Obstetrics & Gynecology

Last updated on: August 13th, 2021

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Abnormal uterine bleeding

Clinicals - History


Abnormal uterine bleeding (AUB) is any type of bleeding from the uterus that is out of the range of normal menstruation; this may be in terms of regularity, frequency, duration, or volume. AUB is a common complaint that is often multifactorial; and it can significantly interfere with the patient's quality of life. The mnemonic “PALM-COEIN” can be used to recall the etiologies causing AUB. “PALM” refers to structural causes—polyps, adenomyosis, leiomyoma, and malignancy; “COEIN” refers to non-structural causes—coagulopathies, ovulatory disorders, endometrial disorders, iatrogenic procedures, and “not otherwise classified” conditions. Multiple disorders may co-exist at the same time.

AUB: heavy menstrual bleeding

AUB can present as heavy menstrual bleeding (HMB)—a blood loss >80 mL per cycle, with or without other symptoms. Earlier, this was termed “hypermenorrhea” or “menorrhagia”. This form of AUB is usually associated with ovulatory cycles.

AUB: prolonged menstrual bleeding

AUB can manifest as prolonged menstrual bleeding—menstruating for >8 days. This was previous termed “menometrorrhagia”. This finding is suggestive of anovulation.

AUB: irregular menstrual bleeding

AUB can also manifest as irregular menstrual bleeding—occurring at intervals with a 20-day variation or more. Earlier, this was termed “menometrorrhagia”. Similar to prolonged menstrual bleeding, this too is suggestive of anovulation.

AUB: intermenstrual bleeding

AUB can present as bleeding that occurs outside the normal menstrual period. Earlier, this was termed “metrorrhagia”. This is triggered by poor corpus luteal development and inadequate progesterone secretion.

Bladder and bowel dysfunction

The presence of associated obstructive or irritative bowel and bladder symptoms is strongly suggestive of uterine fibroids.

Pelvic pain

The presence of chronic pelvic pain favors adenomyosis, especially if it is markedly exacerbated during menstruation. Acute severe pelvic pain may occur in fibroid degeneration.


Subfertility is a common accompaniment. When associated with intermenstrual bleeding, this is more likely to be due to hormonal imbalances. Alternately, this may be due to structural causes (e.g., uterine polyps or fibroids) distorting the uterine cavity and interfering with implantation.

Symptoms of anemia

Symptoms of anemia include fatigue, weakness, pallor, and dizziness. These are typically a consequence of HMB.

Medical history

Affected women may have a history of heavy bleeding since menarche, or of postpartum hemorrhage. A coagulopathy may be suggested by the presence of frequent or easy bruising, bleeding gums or bloody sputum, or bleeding following iatrogenic procedures.

Family history

The presence of a family history of bleeding disorders should raise concern of an inherited coagulopathy.

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