Abnormal/Dysfunctional Uterine Bleeding (AUB/DUB)

Definition

• Menstrual bleeding deviating from normal in quantity, duration or schedule

• Includes intermenstrual bleeding, menorrhagia, postmenopausal bleeding and postcoital bleeding

Classification: PALM-COEIN Framework

Structural Causes (PALM)

• Polyps: Cervical or endometrial

• Adenomyosis: Common in women over 35; presents with cyclical pain and heavy bleeding

• Leiomyoma (Fibroids): Often in women over 35; may cause non-cyclical pain and dyspareunia

• Malignancy/Hyperplasia: Involving endometrium, cervix or ovaries

Non-Structural Causes (COEIN)

• Coagulopathy: Von Willebrand disease, thrombocytopenia

• Ovulatory Dysfunction: Seen in PCOS or hypothyroidism

• Endometrial Causes: Endometritis, hyperplasia

• Iatrogenic: Medications such as anticoagulants, antipsychotics, IUD or COCP

• Not yet classified: STIs, IBS/IBD associated with dysmenorrhoea and pelvic pain

Type-Specific Differentials

• Postmenopausal Bleeding

  • Atrophic vaginitis or endometritis are most common

  • Exclude cervical or endometrial cancer/hyperplasia and polyps

• Intermenstrual Bleeding

  • Consider PID, IUD-related irregularities, cervical ectropion, endometrial hyperplasia or malignancy

• Postcoital Bleeding

  • Cervical causes: Ectropion, polyps, malignancy

  • Consider PID, STIs and atrophic vaginitis

Investigations

• General

  • Transvaginal ultrasound on days 5–10 of the cycle to assess uterine and ovarian structure

  • STI screening if infection is suspected

• Specific for Postcoital Bleeding

  • Cervical co-test and endocervical swabs for chlamydia, gonorrhoea, Mycoplasma genitalium

  • High vaginal swabs for Trichomonas and MCS

• Additional Testing

  • Thyroid function tests for unexplained menorrhagia

  • Endometrial sampling in postmenopausal women or if malignancy is suspected

  • Consider bone mineral density assessment in long-standing cases

Management

General Principles

• Tailor management to the underlying cause identified through the PALM-COEIN framework

• Lifestyle modifications and medical therapy are first-line for many non-structural causes

Medical Treatments

• Tranexamic acid to reduce menstrual blood loss

• NSAIDs to alleviate pain and reduce flow

• Hormonal therapies (combined oral contraceptives, progestogens) especially in ovulatory dysfunction

• Endometrial ablation may be considered for persistent heavy bleeding in selected cases

Surgical Treatments

• Hysteroscopic polypectomy for polyps

• Myomectomy or uterine artery embolisation for fibroids

• Oncological management for malignancy or hyperplasia as indicated

Follow-Up

• Regular monitoring of bleeding patterns, symptom response and overall well-being

• Referral to gynaecology for persistent or unexplained cases and postmenopausal bleeding

Notes:

• Early evaluation is crucial in postmenopausal bleeding to exclude malignancy

• Detailed history including menstrual pattern, family history, medication use and systemic symptoms guides targeted investigation

• A multidisciplinary approach involving gynaecology, endocrinology and haematology improves patient outcomes

• Educate patients on treatment adherence, recognise red flags and the importance of follow-up to prevent complications

• Awareness of the impact of thyroid dysfunction and other endocrine disorders on menstrual irregularities is essential in the workup

• Public health guidelines emphasise screening and prevention strategies for common aetiologies in reproductive-age women