pairs it with descriptive terms denoting the bleeding pattern (ie, heavy, light and menstrual, intermenstrual) and etiology (the acronym PALM-COEIN standing for 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 dysfunction 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.


A. Symptoms and Signs

The diagnosis depends on the following: (1) a history of the duration and amount of flow, associated 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, other significant ...

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