Passing blood clots that are the size of a quarter or larger. Historical clues such as passing blood clots or changing pads/tampons at least hourly suggest heavy menstrual bleeding.31 A history of postcoital bleeding may indicate cervicitis, ectropion, or, rarely, cervical cancer, whereas abdominopelvic pain may suggest infection, structural lesions, or endometriosis. Evidence of polycystic ovaries by ultrasound. [, Munro MG, Mainor N, Basu R, Brisinger M, Barreda L. Oral medroxyprogesterone acetate and combination oral contraceptives for acute uterine bleeding: a randomized controlled trial. Objective: Adenomyosis is a common gynecological disease, which occurs in women in reproductive age and is characterized by the presence of endometrial glands and stroma within the myometrium. Most women only lose about 2 tablespoons of blood each period. CLINICAL BLEEDING PATTERNS AND MANAGEMENT TECHNIQUES OF ABNORMAL UTERINE BLEEDING IN WESTERN KENYA. This article was externally peer-reviewed. Obtaining a thorough medical history should be guided by the PALMCOEIN system and focused on details of the current bleeding episode; related symptoms; and past menstrual, gynecologic, and medical history; which can, in turn, guide appropriate laboratory and radiologic testing. Algorithms could be tested by determining whether physicians follow the correct path (validity) and whether they follow the same path (reliability). Normal menstrual flow typically lasts about five days and occurs every 21 to 35 days. E.g. Brief midcycle spotting can occur at the time of ovulation due to the normal dip in serum estrogen levels.43 However, this is not common and should prompt an endometrial biopsy in women >35 years old.2 A single early period (<21 days) may not require an endometrial biopsy even in a woman over age 35 if subsequent periods are regular and no other abnormal bleeding occurs. Bulk pricing was not found for item. After 3 iterations of this process (total of 300 patients), we agreed on a final algorithm that generally followed the practices we observed, while maintaining consistency with the evidence. 1 Basic PALMCOEIN classification system for the causes of abnormal uterine bleeding in nonpregnant reproductive-aged women. Does my blood loss put me at risk for developing other health conditions? Abnormal uterine bleeding (AUB)or menstrual bleeding that is unpredictable in timing, amount, or durationis a common problem among women. Refer if hyperplasia persists. Please try reloading page. Outpatient management: 2.5 mg of Premarin PO QID plus 25 mg of promethazine PO or IM or per rectum every 4 to 6 hours as needed for nausea. Initial management is based on hemodynamic stability as outlined in Figure 2. The acronym PALM-COEIN facilitates classification, with PALM referring to structural etiologies (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia), and COEIN referring to nonstructural etiologies (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified). This can range from light spotting during or in between menstrual periods, or extremely heavy blood flow during the monthly period. We excluded amenorrhea and postmenopausal bleeding because their generally straightforward evaluation has been well described elsewhere.3,4,33,34 Postoperative, postpartum, and pregnancy-related bleeding were also excluded. Options include IV conjugated equine estrogen, multi-dose regimens of OCs or oral progestins, and tranexamic acid. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. Bleeding may be heavier or lighter than usual and occur often or randomly. Hysterectomy is the definitive and most effective treatment for abnormal uterine bleeding, and it yields a high level of patient satisfaction.44,47,51 A less invasive, lower-risk surgical option is endometrial ablation, which is as effective as the levonorgestrel-releasing intrauterine system.47 A variety of ablative techniques are available, and all are equivalent in terms of bleeding outcomes and patient satisfaction.52 Myomectomy and uterine artery embolization are treatment options for leiomyomas, and endometrial polyps can be treated with polypectomy. Missed periods and prolonged intervals are expected in perimenopause.41,42 Intervals may also decrease in the perimenopause, but repeated intervals less than 21 days or other irregular patterns require endometrial sampling. Frequency (interval between the start of each menstrual cycle), Regularity (variation of menstrual cycle length, measured over 12 months), Volume (total blood loss each menstrual cycle), Amenorrhea for 6 months with previously regular menstrual cycles, Amenorrhea for 12 months without other apparent cause, Hormonal contraception or other hormone therapy, Hypothalamic-pituitary-adrenal axis dysfunction, Immature hypothalamic-pituitary-adrenal axis (adolescence), Tumors, radiation, or trauma of the pituitary/hypothalamus area, Hereditary nonpolyposis colorectal cancer (Lynch syndrome), Type 2 diabetes mellitus, hypertension, gallbladder disease, or thyroid disease, Hemodynamically unstable: 25 mg intravenously every 4 to 6 hours for up to 24 hours, Follow treatment with a progestin to provoke withdrawal bleeding; do not use in patients at increased risk of thrombosis, Hemodynamically stable: 2.5 mg orally every 6 hours for 21 days, 1 monophasic pill containing 35 mcg of ethinyl estradiol orally 3 times daily for 7 days, Other regimens also effective; do not use in patients at increased risk of thrombosis, Norethindrone, 5 mg orally 3 times daily for 7 days, Other high-dose oral progestins are also effective, 10 mg per kg intravenously every 8 hours or 20 to 25 mg per kg orally every 8 hours, Faster onset if given intravenously; do not use in patients at increased risk of thrombosis, 150 mg intramuscularly or 104 mg subcutaneously every 13 weeks, Unscheduled bleeding is a common initial adverse effect, but one-half of patients become amenorrheic after 12 months of use, 1 monophasic pill containing 35 mcg of ethinyl estradiol daily, Other routes (transdermal patch, intravaginal ring) are likely also effective; regimens with no or fewer hormone-free intervals may be more effective, 52-mg (20-mcg-per-day) intrauterine device (Mirena), Effectiveness data are based primarily on trials involving the 20-mcg-per-day device; effect on bleeding suppression may wane before contraceptive effectiveness expires, Other oral nonsteroidal anti-inflammatory drugs are also effective; administer only while patient is bleeding; do not use in patients with coagulopathy, Norethindrone, 2.5 to 5 mg orally once daily, Other oral progestins are also effective; administration during only the luteal phase is significantly less effective for treating heavy bleeding. We constructed a concise but comprehensive algorithm for the management of abnormal uterine bleeding between menarche and menopause that was based on a systematic review of the literature as well as the actual management of patients seen in a gynecology clinic. Data Sources: A PubMed search was completed in Clinical Queries using the key terms abnormal uterine bleeding, heavy menstrual bleeding, irregular menstrual bleeding, menorrhagia, metrorrhagia, and dysfunctional uterine bleeding. Breakthrough bleeding. Cervical cancer screening should be performed if it is not up to date. Dysfunctional uterine Erectile dysfunction (ED) is often a symptom . This happens when your uterus sheds its lining, and the blood and tissue pass through the vagina and out of your body. Cycle oral contraceptive (eg, Necon 1/35). : Population: Nonpregnant women from menarche to menopause who have had abnormal bleeding for three months or longer whose . The need for surgical treatment is based on the clinical stability of the patient, the severity of bleeding, contraindications to medical management, the patients lack of response to medical management, and the underlying medical condition of the patient. Cleveland Clinic is a non-profit academic medical center. Evaluation involves a detailed history and pelvic examination, as well as laboratory testing that includes a pregnancy test and complete blood count. Fig. Once the acute episode of bleeding has been controlled, multiple treatment options are available for long-term treatment of chronic AUB. Centers for Disease Control and Prevention (CDC). Severe Acute Bleeding in the Nonpregnant Patient. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. If abnormal bleeding persists, consider TVUS and endometrial biopsy. Return to appropriate algorithm based on bleeding pattern. The patient then stops the pill for 1 week and then cycles in the usual manner, 3 weeks on and 1 week off, for at least 3 months. Other coagulation factor deficiencies, hemophilia, and platelet function disorders may be associated with AUB in any age group. The choice of surgical management should be based on the patients underlying medical conditions, underlying pathology, and desire for future fertility. Abnormal uterine bleeding (AUB) may be acute or chronic and 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 2. Dilation and curettage (D&C) if no response after 1 to 2 doses of Premarin. Recombinant factor VIII and von Willebrand factor also are available and may be required to control severe hemorrhage 5. prolonged bleeding during menstruation. The audiotapes were used to revise the algorithm. The etiologies in the COEIN group (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified) are nonstructural. Although we could have shortened the algorithm by using general recommendations, such as medical therapy, or appropriate laboratory evaluation, we wanted a practical tool that could stand alone at the point of care. A MEDLINE search (1985 to present) found 76 review articles on abnormal uterine bleeding that appeared to address the topic comprehensively, and 24 of these included an algorithm. No orthostatic hypotension, hemoglobin 10 g/dL, bleeding not profuse. You should never suffer in silence or be embarrassed. Also searched were the Agency for Healthcare Research and Quality evidence reports, Clinical Evidence, the Cochrane database, and UpToDate. (https://pubmed.ncbi.nlm.nih.gov/26254516/). Hysterectomy is the most effective treatment for reducing heavy menstrual bleeding. 2 Includes treatment-related adverse events (e.g., drug side effects); does not include consequences related to the failure to adequately treat the symptom. or call toll-free from U.S.: (800) 762-2264 or (240) 547-2156 Many articles have reviewed the management of abnormal uterine bleeding,3,6,7,15,16,18,21 and they often include management algorithms. Abnormal uterine bleeding is a broad term that describes irregularities in the menstrual cycle involving frequency, regularity, duration, and volume of flow outside of pregnancy. Search dates: August 21, 2017, and November 10, 2018. Abnormal uterine bleeding is a common problem,1 and its management can be complex.2,3 Physicians are often unable to identify the cause of abnormal bleeding after a thorough history and physical examination.4,5 The management of abnormal bleeding can involve many decisions about diagnosis and treatment,3,6,7 which often occur simultaneously and without the benefit of comprehensive, evidence . If your periods are especially heavy or lasting longer than usual, or if youre bleeding outside your menstrual cycle, speak to your provider. Irregular bleeding in nonpregnant patient. The etiologies of acute AUB, which can be multifactorial, are the same as the etiologies of chronic AUB. National Institute for Health and Care Excellence. If breakthrough bleeding occurs after 3 months of use or patient requests intervention sooner, test for chlamydia and gonorrhea, ask about compliance, consider changing to higher estrogen pill (eg, Necon 1/35, Demulen 1/35, Demulen 1/50, LoOvral). Obstet Gynecol 2006;108:9249. Initial evaluation of the patient with acute AUB should include a prompt assessment for signs of hypovolemia and potential hemodynamic instability. Herein we present the systematic evaluation of AUB. The conservative approach is to do the endometrial biopsy whether or not a TVUS is obtained. Simultaneous with IV Premarin, start LoOvral, 1 active pill QID 4d, TID 3d, BID 2d, QD 3 weeks, then one week off, then cycle for at least 3 months. The presence of endometrial tissue in the myometrium is known as adenomyosis. Medical management should be the initial treatment for most patients, if clinically appropriate. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. ABSTRACT: Initial evaluation of the patient with acute abnormal uterine bleeding should include a prompt assessment for signs of hypovolemia and potential hemodynamic instability. Author disclosure: No relevant financial affiliations. Bleeding at unusual times (between periods, after intercourse). Acute AUB refers to an episode of heavy bleeding that, in the opinion of the clinician, is of sufficient quantity to require immediate intervention to prevent further blood loss 1. No. Patients with known or suspected bleeding disorders may respond to the hormonal and nonhormonal management options listed earlier in this section. This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. Platelet function analysis to screen for von Willebrand disease should be ordered in women with severe menorrhagia or other signs of coagulopathy.36,56,58 For treatment, women can be offered oral contraceptives if not contraindicated (Table 2), progestins (Table 3), nonsteroidal anti-inflammatory drugs, or observation. These etiologies are not mutually exclusive, and patients may have more than one cause. Once the acute bleeding episode has been controlled, transitioning the patient to long-term maintenance therapy is recommended. Endometrial ablation, although readily available in most centers, should be considered only if other treatments have been ineffective or are contraindicated, and it should be performed only when a woman does not have plans for future childbearing and when the possibility of endometrial or uterine cancer has been reliably ruled out as the cause of the acute AUB. More information on the diagnosis and management of endometrial cancer is available in a previous American Family Physician article (https://www.aafp.org/afp/2016/0315/p468.html). Evaluation and management of acute menorrhagia in women with and without underlying bleeding disorders: consensus from an international expert panel. Encourage continued use. Endometrial sampling should be performed in patients 45 years and older, and in younger patients with a significant history of unopposed estrogen exposure. If abnormal bleeding interferes with your quality of life, see your provider. Combined OCs and oral progestins, taken in multi-dose regimens, also are commonly used for acute AUB. But your bleeding may be a sign of cancer or conditions that may negatively impact your fertility. Rarely, a thyroid problem, infection of the cervix, or cancer of the uterus can cause abnormal uterine bleeding. Its prevalence ranges from 5% to 70%, and its association with abnormal uterine bleeding is unclear.15 Many patients are asymptomatic, but those who have symptoms typically report painful, heavy, or prolonged menstrual bleeding. Dysfunctional bleeding can be anovulatory, which is characterized by irregular unpredictable bleeding, or ovulatory, which is characterized by heavy but regular periods (ie, menorrhagia).2 Structural causes include fibroids, polyps, endometrial carcinoma, and pregnancy complications. Not everyone who experiences abnormal uterine bleeding reports their symptoms. After acute bleeding start LoOvral, 1 active pill QID 4d, TID 3d, BID 2d, QD 3 weeks, then 1 week off, then cycle for at least 3 months. [, Update to CDCs U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: revised recommendations for the use of contraceptive methods during the postpartum period. Abnormal uterine bleeding, pelvic pain as well as infertility can be associated with adenomyosis. The patient should be evaluated to determine that she has acute AUB and not bleeding from other areas of the genital tract. J Bone Joint Surg Br 2011;93:157785. We compared this algorithm to the actual care provided to a random sample of 100 women with abnormal bleeding who were seen in a university gynecology clinic. Pregnancy is a common cause. We do not capture any email address. Primary disorders of endometrial hemostasis typically occur in the setting of predictable ovulatory cycles and are likely due to vasoconstriction disorders, inflammation, or infection. MMWR Morb Mortal Wkly Rep 2011;60:87883. Heavy menstrual bleeding. Oral Contraceptive Pill-associated Bleeding. After initial assessment and stabilization, the etiologies of acute abnormal uterine bleeding should be classified using the PALMCOEIN system. The algorithm in this study was initially based on the evidence but modified to match the actual care of patients. Unusually long periods (seven days or longer). Leiomyomas (also called fibroids) are benign tumors arising from the uterine myometrium. 557. Advertising on our site helps support our mission. Possible causes include fibroids, polyps, hormone changes and in rare cases cancer. Refer for further counseling and treatment. being unable to get an erection at any time. Other factor deficiencies may need factor-specific replacement. All adolescents and women with either abnormalities in initial laboratory testing or positive screening results for disorders of hemostasis should be considered for specific tests for von Willebrand disease and other coagulopathies, including von Willebrandristocetin cofactor activity, von Willebrand factor antigen, and factor VIII 2 5. [Full Text]. If response inadequate, obtain TVUS to identify polyps, myomas, endometrial hyperplasia, adenomyosis. Lancet 1998;351:4859. Emergency interventions for severe bleeding that causes hemodynamic instability include uterine tamponade, intravenous estrogen, dilation and curettage, and uterine artery embolization. [, Bettocchi S, Ceci O, Vicino M, Marello F, Impedovo L, Selvaggi L. Diagnostic inadequacy of dilatation and curettage. The 20-mcg-per-day formulation of the levonorgestrel-releasing intrauterine system (Mirena) is more effective than other medical therapies for reducing heavy menstrual bleeding. Consider removal. Medications and surgical options are available to manage your bleeding or treat whats causing it. After culturing the cervix, patients with a tender uterus can be treated with 100 mg of doxycycline twice daily for 10 days and possible removal of the IUD. Abnormal uterine bleeding (AUB) in patients of reproductive age is a bleeding pattern that is not consistent with normal menstrual cycle parameters (frequency, regularity, duration, and volume). Obstet Gynecol 2010;116:86575. Contraindications to oral contraceptives include history of thromboembolic event or stroke, estrogen-dependent tumor, active liver disease, pregnancy, hypertriglyceridemia, smoking more than 15 cigarettes per day when age is 35. PubMed If less than age 35 and not otherwise at high risk for endometrial carcinoma and after first 4 to 6 months of use, offer 1.25 mg of Premarin QD for 7 days. You cant prevent many causes of abnormal uterine bleeding. Management and Treatment Prevention Living With Frequently Asked Questions Overview What are irregular periods? [, Hamani Y, Ben-Shachar I, Kalish Y, Porat S. Intrauterine balloon tamponade as a treatment for immune thrombocytopenic purpura-induced severe uterine bleeding. If unacceptable irregular bleeding and patient more than age 35 or otherwise at risk for endometrial carcinoma, do endometrial biopsy. If the abnormal bleeding persists, the IUD can be removed and alternative contraceptive methods discussed. Copyright April 2013 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. For example, irregular bleeding within 2 years of menarche is usually due to anovulation, secondary to an immature hypothalamic-pituitary-ovarian axis.21,39,40 However, adolescents may request more than simple reassurance and can be offered oral contraceptives or a progestin as described in the algorithm (Figure 3). The acronym PALM-COEIN facilitates the classification of abnormal uterine bleeding, with PALM referring to structural etiologies (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia), and COEIN referring to nonstructural etiologies (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified). Avoiding diets that contain a high amount of animal fat can reduce your risk of some cancers. Menorrhagia in the Nonpregnant Patient Figure 6. [, Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women, Assessment of the Patient With Acute Abnormal Uterine Bleeding, Etiologies of Acute Abnormal Uterine Bleeding, http://www.nice.org.uk/nicemedia/live/11002/30401/30401.pdf, Alliance for Innovation on Women's Health, Postpartum Contraceptive Access Initiative. The medical management of abnormal uterine bleeding in reproductive-aged women. For example, Albers and colleagues presented an algorithm that covered several pages in a recent review.3 Space limitations forced the authors to use general recommendations such as medical management rather than specific drugs. A variety of things can cause abnormal uterine bleeding. Hyperplasia without atypia. Menometrorrhagia was once an umbrella term for two different conditions that sound nearly the same: In 2011, the International Federation of Gynecology and Obstetrics (FIGO) changed the names to prevent confusion. Options include intravenous conjugated equine estrogen, multi-dose regimens of combined oral contraceptives or oral progestins, and tranexamic acid. Obstet Gynecol 2013; 121:8916. Copyright April 2013 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. (https://pubmed.ncbi.nlm.nih.gov/30198563/). TVUS is less invasive and less painful than endometrial biopsy. In women more than age 35 and those at risk for endometrial carcinoma (Figure 3), TVUS with or without a saline-infused sonohysterogram may be indicated before, after, or instead of endometrial biopsy. Up to 13% of women with heavy menstrual bleeding have some variant of von Willebrand disease and up to 20% of women may have an underlying coagulation disorder 2 3 4. The algorithm is lengthy, and busy clinicians might find it unwieldy. Your healthcare provider will ask you several questions when working to diagnose abnormal uterine bleeding. Certain hormonal conditions and medications . Symptoms of ED include. Based on the available evidence and expert opinion, the American College of Obstetricians and Gynecologists Committee on Gynecologic Practice makes the following conclusions and recommendations: The etiologies of acute AUB should be classified based on the PALMCOEIN system: Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, and Not otherwise classified. Obstet Gynecol 2012; 120:197206. Consultation with a hematologist is recommended for these patients, especially if bleeding is difficult to control or the gynecologist is unfamiliar with the other options for medical management. Your period usually occurs every 28 days, but normal menstrual cycles can range from 21 days to 35 days. Abnormal uterine bleeding is bleeding between monthly periods, prolonged bleeding or an extremely heavy period. being able to get an erection, but not having it last long enough for sex. If oral contraceptive contraindicated, 10 mg of Provera QD x 14 days, off 14 days, on 14 days, and so on for at least 3 months. A recent clinical trial found that the levonorgestrel intrauterine device (IUD) (Mirena) resulted in comparable quality of life scores and lower costs compared with hysterectomy in women with menorrhagia.59 Women who prefer no hormones can be started on nonsteroidal anti-inflammatory drugs, which decrease blood loss.60,61. ACOG Committee Opinion No. You shouldnt have to double up on menstrual products to manage your blood flow. Approximately 20% of patients with heavy menstrual bleeding have a bleeding disorder, and the prevalence in adolescent girls who bleed heavily is even higher.2123 Von Willebrand disease and platelet dysfunction are the most common coagulopathies associated with abnormal uterine bleeding.24 In addition to heavy menstrual bleeding, adolescents with bleeding disorders may report irregular menstrual bleeding.25. Will you administer my treatment alone, or will it involve a care team? Depo-medroxyprogesterone or Progesterone Only Pill-associated Bleeding. Abnormal uterine bleeding (AUB), a term that refers to menstrual bleeding of abnormal quantity, duration, or schedule, is a common gynecologic problem. Abnormal uterine bleeding is a symptom, not a diagnosis; the term is used to describe bleeding that falls outside population-based 5th to 95th percentiles for menstrual regularity, frequency, duration, and volume (Table 1).7 Abnormal bleeding is considered chronic when it has occurred for most of the previous six months, or acute when an episode of heavy bleeding warrants immediate intervention.5 Intermenstrual bleeding is bleeding that occurs between otherwise normal menstrual periods.7 Use of imprecise terms such as menorrhagia, metrorrhagia, and dysfunctional uterine bleeding is now discouraged. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. By reading this page you agree to ACOG's Terms and Conditions. In the absence of endometritis, patients with a copper IUD (Paragard) can be treated with one cycle of the oral contraceptive pill or 10 mg of medroxyprogesterone daily for 7 days. (Data from Munro MG, Critchley HO, Broder MS, Fraser IS. Endometritis; 100 mg of doxycycline BID for 10 days. Irregular bleeding is a heterogenous category that includes metrorrhagia, menometrorrhagia, oligomenorrhea, prolonged bleeding that can last weeks or months, and other irregular patterns. If more than age 35, obtain endometrial biopsy. Case reports of uterine artery embolization and endometrial ablation show that these procedures successfully control acute AUB 19 20. . 128. ET), Munro MG, Critchley HO, Broder MS, Fraser IS. Fertil Steril 2005;84:13529. Management of excessive menstrual bleeding in women with hemostatic disorders. PubMed ] Bleeding after menopause is never normal. Let your doctor know if you need. 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