Abnormal Uterine Bleeding

The prevalence of abnormal uterine bleeding among reproductive-aged women internationally is estimated to be between 3% to 30% with a higher incidence occurring around menarche and perimenopause.

File:Side View of Postpartum Uterine Massage with Internal Anatomy.png -  Wikimedia Commons


Differentiate into physiological and pathological causes.


Exclude local pathology.
Vagina, Cervical, Uterine.


Vulva: Benign growths or malignancy.
Vagina: Benign growths, sexually transmitted infections, vaginitis, malignancy, trauma, foreign bodies.
Cervix: Benign growths, sexually transmitted infections, malignancy.
Fallopian tubes and ovaries: Pelvic inflammatory disease, malignancy.
Urinary tract: Infections, malignancy.
Gastrointestinal tract: Inflammatory bowel disease, Behcet syndrome.
Pregnancy complications: Spontaneous abortion, ectopic pregnancy, placenta previa.
Uterus: Aetiologies of bleeding arising from the uterine corpus are listed in the acronym PALM-COEIN.
Uterine bleeding PALM-COEIN
P: Polyp
A: Adenomyosis
L: Leiomyoma
M: Malignancy and hyperplasia
C: Coagulopathy
O: Ovulatory dysfunction
E: Endometrial disorders
I:- Iatrogenic
N: Not otherwise classified


PV bleeding – assess frequency and amount.
Weight pads, count pads.
Bleeding or spotting between periods.
Bleeding or spotting after sex.
Period lasting > 7 days.
Heavy bleeding during your period.


Is the patient pregnant – send pregnancy test.
FBC: iron deficiency anaemia, U&E, CRP.
Check coagulation: some have von Willebrand disease and others may have an underlying coagulation disorder.
Pregnancy test in all fertile females.
Transvaginal ultrasound (TVUS) and report to include endometrial thickness.
Diagnostic hysteroscopy is a highly specific, accurate, safe and clinically useful tool for detecting intrauterine abnormalities and to direct treatment at the specific pathology while avoiding unnecessary surgery.
Postmenopausal patients need pelvic ultrasound and/or endometrial biopsy.


ABCDE and acute management when needed. Admit if heavy bleeding and may need transfusion.
Consider TVUS and if abnormal then Refer to gynaecologist for endometrial biopsy (with or without hysteroscopy). Appointment should ideally be within 6 weeks of referral.
Treat any coagulopathy.
Hormonal management is considered the first line of medical therapy for patients with acute AUB without known or suspected bleeding disorders.
Tranexamic acid 1g TDS.