Managing Abnormal Uterine Bleeding

Documents to Request

• Menstrual calendar or bleeding diary
• Prior pelvic ultrasound reports (transvaginal preferred)
• Endometrial biopsy pathology reports
• CBC with platelet count, ferritin
• TSH
• Coagulation studies (if indicated)
• Pap smear and HPV results
• Hysteroscopy reports (if performed)
• Saline infusion sonohysterogram (SIS) reports

Step 1: Apply the FIGO PALM-COEIN Classification

Every case of AUB should be categorized by etiology:

PALM — Structural Causes (assessed by imaging/pathology)

COEIN — Non-Structural Causes (clinical/laboratory diagnosis)

Document the PALM-COEIN category using the notation: AUB-P, AUB-L (SM), AUB-O, etc.

Step 2: Age-Stratified Workup Algorithm

Reproductive Age (< 40 years) with AUB

1. Pregnancy test (mandatory first step)
2. CBC, ferritin (assess for iron deficiency anemia)
3. TSH
4. Transvaginal ultrasound
5. Coagulation screening if: HMB since menarche, family history, bleeding with dental/surgical procedures (screen for von Willebrand disease)
6. Endometrial biopsy if: age ≥ 35 with risk factors, failed medical management, persistent AUB

Perimenopause (40+ years) with AUB

1. Pregnancy test
2. CBC, ferritin, TSH
3. Transvaginal ultrasound
4. Endometrial biopsy — indicated for all women ≥ 45 with AUB, or ≥ 40 with risk factors (obesity, PCOS, tamoxifen, unopposed estrogen, Lynch syndrome)
5. SIS or hysteroscopy if ultrasound suggests intracavitary pathology

Postmenopausal Bleeding

• Any bleeding after 12 months of amenorrhea must be evaluated for endometrial cancer
• Transvaginal ultrasound: endometrial thickness ≤ 4 mm has 99% negative predictive value for cancer
• Endometrial thickness > 4 mm or persistent bleeding → endometrial biopsy
• SIS or hysteroscopy if biopsy is non-diagnostic or insufficient

Step 3: Fibroid Sub-Classification (FIGO)

When leiomyoma is identified, classify by location:

Step 4: Medical and Surgical Management

Medical Management Options

Surgical Options

• Hysteroscopic polypectomy — for AUB-P
• Hysteroscopic myomectomy — for FIGO types 0, 1, 2
• Abdominal/laparoscopic myomectomy — for large or numerous fibroids with desire for fertility
• Endometrial ablation — for completed childbearing, normal cavity, benign pathology
• Uterine artery embolization — for symptomatic fibroids in non-surgical candidates
• Hysterectomy — definitive treatment for completed childbearing and failed medical management

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is pregnancy excluded as the first step in all reproductive-age patients?
2. Is the PALM-COEIN classification assigned with supporting diagnostic evidence?
3. Is endometrial biopsy addressed — performed, indicated, or documented as not indicated with rationale?
4. Does the management plan match the etiology — medical for AUB-O, surgical for AUB-P/L (SM)?
5. Is anemia assessed and managed — ferritin documented, iron replacement initiated if indicated?

Quality Audit

• Pregnancy test documented as performed (reproductive-age patients)
• Bleeding pattern described using FIGO terminology (HMB, IMB, prolonged, irregular)
• PALM-COEIN classification assigned
• CBC and ferritin documented
• TSH documented
• Transvaginal ultrasound performed or ordered
• Endometrial biopsy performed or documented as not indicated (with rationale)
• Fibroid subtype classified by FIGO system (if fibroids present)
• Coagulation screening addressed (performed if indicated, or documented as not indicated)
• Management plan documented with specific agent/procedure and timeline
• Iron replacement documented if ferritin low
• Endometrial cancer risk factors assessed (obesity, PCOS, tamoxifen, unopposed estrogen, Lynch)
• Follow-up plan documented with expected timeframe for treatment response
• Surgical options discussed if medical management fails

Guidelines

1. Always exclude pregnancy first — a positive βhCG completely changes the differential and management.
2. Use PALM-COEIN, not legacy terms — "dysfunctional uterine bleeding" and "menorrhagia" are imprecise. Use the FIGO classification system in all documentation.
3. Biopsy the endometrium liberally — any postmenopausal bleeding, any woman ≥ 45 with AUB, and any woman ≥ 35 with risk factors must have endometrial sampling.
4. Classify fibroids by FIGO type — management depends on location (submucosal vs. intramural vs. subserosal), not just size.
5. LNG-IUD is first-line for HMB — superior to oral medications for blood loss reduction and patient satisfaction.
6. Screen for coagulopathy in young women — von Willebrand disease is present in up to 13% of women with HMB; screen if onset at menarche or positive family history.
7. Document failure of medical management before proceeding to surgery — most payers require documentation of medical trial.
8. Assess for Lynch syndrome — in patients with endometrial cancer under age 50, or family history of endometrial/colon cancer, refer for genetic counseling.