Practice Guidelines

ACOG Releases Guidelines on Management of Abnormal Uterine Bleeding Associated with Ovulatory Dysfunction

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Am Fam Physician. 2014 Jun 15;89(12):987-988.

Key Points for Practice from AFP

  • PALM-COEIN was developed to describe uterine bleeding abnormalities in women of reproductive age. It includes the structural causes (polyp, adenomyosis, leiomyoma [submucosal or other myoma], and malignancy and hyperplasia) and nonstructural causes (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified).

  • Medical treatments for abnormal uterine bleeding associated with ovulatory dysfunction include progestin-only contraception and combined hormonal contraception.

  • If medical treatment fails, is contraindicated, or is not tolerated, or if the patient has concomitant significant intracavitary lesions, surgery, including endometrial ablation and hysterectomy, may be an option.

From the AFP Editors

Abnormal uterine bleeding related to ovulatory dysfunction (i.e., oligoovulation and anovulation) is a range of disorders often associated with heavy, irregular bleeding. Assessment includes a medical history, physical examination, and selected laboratory and imaging tests (i.e., pregnancy test; beta subunit of human chorionic gonadotropin test; measurement of thyroid-stimulating hormone and prolactin levels; endometrial biopsy; and saline infusion sonohysterography, hysteroscopy, or transvaginal ultrasonography). Causes of anovulation, which should be considered during the evaluation, include adolescence, perimenopause, lactation, pregnancy, hyperandrogenic conditions, hypothalamic dysfunction, hyperprolactinemia, thyroid disease, primary pituitary disease, premature ovarian failure, iatrogenic, and medications. The American College of Obstetricians and Gynecologists (ACOG) treatment recommendations are based on the assumption that a physician has confirmed the diagnosis, as well as ruled out endometrial and structural pathologies.

A classification system

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A collection of Practice Guidelines published in AFP is available at

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