Abnormal uterine bleeding (AUB) is one of the most common gynecological complaints among women of reproductive age. It refers to bleeding from the uterus that is abnormal in volume, regularity, frequency, or duration, and is unrelated to pregnancy.
It significantly impacts quality of life, may indicate underlying pathology, and sometimes requires urgent evaluation to rule out malignancy.
To standardize classification, the International Federation of Gynecology and Obstetrics (FIGO) introduced the PALM-COEIN system in 2011, which categorizes causes into structural and non-structural.
Definition
AUB is defined as bleeding from the uterine corpus that is abnormal in timing, amount, or pattern and is not due to pregnancy or systemic illness.
.jpg "Abnormal Uterine Bleeding (AUB) – Causes, PALM COEIN Classification, Diagnosis & Management")
FIGO Classification – PALM COEIN
Structural Causes (PALM)
These are identifiable by imaging or histopathology.
P – Polyp
- Endometrial or endocervical polyps.
- Benign overgrowths of endometrium.
- Cause intermenstrual bleeding, postcoital spotting.
- Diagnosis: Ultrasound, hysteroscopy.
- Management: Polypectomy.
A – Adenomyosis
- Endometrial glands and stroma invade the myometrium.
- Causes bulky uterus, dysmenorrhea, heavy bleeding.
- Common in multiparous women.
- Management: NSAIDs, hormonal therapy, hysterectomy if severe.
L – Leiomyoma (Fibroid)
- Benign smooth muscle tumors of uterus.
- Submucosal fibroids strongly linked with heavy bleeding.
- Symptoms: Menorrhagia, infertility, pelvic pressure.
- Management: Medical (tranexamic acid, hormones), surgical (myomectomy, hysterectomy).
M – Malignancy and Hyperplasia
- Endometrial carcinoma, atypical hyperplasia.
- More common in postmenopausal women.
- Any postmenopausal bleeding = cancer until proven otherwise.
- Management: Endometrial biopsy, surgery, oncological care.
Non-Structural Causes (COEIN)
C – Coagulopathy
- Bleeding disorders (von Willebrand disease, platelet dysfunction).
- History: Heavy periods since menarche, easy bruising.
- Management: Hematology evaluation, tranexamic acid, desmopressin.
O – Ovulatory Dysfunction
- Anovulation causes unopposed estrogen stimulation → irregular bleeding.
- Seen in PCOS, thyroid disease, adolescence, perimenopause.
- Management: Hormonal therapy (combined OCPs, progesterone).
E – Endometrial Dysfunction
- Abnormal local endometrial hemostasis.
- Normal ovulatory cycles but excessive bleeding.
- Diagnosis of exclusion.
- Management: NSAIDs, antifibrinolytics.
I – Iatrogenic
- Drugs like anticoagulants, contraceptives, intrauterine devices.
- Adjusting/removing causative agent helps.
N – Not Otherwise Classified
- Rare causes not in above categories (arteriovenous malformations, chronic endometritis).
Clinical Presentation
- Menorrhagia: Heavy or prolonged menstrual bleeding.
- Metrorrhagia: Irregular bleeding between periods.
- Menometrorrhagia: Heavy and irregular bleeding.
- Postcoital bleeding
- Postmenopausal bleeding (must rule out cancer).
Diagnostic Evaluation
1. History & Examination
- Menstrual history, systemic diseases, drug use.
- Pelvic exam.
2. Investigations
- Pregnancy test (rule out miscarriage, ectopic).
- CBC, coagulation profile.
- Hormonal assays (TSH, prolactin).
- Imaging: Ultrasound, MRI.
- Endometrial sampling (biopsy, curettage).
- Hysteroscopy.
- Saline infusion sonohysterography.
Management
Medical
NSAIDs – Reduce prostaglandin levels.Hormones:
- Combined oral contraceptives
- Cyclic or continuous progesterone
- Levonorgestrel IUD
Surgical
- Polypectomy, myomectomy.
- Endometrial ablation.
- Hysterectomy (definitive treatment).
Treatment Based on Age
- Adolescents: Often ovulatory dysfunction → hormonal management.
- Reproductive age: Depends on fertility desire.
- Perimenopause/postmenopause: Rule out malignancy first.
Complications of Untreated AUB
- Severe anemia
- Infertility
- Reduced quality of life
- Progression to malignancy (in hyperplasia cases)
Quick Reference – PALM COEIN
| Category | Cause |
|---|---|
| P | Polyp |
| A | Adenomyosis |
| L | Leiomyoma |
| M | Malignancy & Hyperplasia |
| C | Coagulopathy |
| O | Ovulatory dysfunction |
| E | Endometrial dysfunction |
| I | Iatrogenic |
| N | Not otherwise classified |
FAQs
1. What is the most common cause of AUB in reproductive-aged women?
Fibroids (leiomyomas) and ovulatory dysfunction.
2. When should postmenopausal bleeding be considered serious?
Always — it must be evaluated for endometrial cancer.
3. Can stress cause abnormal uterine bleeding?
Yes, stress can disrupt ovulation leading to irregular cycles.
4. Is hysterectomy the only treatment for AUB?
No, many cases can be managed with medication or minimally invasive procedures.
5. How does AUB affect fertility?
Structural causes like fibroids or polyps can hinder implantation, while hormonal causes can disrupt ovulation.
