47.2 Abnormal Uterine Bleeding & Acute Menstrual Disorders

ABFM Family Medicine Certification Study Guide Exam

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7 Chapter 7: Pediatric Health Maintenance & Surveillance

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8 Chapter 8: Behavioral Health & Safety Screening

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9 Chapter 9: Adult Preventive Screening: Cardiovascular & Metabolic

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10 Chapter 10: Adult Cancer Screening: Breast & Gynecologic

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12 Chapter 12: Sexual Health, Infectious Disease Screening & Contraception

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13 Chapter 13: Reproductive Life Planning, Lactation & Preoperative Care

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14 Chapter 14: Emergent Cardiovascular Conditions

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17 Chapter 17: Neurologic Emergencies: Stroke & Altered Consciousness

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18 Chapter 18: Neurologic Trauma & Acute Cranial Emergencies

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19 Chapter 19: Acute Abdominal, Pelvic & Gastrointestinal Emergencies

19.1 Acute Abdominal & Pelvic Pain Triage 19.2 Upper & Lower Gastrointestinal Bleeding 19.3 Acute Hepatic Failure, Cholangitis & Severe Jaundice

20 Chapter 20: Acute Pulmonary & Airway Emergencies

20.1 Acute Hypoxic Respiratory Failure & ARDS 20.2 Severe Community-Acquired Pneumonia & Empyema 20.3 Acute Severe Epistaxis & Airway Obstruction

21 Chapter 21: Acute Traumatic Injuries & Wound Care

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22 Chapter 22: Acute Orthopedic & Musculoskeletal Emergencies

22.1 Acute Ambulatory Fractures & Initial Splinting 22.2 Compartment Syndrome & Major Orthopedic Trauma 22.3 Septic Arthritis & Acute Microcrystalline Crises

23 Chapter 23: Severe Infections, Sepsis & Systemic Emergencies

23.1 Sepsis, Septic Shock & Initial Fluid Resuscitation 23.2 Necrotizing Soft Tissue Infections & Severe CNS Infections 23.3 Anaphylaxis Diagnosis, Epinephrine Dosing & Airway Protection

24 Chapter 24: Metabolic, Endocrine & Electrolyte Emergencies

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25 Chapter 25: Hematologic, Urologic & Dental Emergencies

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26 Chapter 26: Psychiatric, Behavioral & Obstetric/Gynecologic Emergencies

26.1 Suicidal Ideation, Acute Agitation & Behavioral Emergencies 26.2 Acute Physical & Sexual Assault Care 26.3 Life-Threatening Vaginal Bleeding & Ectopic Pregnancy 26.4 Environmental Heat Stroke & Severe Hypothermia

27 Chapter 27: Acute Head, Neck & Neurologic Symptoms

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28 Chapter 28: Acute Cranial Nerves, Hearing & Sensory Symptoms

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29 Chapter 29: Acute Upper Respiratory Tract Infections

29.1 Acute Viral Rhinosinusitis vs. Bacterial Rhinosinusitis 29.2 Acute Pharyngitis: Group A Streptococcus & Centor Criteria 29.3 Acute Otitis Media, Otitis Externa & Serous Effusion

30 Chapter 30: Acute Lower Respiratory Infections & Cough

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31 Chapter 31: Allergic, Nasal & Non-Infectious Pulmonary Conditions

31.1 Allergic Rhinitis & Acute Non-Anaphylactic Allergic Reactions 31.2 Acute Dyspnea in Ambulatory Care 31.3 Interstitial Lung Diseases & Sarcoidosis Presentation

32 Chapter 32: Acute Chest, Cardiac & Vascular Symptoms

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33 Chapter 33: Acute Upper Gastrointestinal Conditions

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34 Chapter 34: Acute Lower Gastrointestinal Conditions

34.1 Acute Infectious Diarrhea & Gastroenteritis 34.2 Acute Constipation & Functional Bowel Changes 34.3 Ano-Rectal Disorders: Hemorrhoids, Fissures, Abscesses & Pruritus Ani

35 Chapter 35: Inflammatory, Functional & Malabsorptive GI Disorders

35.1 Acute Flares of Inflammatory Bowel Disease 35.2 Irritable Bowel Syndrome: Diagnosis, Subtyping & Management 35.3 Celiac Disease & Malabsorption Syndromes

36 Chapter 36: Acute Abdominal, Hepatic & Biliary Disorders

36.1 Ambulatory Abdominal & Pelvic Pain Triage 36.2 Acute Cholecystitis, Biliary Colic & Pancreatitis 36.3 Acute Liver Injury & Viral Hepatitis

37 Chapter 37: Acute Abdominal Wall, Hernias & Dental Conditions

37.1 Abdominal Wall, Inguinal & Ventral Hernias 37.2 Acute Dental Pain, Odontogenic Abscess & Aphthous Ulcers 37.3 Acute Edema: Unilateral vs. Bilateral Diagnostic Evaluation

38 Chapter 38: Acute Infectious Dermatoses

38.1 Bacterial Skin Infections: Impetigo, Cellulitis & Cutaneous Abscesses 38.2 Fungal Skin Infections: Tinea Corporis, Cruris, Pedis & Onychomycosis 38.3 Viral Cutaneous Infections: Herpes Simplex, Zoster & Molluscum Contagiosum

39 Chapter 39: Inflammatory, Allergic & Autoimmune Dermatoses

39.1 Atopic Dermatitis, Contact Dermatitis & Eczematous Flares 39.2 Non-Infectious Rashes: Urticaria, Drug Eruptions & Erythema Multiforme 39.3 Cutaneous Malignancies & Premalignant Lesions: AK, BCC, SCC & Melanoma

40 Chapter 40: Acute Shoulder, Elbow & Upper Extremity Injuries

40.1 Rotator Cuff Pathology, Tendinopathy & Shoulder Impingement 40.2 Lateral & Medial Epicondylitis, Olecranon Bursitis & Elbow Sprains 40.3 Wrist & Hand Soft-Tissue Injuries: De Quervain, TFCC & Finger Sprains

41 Chapter 41: Acute Knee, Ankle & Lower Extremity Injuries

41.1 Meniscal Tears, Ligamentous Knee Injuries & Patellofemoral Pain 41.2 Ankle Sprains, Ottawa Ankle Rules & Achilles Tendinopathy 41.3 Plantar Fasciitis, Shin Splints & Overuse Syndromes

42 Chapter 42: Acute Ambulatory Fractures & Dislocations

42.1 Distal Radius, Scaphoid & Common Upper Extremity Fractures 42.2 Metatarsal, Clavicle & Common Lower Extremity Fractures 42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

43 Chapter 43: Acute Axial Musculoskeletal Pain & Falls

43.1 Acute Low Back Pain: Red Flags, Strain & Disc Herniation 43.2 Acute Cervical Strain, Whiplash & Axial Neck Pain 43.3 Evaluation of Falls in Ambulatory & Older Patients

44 Chapter 44: Acute Inflammatory Arthropathies & Generalized Pain

44.1 Acute Inflammatory Arthritis & Spondyloarthropathies 44.2 Myalgias, Rhabdomyolysis & Post-Viral Pain Syndromes 44.3 Acute Non-Headache Pain Management Strategies

45 Chapter 45: Acute Renal, Urinary & Genitourinary Conditions

45.1 Uncomplicated UTI, Pyelonephritis & Acute Urethritis 45.2 Hematuria Workup & Glomerulonephritis 45.3 Nephrolithiasis & Acute Urinary Tract Obstruction

46 Chapter 46: Acute Male Genitourinary & Prostatic Conditions

46.1 Acute Prostatitis, Epididymitis & Orchitis 46.2 Acute Scrotal Pain: Torsion vs Appendage, BPH & Male Genital Emergencies 46.3 Acute Urinary Retention & Incontinence Evaluation

47 Chapter 47: Acute Women's Health & Early Pregnancy Care

47.1 Early Pregnancy Diagnosis, Dating & Initial Complications 47.2 Abnormal Uterine Bleeding & Acute Menstrual Disorders 47.3 Premenstrual Syndrome & Premenstrual Dysphoric Disorder

48 Chapter 48: Breast Disorders, STIs & Pediatric Elimination

48.1 Palpable Breast Mass, Mastitis & Nipple Discharge 48.2 Sexually Transmitted Infections: Diagnosis, Staging & CDC Guidelines 48.3 Pediatric Enuresis & Encopresis

49 Chapter 49: Systemic Signs, Metabolic Dysregulation & Miscellaneous Infections

49.1 Acute Fever, Sepsis Screening & FUO in Primary Care 49.2 Acute Hyperglycemia & Symptomatic Hypoglycemia 49.3 Electrolyte Abnormalities: Mild-to-Moderate Disturbances 49.4 Vector-Borne, Tick-Borne & Rickettsial Illnesses

50 Chapter 50: Chronic Cardiovascular Diseases: Hypertension & Ischemia

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51 Chapter 51: Chronic Vascular, Valvular & Dyslipidemic Diseases

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52 Chapter 52: Chronic Respiratory Diseases: Asthma & COPD

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53 Chapter 53: Chronic Metabolic Diseases: Diabetes Mellitus

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54 Chapter 54: Obesity, Nutrition & Metabolic Bone Diseases

54.1 Medical & Behavioral Management of Obesity & Incretin Mimetics 54.2 Osteoporosis & Metabolic Bone Disease: DEXA, FRAX & Antiresorptives 54.3 Nutritional Deficiencies: Vitamin D, B12, Iron & Malnutrition

55 Chapter 55: Chronic Endocrine Disorders

55.1 Primary & Subclinical Hypothyroidism, Hyperthyroidism & Nodules 55.2 Adrenal Disorders: Addison's Disease & Cushing's Syndrome 55.3 Hypercalcemia, Hyperparathyroidism & Pituitary Disorders

56 Chapter 56: Chronic Kidney Disease & Venous Disorders

56.1 Chronic Kidney Disease: KDIGO Staging & Renoprotective Therapy 56.2 Chronic Venous Insufficiency, Stasis Dermatitis & Lymphedema 56.3 Chronic Electrolyte & Acid-Base Management in CKD

57 Chapter 57: Chronic Gastrointestinal & Hepatic Diseases

57.1 Gastroesophageal Reflux Disease, Barrett's Esophagus & Dyspepsia 57.2 Chronic Liver Disease: MASLD/NAFLD, Cirrhosis & Portal Hypertension 57.3 Viral Hepatitis B & C: Long-Term Monitoring & DAA Therapy

58 Chapter 58: Colorectal Surveillance & Chronic Pancreaticobiliary Care

58.1 Post-Polypectomy Colorectal Polyp Surveillance Guidelines 58.2 Chronic Pancreatitis & Exocrine Pancreatic Insufficiency 58.3 Chronic Nausea, Gastroparesis & Functional GI Disorders

59 Chapter 59: Chronic Musculoskeletal & Rheumatologic Disorders

59.1 Osteoarthritis: Hip, Knee & Hand Management 59.2 Spinal Conditions: Spinal Stenosis, Spondylolisthesis & Compression Fractures 59.3 Chronic Myopathies & Fibromyalgia Syndrome

60 Chapter 60: Chronic Neurologic & Neurodegenerative Disorders

60.1 Dementia: Alzheimer's, Vascular & Lewy Body Disease 60.2 Parkinson's Disease & Essential Tremor 60.3 Epilepsy: Chronic Antiseizure Medications & Post-Stroke Care

61 Chapter 61: Chronic Peripheral Nerves, Pain & Sensory Disorders

61.1 Diabetic & Chronic Peripheral Neuropathies 61.2 Chronic Pain Syndromes & Chronic Daily Headaches 61.3 Chronic Tinnitus, Presbycusis & Persistent Dizziness

62 Chapter 62: Chronic Psychiatric Disorders

62.1 Major Depressive Disorder & Generalized Anxiety Disorder 62.2 Bipolar Disorder: Maintenance Pharmacotherapy & Lithium Monitoring 62.3 Adult & Pediatric Attention-Deficit/Hyperactivity Disorder

63 Chapter 63: Chronic Behavioral Health & Neurodevelopmental Conditions

63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization 63.2 Autism Spectrum Disorder & Intellectual Disabilities 63.3 Eating Disorders: Anorexia Nervosa, Bulimia & Binge Eating

64 Chapter 64: Chronic Substance Use Disorders & Tobacco Cessation

64.1 Alcohol Use Disorder: Pharmacotherapy & Relapse Prevention 64.2 Opioid & Stimulant Use Disorders: MOUD & Harm Reduction 64.3 Longitudinal Tobacco Cessation Pharmacotherapy

65 Chapter 65: Chronic Dermatologic Conditions

65.1 Acne Vulgaris, Rosacea & Seborrheic Dermatitis 65.2 Chronic Plaque Psoriasis & Biologic Therapies 65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

66 Chapter 66: Chronic Reproductive, Infectious & Geriatric Special Care

66.1 Chronic Menstrual Disorders, Infertility & Sexual Dysfunction 66.2 Menopause Management & Hormone Replacement Therapy 66.3 Chronic HIV Infection Management & Primary Care Integration 66.4 Gender-Affirming Primary Care & Hormone Therapy 66.5 Advance Care Planning, Palliative Care & End-of-Life Symptom Control

67 Chapter 67: Continuity Care: Sleep, Fatigue, Cancer, Pregnancy & the Adult Preventive Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea 67.2 Chronic Malaise, Fatigue & ME/CFS 67.3 Primary Care During Cancer Treatment & Survivorship 67.4 Routine Prenatal Care & Longitudinal Pregnancy Management 67.5 The Periodic Adult Health Examination & Medicare Annual Wellness Visit

47.2 Abnormal Uterine Bleeding & Acute Menstrual Disorders

Key Takeaways Explain This Topic AI

The FIGO PALM-COEIN classification categorizes abnormal uterine bleeding (AUB) into structural etiologies (Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia) and non-structural etiologies (Coagulopathy, Ovulatory dysfunction, Endometrial primary dysfunction, Iatrogenic, Not otherwise classified).

A urine pregnancy test is the mandatory first step in every reproductive-age female presenting with abnormal uterine bleeding; transvaginal ultrasound (TVUS) is the initial imaging modality of choice to measure the endometrial stripe thickness and evaluate myometrial architecture.

Endometrial biopsy (EMB) is mandatory in all women aged >=45 years with AUB, women <45 years with AUB and risk factors for chronic unopposed estrogen (obesity BMI >=30, PCOS, nulliparity, tamoxifen, Lynch syndrome), and all postmenopausal women with bleeding and an endometrial stripe >4 mm on TVUS (stripe <=4 mm has a >99% negative predictive value for endometrial cancer).

von Willebrand disease (vWD) is the most common inherited bleeding disorder, presenting as AUB-C with heavy menstrual bleeding since menarche, epistaxis, and easy bruising; workup includes vWF antigen, vWF ristocetin cofactor activity, and Factor VIII activity.

Acute severe, hemodynamically destabilizing AUB is managed medically with intravenous conjugated equine estrogens (Premarin 25 mg IV q4-6h) to induce rapid re-epithelialization, high-dose oral progestins (medroxyprogesterone acetate 20 mg TID), high-dose combined oral contraceptive tapers, tranexamic acid, intrauterine tamponade with a 26-30 Fr Foley catheter balloon, or emergent dilation and curettage (D&C).

Last updated: September 2026

Terminology & Normal Menstrual Parameters

Abnormal Uterine Bleeding (AUB) is defined as any departure from the normal menstrual parameters regarding frequency, regularity, duration, or volume of menstrual blood flow in non-pregnant individuals of reproductive age. In 2011 (and updated in 2018), the International Federation of Gynecology and Obstetrics (FIGO) formally retired ambiguous historical terms—including "dysfunctional uterine bleeding (DUB)," "menorrhagia," "metrorrhagia," and "oligomenorrhea"—replacing them with standardized descriptive clinical terminology categorized under the PALM-COEIN classification system. NORMAL MENSTRUAL CYCLE PARAMETERS (FIGO STANDARDS)

• Clinical Parameter Normal Physiological Range Abnormal Bleeding Terminology
• ═══════════════════════════════════════════════════════════════════════════════════════════════════════
• Frequency 24 to 38 days < 24 days: Frequent
• > 38 days: Infrequent
• Absent: Amenorrhea (>=90 days)

Duration <= 8 days > 8 days: Prolonged menstrual bleeding

• Regularity Cycle variation <= 7 to 9 days Irregular menstrual bleeding
• (Shortest to longest cycle) (variation >= 8 to 10 days)

• Volume (Patient-Determined) Subjective: does not interfere Heavy Menstrual Bleeding (HMB)
• with physical/social life (interferes with physical, social,
• (historically <=80 mL blood loss) emotional, or material quality of life)
• ═══════════════════════════════════════════════════════════════════════════════════════════════════════
• The FIGO PALM-COEIN Classification System

The PALM-COEIN framework separates AUB etiologies into structural components (measurable by imaging or histopathology: PALM ) and non-structural components (systemic, endocrinologic, or functional: COEIN ). THE FIGO PALM-COEIN CLASSIFICATION FOR AUB

• Category Classification Component Key Pathophysiologic Features & Presentation
• ═══════════════════════════════════════════════════════════════════════════════════════════════════════
• STRUCTURAL P - Polyp (AUB-P) Endometrial or endocervical glandular outgrowths;

(PALM) presents with intermenstrual or postcoital spotting.

• A - Adenomyosis (AUB-A) Ectopic endometrial glands/stroma within myometrium;
• globoid, symmetrically enlarged, tender boggy uterus;

severe dysmenorrhea and heavy cyclic menses.

• L - Leiomyoma (AUB-L) Benign smooth muscle neoplasms (fibroids);
• firm, irregularly enlarged, nodular uterus;

Submucosal (Type 0-2) cause heaviest bleeding.

M - Malignancy & Hyperplasia Endometrial hyperplasia with/without atypia or

(AUB-M) endometrial adenocarcinoma; postmenopausal bleeding.

• ───────────────────────────────────────────────────────────────────────────────────────────────────────
• NON-STRUCTURAL C - Coagulopathy (AUB-C) Systemic hemostatic defects; von Willebrand disease

(COEIN) most common; heavy bleeding since menarche.

O - Ovulatory Dysfunction Anovulatory cycles (PCOS, perimenopause, obesity);

(AUB-O) unopposed estrogen causing irregular, painless bleeding.

E - Endometrial Primary Primary hemostatic defects within endometrium;

Dysfunction (AUB-E) regular ovulatory cycles with heavy cyclic bleeding.

I - Iatrogenic (AUB-I) Exogenous hormones, copper/levonorgestrel IUDs,

anticoagulants, psychotropics causing hyperprolactinemia.

N - Not Otherwise Classified Arteriovenous malformations (AVMs), isthmocele

(AUB-N) (cesarean scar defect), chronic endometritis.

• ═══════════════════════════════════════════════════════════════════════════════════════════════════════
• Detailed Analysis of Structural Etiologies (PALM)

Endometrial & Endocervical Polyps (AUB-P) :

Localized hyperplastic outgrowths of endometrial glands and vascular stroma projecting into the uterine cavity.

Typically benign (<2% harbor malignancy in premenopausal women; increases to 5% to 6% in postmenopausal women).

Presentation: Intermenstrual bleeding (spotting between cycles), postcoital bleeding, or light unscheduled spotting. Best visualized using Saline Infusion Sonohysterography (SIS) or diagnostic hysteroscopy.

Adenomyosis (AUB-A) :

Ectopic presence of endometrial basalis glands and stroma invaginating into the myometrium, accompanied by reactive hypertrophy and hyperplasia of surrounding myometrial smooth muscle.

Demographics: Multiparous women typically in their late 30s to 40s.

Presentation: Progressive secondary dysmenorrhea (pain worsening over years) and heavy menstrual bleeding.

Physical Examination : The uterus is palpated as symmetrically enlarged, globoid, soft, boggy, and globally tender to palpation, rarely exceeding 12 to 14 weeks gestational size.

Imaging: TVUS reveals myometrial asymmetry, subendometrial echogenic linear striations, and myometrial cysts. Pelvic MRI demonstrating a thickened junctional zone >12 mm confirms the diagnosis.

Leiomyomas / Uterine Fibroids (AUB-L) :

Monoclonal benign smooth muscle tumors of the myometrium. Classified by FIGO anatomical depth:

Submucosal (FIGO 0, 1, 2) : Lie directly beneath the endometrium and distort the uterine cavity. Even tiny submucosal fibroids (<1 to 2 cm) cause profound, life-threatening heavy menstrual bleeding and severe anemia due to focal endovascular ulceration, increased surface area, and impairment of myometrial contractility.

Intramural (FIGO 3, 4, 5) : Confined to the thick myometrial wall. Cause heavy bleeding and pelvic pressure once large.

Subserosal (FIGO 6, 7) : Project outward from the serosa. Cause bulk symptoms (urinary frequency, pelvic fullness, hydronephrosis, constipation) but rarely alter menstrual blood volume.

Physical Examination : Palpation reveals a firm, irregularly enlarged, asymmetric, nodular, and non-tender uterus ("knobby" contour).

Endometrial Malignancy & Hyperplasia (AUB-M) :

Encompasses Endometrial Intraepithelial Neoplasia (EIN / atypical endometrial hyperplasia) and Endometrial Adenocarcinoma (predominantly endometrioid histology).

Cardinal red flag: Any postmenopausal vaginal bleeding or prolonged abnormal bleeding in women with chronic unopposed estrogen exposure.

Detailed Analysis of Non-Structural Etiologies (COEIN)

Coagulopathy (AUB-C) :

Found in up to 20% of adolescents presenting with severe heavy menstrual bleeding at menarche requiring hospitalization.

von Willebrand Disease (vWD) : The most common inherited bleeding disorder, transmitted primarily in an autosomal dominant pattern. Results from quantitative (Type 1, Type 3) or qualitative (Type 2) deficiency in von Willebrand factor, which mediates platelet adhesion to subendothelial collagen and stabilizes circulating Factor VIII.

Screening Questions : A structured clinical screening tool is positive if the patient has:

• Heavy menstrual bleeding since menarche;
• History of postpartum hemorrhage, surgery-related bleeding, or bleeding with dental work; OR

Two or more of: bruising >=1-2 times/month, epistaxis >=1-2 times/month, frequent gum bleeding, or family history of bleeding symptoms.

Diagnostic Panel : CBC (platelet count typically normal), PT/INR (normal), PTT (normal or mildly prolonged), vWF antigen, vWF ristocetin cofactor activity, and Factor VIII coagulant activity.

Ovulatory Dysfunction (AUB-O) :

Pathophysiologic Mechanism: In anovulatory cycles, no dominant follicle ovulates, and no corpus luteum forms. Consequently, progesterone is never produced . The endometrium is exposed to continuous, unopposed estrogen , stimulating unrelenting cellular proliferation without organized structural stroma.

Eventually, the hyperplastic endometrium outgrows its blood supply, leading to patchy, asynchronous tissue breakdown, fragile capillary rupture, and unpredictable, irregular, non-cyclic, and often prolonged, heavy bleeding .

Etiologies: Polycystic Ovary Syndrome (PCOS; triad of hyperandrogenism, ovulatory dysfunction, and polycystic morphology), perimenopausal transition (erratic follicular recruitment), adolescent post-menarche (immature hypothalamic-pituitary-ovarian axis), obesity (peripheral conversion of androstenedione to estrone by adipose aromatase), thyroid disease (hypothyroidism causing hyperprolactinemia), hyperprolactinemia, and hypothalamic amenorrhea (eating disorders, strenuous endurance exercise, psychological stress).

Endometrial Primary Dysfunction (AUB-E) :

Occurs in individuals with regular, predictable, ovulatory 28-day cycles who nonetheless experience excessive heavy menstrual bleeding.

Driven by primary defects in local endometrial hemostasis: deficiency in local vasoconstrictors (endothelin-1, prostaglandin F2-alpha) or excessive local production of vasodilators (prostaglandin E2, prostacyclin) and tissue plasminogen activator (tPA).

Iatrogenic (AUB-I) :

Breakthrough unscheduled bleeding induced by hormonal contraceptives (DMPA, progestin subdermal implants, levonorgestrel IUDs during the initial 3 to 6 months), copper IUDs (causes increased menorrhagia and dysmenorrhea), systemic anticoagulants (warfarin, DOACs), or psychotropic medications (antipsychotics that block dopamine receptors, inducing hyperprolactinemia and secondary anovulation).

Diagnostic Evaluation & Endometrial Biopsy Thresholds DIAGNOSTIC STEPWISE EVALUATION FOR AUB

• Step Diagnostic Test Clinical Objective / High-Yield Pearl
• ═══════════════════════════════════════════════════════════════════════════════════════════════════════

1. Urine Pregnancy Test MANDATORY FIRST STEP in ALL reproductive-age females.

Excludes ectopic, miscarriage, or gestational trophoblastic.

2. Complete Blood Count (CBC) Assesses severity of anemia; provides baseline platelets.

Serum Ferritin Identifies iron deficiency BEFORE overt anemia develops.

3. Endocrine Panel: TSH rules out thyroid disease; Prolactin rules out

TSH, Serum Prolactin hyperprolactinemic anovulation.

4. Coagulation Panel (if indicated) Ordered in adolescents with HMB or adults with positive

vWF antigen, ristocetin, FVIII bleeding screen; PT/PTT alone is INSUFFICIENT.

5. Transvaginal Ultrasound (TVUS) Initial imaging modality of choice; assesses endometrial

stripe thickness, polyps, adenomyosis, and fibroid mapping.

6. Endometrial Biopsy (EMB) Tissue diagnosis to rule out endometrial carcinoma and

atypical hyperplasia in stratified high-risk groups.

• ═══════════════════════════════════════════════════════════════════════════════════════════════════════
• The Postmenopausal Bleeding Paradigm & TVUS Stripe Cutoff

Warning

POSTMENOPAUSAL BLEEDING IS ENDOMETRIAL CANCER UNTIL PROVEN OTHERWISE Vaginal bleeding occurring >12 months after the cessation of menses in a postmenopausal woman requires aggressive, prompt diagnostic evaluation. Although benign atrophy accounts for 60% to 80% of cases, endometrial cancer is diagnosed in approximately 10% of postmenopausal bleeding presentations.

TVUS Endometrial Stripe Measurement :

Stripe <= 4.0 mm : Carries a >99% Negative Predictive Value (NPV) for endometrial adenocarcinoma. If the ultrasound confirms a thin, smooth, homogeneous stripe <=4 mm and bleeding has completely stopped, invasive tissue biopsy can be safely deferred with close clinical observation.

Stripe > 4.0 mm (or heterogeneous, indistinct, irregular stripe, or persistent/recurrent bleeding): Mandates immediate Endometrial Biopsy (EMB) to obtain histologic tissue confirmation.

Formal Clinical Indications for Endometrial Biopsy (EMB)

According to ACOG and family medicine board guidelines, outpatient pipelle endometrial biopsy is strictly indicated in:

All postmenopausal women presenting with abnormal vaginal bleeding and an endometrial stripe > 4 mm (or unmeasurable/blind stripe on TVUS);

All women aged >= 45 years presenting with abnormal uterine bleeding (first-line diagnostic test before instituting long-term medical therapy);

Women aged < 45 years with abnormal uterine bleeding who possess risk factors for chronic unopposed estrogen exposure :

• Chronic anovulation or Polycystic Ovary Syndrome (PCOS);
• Severe obesity (BMI >= 30 kg/m²; marked peripheral aromatization of estrone);
• Nulliparity or early menarche / late menopause;

Tamoxifen therapy (selective estrogen receptor modulator with antagonistic breast effects but agonistic endometrial pro-proliferative actions);

Lynch Syndrome (Hereditary Non-Polyposis Colorectal Cancer [HNPCC]; carries a 40% to 60% lifetime risk of endometrial carcinoma; annual endometrial screening begins at age 30 to 35);

Persistent abnormal uterine bleeding despite conservative medical therapy.

Medical Management of Chronic Abnormal Uterine Bleeding

Once structural malignancy is excluded, medical therapy serves as the primary management strategy. MEDICAL PHARMACOTHERAPY REGIMENS FOR CHRONIC AUB

• Therapeutic Agent Dosage & Administration Mechanism & Clinical Pearl
• ═══════════════════════════════════════════════════════════════════════════════════════════════════════
• Levonorgestrel IUD 52 mg device (Mirena / Liletta) GOLD STANDARD for HMB;
• (LNG-IUD) Intrauterine placement; lasts 8 yrs reduces blood loss by 70-90%;

induces marked endometrial atrophy.

• Combined Oral Monophasic COC (30-35 mcg EE) Stabilizes endometrium via estrogen;
• Contraceptives (COCs) Daily oral tablet progestin prevents hyperproliferation;

(cyclic or extended cycle) regulates cycles and reduces loss by 50%.

• Oral Progestins: 10 to 20 mg PO daily continuously Atrophies endometrium; ideal in PCOS
• Medroxyprogesterone (MPA) OR 10 mg PO daily for 12-14 days/mo or when estrogens are contraindicated

Norethindrone acetate 5 to 15 mg PO daily continuously (hypertension, thrombophilia, smoker >=35).

• Tranexamic Acid (TXA) 1,300 mg PO three times daily (TID) Antifibrinolytic; reversible plasminogen
• (Non-Hormonal) taken ONLY during heavy menses inhibitor; reduces blood loss by 40-50%;

(maximum 5 consecutive days) preferred for women seeking conception.

• NSAIDs: Naproxen 500 mg PO BID OR Inhibits cyclooxygenase; shifts balance
• (Non-Hormonal) Ibuprofen 600-800 mg PO TID to vasoconstrictive PGF2-alpha;

taken with onset of menses reduces blood loss by 25-30% + relieves pain.

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• Acute Severe Abnormal Uterine Bleeding: Emergency Stabilization

Acute severe AUB is defined as an episode of substantial uterine hemorrhage requiring immediate medical or surgical intervention to prevent acute hemodynamic collapse, symptomatic severe anemia, or shock.

• Acute Resuscitation Principles
• Establish airway, breathing, circulation (ABCs);
• Place two large-bore (14- to 16-gauge) peripheral IV lines;
• Initiate rapid crystalloid infusion (Normal Saline or Lactated Ringer's);

Draw stat type and screen / crossmatch (prepare 2-4 units of packed red blood cells [PRBCs]), complete blood count, coagulation studies (PT/INR, PTT, fibrinogen), and a stat point-of-care pregnancy test;

Assess for signs of hypovolemic shock (hypotension, resting tachycardia >110 bpm, orthostatic dizziness, pale cool extremities, oliguria).

Pharmacologic Protocols for Acute Hemorrhage EMERGENCY MEDICAL PROTOCOLS FOR ACUTE SEVERE AUB

• Protocol Option Dosage & Route Clinical Mechanism & Instructions
• ═══════════════════════════════════════════════════════════════════════════════════════════════════════
• Intravenous Conjugated Premarin 25 mg IV every 4 to 6 RAPID VASOSPASM & RE-EPITHELIALIZATION;
• Equine Estrogens (CEE) hours for up to 24 hours promotes immediate clotting cascade and
• (maximum 3 to 4 doses) endometrial regrowth. Once bleeding

stops, MUST transition to oral progestin!

High-Dose Oral Combined Monophasic 35 mcg EE COC: TAPER SCHEDULE: Estrogen stabilizes the

Contraceptive Taper 1 tab PO TID x 7 days lining; progestin prevents further loss.

THEN 1 tab PO BID x 7 days Provide scheduled antiemetic (ondansetron)

THEN 1 tab PO daily x 7-14 days to combat high-dose estrogen nausea.

• High-Dose Oral Progestin Medroxyprogesterone acetate (MPA) PROGESTIN STABILIZATION; indicated when
• Monotherapy 20 mg PO TID x 7 to 10 days estrogens are strictly contraindicated

OR Norethindrone 5-10 mg PO TID (active VTE, severe uncontrolled HTN).

Tranexamic Acid (TXA) 10 mg/kg IV (max 1,000 mg) q8h ANTIFIBRINOLYTIC STABILIZATION; highly

Intravenous / Oral OR 1,300 mg PO TID effective adjuvant; preserves fibrin clots.

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• Mechanical & Surgical Interventions for Refractory Bleeding

Intrauterine Balloon Tamponade :

Rapid bedside mechanical compression of bleeding endomyometrial vascular channels.

Technique : Insert a sterile 26 to 30 French Foley catheter (or specialized Bakri postpartum balloon) through the dilated cervix into the endometrial cavity. Inflate the balloon with 30 to 50 mL of sterile saline until resistance is met. Apply gentle downward traction and tape the catheter to the patient's inner thigh. Maintain in place for 12 to 24 hours alongside prophylactic broad-spectrum antibiotics. Provides rapid tamponade when medical pharmacotherapy is taking effect or while preparing the operating room.

Emergent Dilation and Curettage (D&C) :

The definitive emergency surgical intervention for acute uterine hemorrhage in patients who are hemodynamically unstable, presenting in active shock, or refractory to initial medical therapy.

Mechanically debulks necrotic, hyperplastic tissue, allows endomyometrial vasospasm, and immediately obtains vital tissue for histopathologic exclusion of malignancy.

Uterine Artery Embolization (UAE) or Emergent Hysterectomy :

Reserved for life-threatening, intractable hemorrhage refractory to D&C and intrauterine balloon tamponade.

Loading diagram... Clinical Diagnostic & Therapeutic Algorithm for Abnormal Uterine Bleeding (AUB)