What Is Considered Abnormal Uterine Bleeding?
 

• Heavy menstrual bleeding that interferes with daily activities or quality of life

• Periods lasting longer than about 7 days

• Bleeding or spotting between periods

• Menstrual cycles that are persistently unusually frequent, infrequent, or irregular

• Bleeding after sex

• Any bleeding after menopause

• A significant change from a person's usual menstrual pattern

Causes of Abnormal Uterine Bleeding
 

Structural Causes — "PALM"

Polyps
 

Uterine or cervical polyps are usually benign growths that can cause irregular bleeding, spotting between periods, or bleeding after sex.

Adenomyosis
 

Adenomyosis occurs when tissue similar to the uterine lining grows into the muscular wall of the uterus. It can cause:

• Heavy periods

• Painful periods

• Pelvic pain or pressure

• An enlarged or tender uterus

Leiomyomas (Fibroids)
 

Fibroids are benign tumors of uterine muscle. Depending on their size and location, they can cause:

• Heavy or prolonged periods

• Pelvic pressure or fullness

• Pain

• Urinary or bowel symptoms

• Fertility problems

Malignancy & Hyperplasia
 

Endometrial hyperplasia is abnormal thickening or overgrowth of the uterine lining. Some forms can progress to endometrial cancer.

Risk is increased by prolonged exposure to estrogen without adequate progesterone, which may occur with:

• Obesity

• Chronic anovulation

• PCOS

• Certain estrogen therapies

• Increasing age

Abnormal bleeding—particularly postmenopausal bleeding—can sometimes be the first sign of endometrial cancer.

Nonstructural Causes — "COEIN"

Coagulopathy
 

Bleeding disorders can cause unusually heavy menstrual bleeding. Clues include:
 

• Heavy periods beginning around the time menstruation first started

• Easy bruising

• Frequent nosebleeds

• Excessive bleeding after dental work, surgery, or childbirth

• Family history of abnormal bleeding

Von Willebrand disease is an important inherited cause.

Ovulatory Dysfunction
 

When ovulation does not occur regularly, the uterine lining may build up and shed unpredictably. Possible causes include:
 

• Adolescence

• Perimenopause

• PCOS

• Thyroid disorders

• Elevated prolactin

• Significant weight changes

• Excessive exercise

• Stress

• Certain medications

• Other hormonal disorders

Bleeding may be irregular, unpredictable, heavy, or prolonged.

Endometrial Causes
 

Sometimes the structure of the uterus and ovulation appear normal, but abnormalities in how the uterine lining regulates bleeding cause heavy menstruation.

Iatrogenic Causes

Medications and medical treatments can cause abnormal bleeding, including:
 

• Hormonal birth control

• IUDs

• Anticoagulants

• Some medications that affect ovulation or hormones

• Tamoxifen

Breakthrough bleeding is particularly common during the first several months after starting or changing hormonal contraception.

Not Otherwise Classified

Pregnancy

Pregnancy should be excluded in reproductive-age patients with new abnormal uterine bleeding when pregnancy is possible. Pregnancy-related bleeding can occur with:
 

• Normal early pregnancy

• Miscarriage

• Ectopic pregnancy

• Other pregnancy complications
   

Bleeding accompanied by significant pelvic or abdominal pain, fainting, severe dizziness, shoulder pain, or weakness during a possible pregnancy requires urgent evaluation for ectopic pregnancy or significant bleeding.
 

Evaluation
 

The evaluation depends on age, bleeding pattern, pregnancy possibility, symptoms, medications, medical history, and risk factors. It may include:
 

-Pregnancy Test, Complete Blood Count (CBC), Iron Studies, TSH, Prolactin, STI testing,  cervical cancer screening when due, testing for bleeding disorder, other hormonal testing when clinically indicated

-Pelvic Examination

A pelvic examination may help determine whether bleeding is actually coming from the uterus or from the cervix or vagina. It may also identify cervical lesions, polyps, infection, uterine enlargement, pelvic tenderness, or other abnormalities.
 

-Transvaginal ultrasound, and sometimes transabdominal ultrasound, is generally the first-line imaging test when a structural cause is suspected. It can help identify:
 

• Fibroids

• Endometrial abnormalities

• Adenomyosis

• Some polyps

• Ovarian abnormalities

• Other pelvic pathology

​

-Endometrial Biopsy
 

Postmenopausal Bleeding
 

Any vaginal bleeding after menopause should be evaluated. Most cases are not caused by cancer, but endometrial cancer must be excluded. Evaluation may involve:
 

• Transvaginal ultrasound to measure endometrial thickness

• Endometrial biopsy

In a postmenopausal patient with bleeding, an endometrial thickness of 4 mm or less on transvaginal ultrasound is generally very reassuring. Persistent or recurrent bleeding may still require endometrial sampling even when the lining appears thin.
 

Treatment
 

Treatment depends on the cause, severity of bleeding, age, medical conditions, contraceptive needs, and whether future pregnancy is desired.

-Hormonal Treatment
 

• Levonorgestrel-releasing IUD

• Combined hormonal contraceptives

• Oral or injectable progestins

Levonorgestrel IUD is particularly effective for many patients with heavy menstrual bleeding.

-Nonhormonal Treatments - NSAIDs
 

Medications such as ibuprofen or naproxen can reduce both menstrual bleeding and menstrual cramps in appropriate patients.

-Tranexamic Acid
 

Tranexamic acid is a nonhormonal medication taken during menstruation that reduces bleeding by helping stabilize blood clots.

-Treating the Underlying Cause

​

• Thyroid disease

• PCOS or chronic anovulation

• A bleeding disorder

• Iron deficiency

• Medication-related bleeding

-Procedures

​

• Removal of a uterine polyp

• Fibroid treatment or removal

• Hysteroscopy

• Endometrial ablation in appropriately selected patients who do not desire future pregnancy

• Hysterectomy in selected cases

                                                                         References & Guidelines
 

• American College of Obstetricians and Gynecologists (ACOG). Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women.

• American College of Obstetricians and Gynecologists (ACOG). Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women.

• American College of Obstetricians and Gynecologists (ACOG). The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With Postmenopausal Bleeding.

• International Federation of Gynecology and Obstetrics (FIGO). PALM-COEIN Classification System for Causes of Abnormal Uterine Bleeding.