Abnormal Uterine Bleeding in Premenopausal Women

 

Am Fam Physician. 2019 Apr 1;99(7):435-443.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/abnormal-uterine-bleeding/.

Author disclosure: No relevant financial affiliations.

Abnormal uterine bleeding is a common symptom in women. The acronym PALM-COEIN facilitates classification, with PALM referring to structural etiologies (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia), and COEIN referring to nonstructural etiologies (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified). Evaluation involves a detailed history and pelvic examination, as well as laboratory testing that includes a pregnancy test and complete blood count. Endometrial sampling should be performed in patients 45 years and older, and in younger patients with a significant history of unopposed estrogen exposure. Transvaginal ultrasonography is the preferred imaging modality and is indicated if a structural etiology is suspected or if symptoms persist despite appropriate initial treatment. Medical and surgical treatment options are available. Emergency interventions for severe bleeding that causes hemodynamic instability include uterine tamponade, intravenous estrogen, dilation and curettage, and uterine artery embolization. To avoid surgical risks and preserve fertility, medical management is the preferred initial approach for hemodynamically stable patients. Patients with severe bleeding can be treated initially with oral estrogen, high-dose estrogen-progestin oral contraceptives, oral progestins, or intravenous tranexamic acid. The most effective long-term medical treatment for heavy menstrual bleeding is the levonorgestrel-releasing intrauterine system. Other long-term medical treatment options include estrogen-progestin oral contraceptives, oral progestins, oral tranexamic acid, nonsteroidal anti-inflammatory drugs, and depot medroxyprogesterone. Hysterectomy is the definitive treatment. A lower-risk surgical option is endometrial ablation, which performs as well as the levonorgestrel-releasing intrauterine system. Select patients with chronic uterine bleeding can be treated with myomectomy, polypectomy, or uterine artery embolization.

Abnormal uterine bleeding is a common condition, with a prevalence of 10% to 30% among women of reproductive age.1 It negatively affects quality of life and is associated with financial loss, decreased productivity, poor health, and increased use of health care resources.24 In 2011 the International Federation of Gynecology and Obstetrics convened a working group that produced standardized definitions and classifications for menstrual disorders, which the American College of Obstetricians and Gynecologists subsequently endorsed.5,6 The updated terminology pertains only to nonpregnant women of reproductive age, which is the scope of this review.

WHAT IS NEW ON THIS TOPIC

The acronym PALM-COEIN facilitates the classification of abnormal uterine bleeding, with PALM referring to structural etiologies (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia), and COEIN referring to nonstructural etiologies (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified).

Among medical therapies, the 20-mcg-per-day formulation of the levonorgestrel-releasing intrauterine system (Mirena) is most effective for decreasing heavy menstrual bleeding (71% to 95% reduction in blood loss) and performs similarly to hysterectomy when quality-adjusted life years are considered.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The International Federation of Gynecology and Obstetrics classification system should be used to characterize abnormal uterine bleeding.

C

5, 6

All patients with abnormal uterine bleeding should be tested for pregnancy and anemia.

C

6

Endometrial biopsy should be performed in all patients with abnormal uterine bleeding who are 45 years or older, in younger patients with a significant history of unopposed estrogen exposure, persistent bleeding, or in whom medical management is ineffective.

C

6

Transvaginal ultrasonography is the first-line imaging choice for evaluating abnormal uterine bleeding in most patients.

C

6, 36

The 20-mcg-per-day formulation of the levonorgestrel-releasing intrauterine system (Mirena) is more effective than other medical therapies for reducing heavy menstrual bleeding.

A

44, 47

Hysterectomy is the most effective treatment for reducing heavy menstrual bleeding.

A

44, 47


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The International Federation of Gynecology and Obstetrics classification system should be used to characterize abnormal uterine bleeding.

C

5, 6

All patients with abnormal uterine bleeding should be tested for pregnancy

The Authors

show all author info

NOAH WOUK, MD, is a family medicine physician at Piedmont Health Services, Prospect Hill, N.C., and an adjunct assistant professor in the Department of Family Medicine at the University of North Carolina School of Medicine, Chapel Hill...

MARGARET HELTON, MD, is a professor in the Department of Family Medicine at the University of North Carolina School of Medicine.

Address correspondence to Noah Wouk, MD, Piedmont Health Services, 322 Main St., Prospect Hill, NC 27314 (e-mail: woukno@piedmonthealth.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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