Abnormal Uterine Bleeding

A new classification system

Abnormal Uterine Bleeding

• Overarching term for the symptom of disturbed menstral bleeding

• Discarded terms– DUB– Menorrhagia

• AUB will be subdivided by causes such as polyps, ovulation disorders, etc

PALM-COEIN

• P– Polyps either endometrial or endocervical– AUB-P

• A– Adenomyosis– AUB-A

• L– Leiomyoma– AUB-L

PALM-COEIN

• M– Malignancy/hyperplasia– AUB-M

• C– Coagulopathy either from clinical disorder or from

anticoagulant medication– AUB-C

• O– Ovulatory disorders– AUB-O

PALM-COEIN

• E– Endometrial disorders– AUB-E

• I– Iatrogenic– AUB-I

• N– Non yet classified– AUB-N

Patient with AUB

• Could they be anemic• Are they on a drug that could cause AUB• Are they ovulatory• Are they at risk of hyperplasia/malignancy

Chronic AUB: =3 months of disturbed menstrual bleeding

Are they on a drug that could cause

AUB?

Yes

AUB-I AUB-C

No

Are they ovulatory

No

AUB-O

Yes

Evaluate the uterus

Ultrasound, sonohysterogram, hysteroscopy

negative

AUB-E

AUB-A

Are they at risk for malignancy/hyperplasia

yes

Endometrial sampling

AUB-M

Could they be anemic? CBC

Positive

AUB-P AUB-L

AUB-I

• Hormonal contraception• IUD• Tricyclic antidepressants, phenothiazines

AUB-C

• Anticoagulant meds• coagulopathies

Chronic AUB: =3 months of disturbed menstrual bleeding

Are they on a drug that could cause

AUB?

Yes

AUB-I AUB-C

No

Are they ovulatory

No

AUB-O

Yes

Evaluate the uterus

Ultrasound, sonohysterogram, hysteroscopy

negative

AUB-E

AUB-A

Are they at risk for malignancy/hyperplasia

yes

Endometrial sampling

AUB-M

Could they be anemic? CBC

Positive

AUB-P AUB-L

AUB-O

• Most of the time no etiology• PCOS• Hypothyroid• Hyperprolactinemia• Mental stress• Extreme changes in weight or exercise

Chronic AUB: =3 months of disturbed menstrual bleeding

Are they on a drug that could cause

AUB?

Yes

AUB-I AUB-C

No

Are they ovulatory

No

AUB-O

Yes

Evaluate the uterus

Ultrasound, sonohysterogram, hysteroscopy

negative

AUB-E

AUB-A

Are they at risk for malignancy/hyperplasia

yes

Endometrial sampling

AUB-M

Could they be anemic? CBC

Positive

AUB-P AUB-L

Posterior Fibroid

Slide courtesy of Linda Darlene Bradley, MD.

Saline Infusion Sonography

Posterior Class 3 Fibroid

Slide courtesy of Linda Darlene Bradley, MD.

Endometrial Polyps

Slide courtesy of Linda Darlene Bradley, MD.

Endometrial Polyps

Slide courtesy of Linda Darlene Bradley, MD.

Chronic AUB: =3 months of disturbed menstrual bleeding

Are they on a drug that could cause

AUB?

Yes

AUB-I AUB-C

No

Are they ovulatory

No

AUB-O

Yes

Evaluate the uterus

Ultrasound, sonohysterogram, hysteroscopy

negative

AUB-E

AUB-A

Are they at risk for malignancy/hyperplasia

yes

Endometrial sampling

AUB-M

Could they be anemic? CBC

Positive

AUB-P AUB-L

Possible Endometrial Biopsy Findings

• Proliferative, secretory, benign, or atrophic endometrium

• Inactive endometrium• Tissue insufficient for analysis• No endometrial tissue seen• Simple or complex hyperplasia without atypia• Simple or complex hyperplasia with atypia• Endometrial adenocarcinoma

Chronic AUB: =3 months of disturbed menstrual bleeding

Are they on a drug that could cause

AUB?

Yes

AUB-I AUB-C

No

Are they ovulatory

No

AUB-O

Yes

Evaluate the uterus

Ultrasound, sonohysterogram, hysteroscopy

negative

AUB-E

AUB-A

Are they at risk for malignancy/hyperplasia

yes

Endometrial sampling

AUB-M

Could they be anemic? CBC

Positive

AUB-P AUB-L

AUB-A

• Adenomyosis usually found on hysterectomy specimen

• MRI

AUB-E

• Problem with prostiglandins• Receptor problems• Areas for research