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Abnormal uterine bleeding

What's new

Updated 2024 AAFP guidelines for the management of abnormal uterine bleeding related to hormonal contraception.

Background

Overview

Definition
AUB is defined as bleeding from the uterine corpus that is abnormal in regularity, volume, frequency, or duration and occurs in the absence of pregnancy.
1
Pathophysiology
The key pathophysiological mechanisms of AUB include hormonal imbalances, endometrial abnormalities, and coagulation disorders. Hormonal imbalances, such as anovulation, can lead to AUB, as it is one of the most common causes of this condition.
2
Epidemiology
The prevalence of AUB in the US is estimated at around 16.4% in 2019-2021.
3
Disease course
The clinical presentations of AUB can vary. It can present as heavy menstrual bleeding, irregular menstrual bleeding, intermenstrual bleeding, or even postmenopausal bleeding.
2
Prognosis and risk of recurrence
The prognosis is generally benign, but it can significantly impact a woman's QoL due to its direct influence on healthcare resources, costs, and utilization.
4

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of abnormal uterine bleeding are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024,2019), the American College of Radiology (ACR 2020), the American College of Obstetricians and Gynecologists (ACOG 2019,2013,2012), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2019,2018,2015), and the Society...
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Classification and risk stratification

Classification: as per AAFP 2019 guidelines, Use the International Federation of Gynecology and Obstetrics classification system to characterize AUB.
B
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Diagnostic investigations

History and physical examination: as per SOGC 2018 guidelines, Elicit history and perform physical examination to determine the cause of AUB and direct the need for further investigation and treatment.
B

More topics in this section

  • Pregnancy testing

  • Ultrasound

  • MRI

  • Laboratory testing

Diagnostic procedures

Hysteroscopy
As per SOGC 2018 guidelines:
Perform hysteroscopy to acquire additional information to assist in patient assessment and treatment in indicated circumstances.
A
Perform hysteroscopy for the diagnosis and characterization of discrete intrauterine abnormalities, such as submucosal fibroids.
A

More topics in this section

  • Endometrial biopsy

Medical management

General principles
As per SOGC 2018 guidelines:
Initiate medical treatment as first-line therapy in patients with AUB once malignancy and significant pelvic pathology is ruled out.
A
Tailor medical treatment to individual patient's therapeutic goals, desire for contraception, underlying medical conditions and tolerance of side effects to encourage compliance and maximize the likelihood of treatment success.
B

More topics in this section

  • Management of acute bleeding

  • Hormone therapy

  • Antifibrinolytics

  • NSAIDs

Therapeutic procedures

Intrauterine devices: as per AAFP 2019 guidelines, Offer 20 µg/day formulation of the levonorgestrel releasing intrauterine system over other medical therapies for reducing heavy menstrual bleeding.
A

More topics in this section

  • Endometrial ablation

Surgical interventions

General principles: as per ACOG 2013 guidelines, Decide on performing surgery based on the following factors:
clinical stability
severity of bleeding
contraindications to medical management
lack of response to medical management
underlying medical condition
patient's desire for future fertility.
E

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  • Hysterectomy

  • Myomectomy

Specific circumstances

Adolescent patients, evaluation: as per ACOG 2019 guidelines, Recognize that heavy menstrual bleeding at menarche and in adolescence may be an important sentinel for an underlying bleeding disorder.
E
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More topics in this section

  • Adolescent patients (management)

  • Patients on hormonal contraception

  • Patients with inherited bleeding disorders

  • Patients undergoing cancer treatment