Abnormal Uterine Bleeding (AUB)

Abnormal Uterine Bleeding (AUB) also called as dysfunctional uterine bleeding is a common problem especially at the beginning and end of the reproductive years affecting 14–25% of women.

An orderly approach using the International Federation of Gynecology and Obstetrics

(FIGO) PALM-COEIN (Polyp, Adenomyosis, Leiomyoma, Malignancy (and hyperplasia), Coagulopathy, Ovulatory disorders, Endometrial, Iatrogenic and Not otherwise classified) classification helps in arriving at accurate diagnosis and well informed management options for the patient.

Fibroids are the most common cause in women presenting with AUB especially by the age of 50, According to a paper by Baird  DD et al the estimated cumulative incidence at this age is almost 70% of white women and >80% of black women will have developed at least one fibroid.

As women postpone motherhood in favor of better career choices, fertility preservation and newer medical options becomes genuine choices as treatment options.

This review by Whitaker L and Critchley H.O.D published in forthcoming issue of Best Practice & Research Clinical Obstetrics & Gynecology considers the FIGO classification of   AUB and addresses the general principles of managing it in premenopausal women.

FIGO in 2009 defined chronic AUB as ‘bleeding from the uterine corpus that is abnormal in volume, regularity and/or timing that has been present for the majority of the last 6 months’.

With regard to volume, however, both the Royal College of Obstetricians and Gynaecologists (RCOG) and American College of Obstetricians and Gynecologists (ACOG) prefer the patient-centered definition of HMB, ‘excessive menstrual blood loss which interferes with a woman's physical, social, emotional and/or material quality of life’ as an indication for investigation and treatment options.

FIGO classification of cause: ‘PALM-COEIN’ is now being increasingly used for categorising causes: Polyp, Adenomyosis, Leiomyoma, Malignancy (and hyperplasia), Coagulopathy, Ovulatory disorders, Endometrial, Iatrogenic and Not otherwise classified The ‘PALM’ are assessed visually (imaging and histopathology) and the ‘COEIN’ are non-structural.

Adapted from Best Practice & Research Clinical Obstetrics & Gynecology March 2016 issue.

Assessment of the patient presenting with AUB and fibroids

Adapted from Best Practice & Research Clinical Obstetrics & Gynecology March 2016 issue.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Structured history for coagulopathy screen. Adapted from Koudies et al. .

Criteria
1. Heavy bleeding since the menarche
2. One of the following: Postpartum haemorrhage •Surgical-related bleeding •Bleeding associated with dental work
3. Two or more of the following: Bruising 1–2 times/month Epistaxis 1–2 times per/month Frequent gum bleeding Family history of bleeding problems

Endometrial sampling

Endometrial sampling: In the UK, NICE recommend endometrial sampling in women with persistent inter-menstrual bleeding or aged ≥45 years with treatment failure .This has been highlighted in the RCOG guidelines with an exception of reducing the age of sampling in the context of treatment failure to 40 . With the marked increase in endometrial cancer, the authors would encourage all gynaecologists to continue to excise their clinical judgement for those women aged <40 years with HMB who have risk factors for premalignant change such as obesity and PCOS.

Approach to management

In those patients where the cause of AUB is fibroid, the treatment should be tailored based on individual symptoms and requirements.  It should be based upon fertility desire, age of the patient, and associated co morbidities.

Specific treatment options for individual PALM-COEIN causes of AUB.

AUB  Sub-classification	Specific treatment
Polyp	Resection
Adenomyosis	Surgery: hysterectomy; adenomyomectomy (not frequently performed)
Malignancy	Surgery +/− adjuvant treatment High-dose progestogens (if surgery not possible)  Palliation (including radiotherapy)
Coagulopathy	Tranexamic acid  DDVAP
Ovulation	Lifestyle modification Cabergoline (if hyperprolactinaemia)  Levothyroxine (if hypothyroid)
Endometrial	Specific therapies await further delineation of underlying mechanisms
Iatrogenic	Refer to FSRH CEU guidance on problematic bleeding with hormonal contraception
Not otherwise classified	Antibiotics for endometritis  Embolisation of AV malformation

Some salient features in  the management are:

• Fully non hormonal medical options are Tranexamic acid and NSAIDs (e.g. mefenamic acid)
• While the risk for expulsion due to distortion of the cavity does exist, (LNG–IUS) are still efficacious in controlling the bleeding.
• The current Cochrane review only includes mifepristone, and a future review that includes other medical options is awaited. Although  PEARL II study has documented the efficacy of SPRM ulipristal acetate (UPA) particularly in short term use before surgery.
• With regards to interventional radiological procedures like uterine artery embolism and it’s comparison to myomectomy, the authors are awaiting the result of FEMME trial to provide robust evidence.
• Hysterectomy will remain the definitive treatment, especially in context of HMB in patients who have completed the families, until alternative treatment strategies are developed and well documented.

References:

http://www.bestpracticeobgyn.com/article/S1521-6934%2815%2900226-6/fulltext

Fraser, I.S., Langham, S., and Uhl-Hochgraeber, K. Health-related quality of life and economic burden of abnormal uterine bleeding. Expert Rev Obstet Gynecol. 2009; 4: 179–189

Baird, D.D., Dunson, D.B., Hill, M.C. et al. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003; 188: 100–107

NICE. Clinical Guideline 44; Heavy menstrual bleeding 2007. National Institute for Health and Clinical Excellence (NICE); Available at: http://www.nice.org.uk/nicemedia/pdf/CG44FullGuideline.pdf.

Munro, M.G., Critchley, H.O., Fraser, I.S., and for the FIGO Working Group on Menstrual Disorders. The FIGO classification of causes of abnormal uterine bleeding.. Int J Gynaecol Obstet. 2011; 113: 1–2

Kouides, P.A., Conard, J., Peyvandi, F. et al. Hemostasis and menstruation: appropriate investigation for underlying disorders of hemostasis in women with excessive menstrual bleeding. Fertil Steril. 2005; 84: 1345–1351