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
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| Adapted from Best Practice & Research Clinical Obstetrics & Gynecology March 2016 issue. |
| Criteria |
|---|
| 1. Heavy bleeding since the menarche |
2. One of the following:
|
3. Two or more of the following:
|
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:
Health-related quality of life
and economic burden of abnormal uterine bleeding. Expert Rev Obstet Gynecol. 2009; 4: 179–189
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.
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
