Management of Abnormal Uterine Bleeding

Overview

Management of Abnormal Uterine Bleeding is the systematic investigation and evidence-based medical and surgical treatment of heavy, irregular, prolonged, or abnormal menstrual bleeding that significantly impacts a woman's quality of life, causes iron deficiency anaemia, or raises the concern for underlying malignant or pre-malignant pathology. Abnormal uterine bleeding affects 1 in 4 women of reproductive age and is one of the most common reasons for gynaecological referral and hospital admission. The PALM-COEIN classification system provides a structured framework for identifying structural (polyps, adenomyosis, fibroids, malignancy) and non-structural (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic) causes. Exclusion of endometrial malignancy is mandatory before initiating any medical treatment.

Types of Management of Abnormal Uterine Bleeding

• Heavy menstrual bleeding (HMB) — regular menstrual cycles with excessively heavy flow causing anaemia, social limitation, and reduced quality of life
• Intermenstrual bleeding (IMB) — unpredictable vaginal bleeding between regular menstrual periods requiring investigation to exclude cervical and endometrial pathology
• Post-coital bleeding (PCB) — vaginal bleeding following sexual intercourse requiring colposcopy to exclude cervical lesion or cancer
• Post-menopausal bleeding (PMB) — any vaginal bleeding occurring more than 12 months after the final period requiring urgent 2-week wait endometrial assessment
• Irregular uterine bleeding from anovulation — unpredictable heavy and prolonged bleeding from unopposed oestrogen stimulation associated with PCOS or perimenopause

Risk Factors of Management of Abnormal Uterine Bleeding

• Uterine fibroids — particularly submucosal fibroids distorting the endometrial cavity — causing heavy, prolonged, and irregular menstrual bleeding
• Endometrial polyps — benign endometrial overgrowths causing intermenstrual spotting and heavy menstrual bleeding
• Adenomyosis — endometrial gland tissue embedded within the uterine muscle causing progressive dysmenorrhoea and heavy periods
• Polycystic ovary syndrome causing chronic anovulation with unopposed oestrogen effect on the endometrium leading to irregular heavy bleeding
• Obesity causing excess peripheral oestrogen production from adipose tissue aromatase stimulating the endometrium
• Use of anticoagulant medications (warfarin, direct oral anticoagulants) causing excessive menstrual blood loss

Symptoms of Management of Abnormal Uterine Bleeding

• Menstrual flow requiring more than one pad or tampon per hour for several consecutive hours indicating clinically significant heavy bleeding
• Passage of blood clots larger than a 50 pence piece during menstruation suggesting insufficient uterine fibrin clot formation
• Periods lasting more than 7 days significantly beyond the woman's previous normal menstrual cycle duration
• Symptoms of iron deficiency anaemia — profound fatigue, breathlessness on minimal exertion, pallor, palpitations, and poor concentration
• Pelvic pressure, bloating, and urinary frequency from the mechanical bulk effect of large uterine fibroids
• Dysmenorrhoea (painful periods) progressively worsening over time and increasingly requiring strong analgesia suggesting adenomyosis
• Intermenstrual or post-coital spotting distinct from the regular menstrual period requiring investigation to exclude malignancy
• Social limitation — avoiding exercise, travel, or social activities — and anxiety about embarrassing flooding incidents affecting quality of life