# Abnormal uterine bleeding

Abnormal uterine bleeding (AUB), also known as atypical vaginal bleeding (AVB), is vaginal bleeding from the uterus that is abnormally frequent, lasts excessively long, is heavier than normal, or is irregular. The term dysfunctional uterine bleeding was used when no underlying cause was present. Vaginal bleeding during pregnancy is excluded. Iron deficiency anemia may occur and quality of life may be negatively affected.
The underlying causes may include ovulation problems, fibroids, the lining of the uterus growing into the uterine wall, uterine polyps, underlying bleeding problems, side effects from birth control, or cancer. More than one category of causes may apply in an individual case. The first step in work-up is to rule out a tumor or pregnancy. Medical imaging or hysteroscopy may help with the diagnosis.
Treatment depends on the underlying cause. Options may include hormonal birth control, gonadotropin-releasing hormone (GnRH) agonists, tranexamic acid, NSAIDs, and surgery such as endometrial ablation or hysterectomy. Over the course of a year, roughly 20% of reproductive-aged women self-report at least one symptom of AUB.
As adenomyosis is a common disorder with a prevalence of 20-35% it is often causative related. Recent research suggests that abnormal angiogenesis is associated to conditions of adenomyosis leading to abnormal uterine bleeding. This suggests options for therapeutic intervention with angiogenesis inhibitors.

## Signs and symptoms

Symptoms include vaginal bleeding that occurs irregularly, at abnormal frequency, lasts excessively long, or is more than normal. Normal frequency of periods is 22 to 38 days. Variation in the length of time between cycles is typically less than 21 days. Bleeding typically last less than nine days and blood loss is less than 80 mL. Excessive blood loss may also be defined as that which negatively affects a person's quality of life. Bleeding more than six months after menopause is also a concern.

## Causes

The causes of AUB are divided into nine groups: uterine polyps, fibroids, adenomyosis, cancer, blood clotting disorders, problems with ovulation, endometrial problems, healthcare induced, and not yet classified. More than one category of causes may apply in an individual case. Healthcare induced causes may include side effects of birth control.

## Diagnosis

Diagnosis of AUB starts with a medical history and physical examination. Normal menstrual bleeding patterns vary from woman to woman, so the medical history covers specific details about the woman's individual menstrual bleeding pattern, such as its predictability, length, volume, and whether she experiences cramps or other pain. The healthcare provider will also check to see whether she or any family members have any potentially related health conditions, and whether she is taking medication that might increase or decrease menstrual bleeding, such as herbal supplements, hormonal contraceptives, over-the-counter drugs such as aspirin, or blood thinners.
Medical tests include a blood test, to see whether the abnormal bleeding has caused anemia, and a pelvic ultrasound, to see whether the abnormal bleeding is caused by a structural problem, such as a uterine fibroid. Ultrasound is specifically recommended in those over the age of 35 or those in whom bleeding continues despite initial treatment. Laboratory assessment of thyroid stimulating hormone (TSH), pregnancy, and chlamydia is also recommended.
More extensive testing might include an MRI and endometrial sampling. Endometrial sampling is recommended in those over the age of 45 who do not improve with treatment and in those with intermenstrual bleeding that persists. The PALM-COEIN system may be used to classify the uterine bleeding.

## Management

Treatment depends on the underlying cause. Options may include hormonal birth control, gonadotropin-releasing hormone (GnRH) agonists, tranexamic acid, NSAIDs, and surgery such as endometrial ablation or hysterectomy. Polyps, adenomyosis, and cancer are generally treated by surgery. Iron supplementation may be needed.

## Terminology

The terminology "dysfunctional uterine bleeding" is no longer recommended. Historically dysfunctional uterine bleeding meant there was no structural or systemic problems present. In AUB underlying causes may be present.

## Epidemiology

About one-third of all medical appointments with gynecologists involve AUB, with the proportion rising to 70% in the years around menopause.