Abnormal uterine bleeding

Definition

Normal Cycle as a Benchmark

• Normal cycle length: 24 to 38 days.
• Normal duration of bleeding: up to 8 days.
• Normal blood loss: 30 to 80 ml per period.
• How to assess the amount in practice: pad/tampon use, presence of clots.

Classification

Rhythm Disorders

• Oligomenorrhoea: cycle interval > 38 days.
• Polymenorrhoea: cycle interval < 24 days.
• Primary amenorrhoea: menstruation has never occurred.
• Secondary amenorrhoea: absence for > 3 months.

Disorders of Amount and Duration

• Hypermenorrhoea: excessively heavy bleeding (> 80 ml/cycle).
• Hypomenorrhoea: abnormally light menstrual bleeding.
• Menorrhagia: excessively long bleeding (> 8 days).
• Metrorrhagia: acyclic, continuous bleeding without rhythm.
• Additional bleeding: intermenstrual bleeding.
• Postmenopausal bleeding: bleeding after > 12 months of amenorrhea.

Special Cases

• Dysmenorrhoea: painful menstruation.
• Contact bleeding: bleeding after intercourse/exam.
• What any postmenopausal bleeding necessitates: an etiological workup.

Aetiopathogenesis

Idea Behind the Acronym

• What PALM-COEIN classifies: causes of AUB in non-pregnant women.
• The dividing line in the acronym: PALM: structural, COEIN: non-structural causes.

PALM — The Structural Causes

• P: polyp (endometrial/cervical).
• A: adenomyosis uteri.
• L: leiomyoma (FIGO classified).
• M: malignancy and hyperplasia.
• Which fibroids typically cause heavy bleeding: submucosal and cavity-distorting.

COEIN — The Non-Structural Causes

• C: coagulopathy.
• O: ovulatory dysfunction.
• E: endometrial dysfunction.
• I: iatrogenic causes.
• N: not yet classified.
• The most common underlying coagulation disorder: von Willebrand disease.

Anovulatory Bleeding

• What is missing: ovulation and progesterone phase.
• Consequence for the endometrium: unstable proliferation due to estrogen.
• Typical life stages: years after menarche and perimenopause.
• The classic endocrine cause in middle age: PCOS with chronic anovulation.

Clinical features

Adolescent

• Most common cause of irregular bleeding in the first few years: anovulation with immature HPO axis.
• What still needs to be investigated: heavy or anaemia-inducing bleeding.
• To be ruled out above all: coagulopathy (esp. von Willebrand).
• In case of primary amenorrhoea with cyclical pain: outflow obstruction (hymen, vaginal septum).
• Examination in this age group: inspection, abdominal ultrasound.

Perimenopausal Woman

• Why bleeding becomes irregular: anovulatory cycles, oestrogen fluctuation.
• In case of endometrial thickening with a bleeding disorder: hysteroscopy with fractional curettage.

More facts from the study questions

• Secondary amenorrhoea is the absence of menstruation for more than three months in a woman who has previously had cycles.
• Polymenorrhoea is a tempo anomaly.
• It is characterised by shortened cycle intervals of less than 24 days.
• Bleeding that occurs after sexual intercourse or a gynaecological examination is termed contact bleeding.
• It always requires investigation, starting with inspection of the cervix.
• Oligomenorrhoea is a tempo anomaly.
• It is defined by prolonged cycle intervals of more than 38 days.
• Menorrhagia is excessively prolonged bleeding (lasting more than about eight days).
• Excessively heavy bleeding is termed hypermenorrhoea (heavy menstrual bleeding).
• The 'P' in the PALM acronym stands for polyps, which can occur in both the endometrium and the cervix.

Keep learning in the app

Further reading (selection)

1. StatPearls: Abnormal Uterine Bleeding (NCBI Bookshelf)
2. DocCheck Flexikon, Menorrhagie
3. DocCheck Flexikon, PALM-COEIN-Klassifikation
4. DocCheck Flexikon, Corpus-luteum-Insuffizienz
5. DocCheck Flexikon, Perimenopause

Cross-references