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  • Accurate diagnosis of abnormal uterine bleeding (AUB) depends on appropriate categorization and diagnostic tests1.

  • 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. Abnormal uterine bleeding (AUB) refers to menstrual bleeding of abnormal quantity, duration, or schedule. The International Federation of Gynecology and Obstetrics (FIGO) introduced the current classification system for abnormal uterine bleeding in 2011, which was then endorsed by the American College of Obstetrics and Gynecology. This classification system pairs AUB 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) confirming uterine source of the bleeding; (2) excluding pregnancy and confirming patient is premenopausal; (3) ascertaining whether the bleeding pattern suggests regular ovulatory bleeding or anovulatory bleeding; (4) determining contribution of structural abnormalities (PALM), including risk for malignancy/hyperplasia; (5) identifying risk of medical conditions that may impact bleeding (eg, inherited bleeding disorders, endocrine disease, risk of infection); and (6) assessing contribution of current medications, including contraceptives or natural product supplements or combinations that may affect bleeding.

B. Laboratory Studies

A complete blood count, pregnancy test, and thyroid tests should be done. For adolescents with heavy menstrual bleeding and ...

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