OG24.1 | Abnormal Uterine Bleeding — Summary & Reflection

KEY TAKEAWAYS

Abnormal uterine bleeding (AUB): any bleeding outside normal parameters (cycle 24–38 days; duration 4.5–8 days; volume ≤80 mL). Classified by the FIGO PALM-COEIN system — PALM (structural): AUB-P (polyp), AUB-A (adenomyosis), AUB-L (leiomyoma, especially submucosal types 0–2), AUB-M (malignancy/hyperplasia); COEIN (non-structural): AUB-C (coagulopathy — vWD most common), AUB-O (ovulatory dysfunction — PCOS, hypothyroidism, hyperprolactinaemia), AUB-E (endometrial haemostatic failure), AUB-I (iatrogenic), AUB-N (not classified). Investigation: pregnancy test first; FBC + iron; TVUS (endometrial thickness, fibroids, polyps); hysteroscopy + endometrial biopsy if ≥45 yr or risk factors for cancer; TSH, prolactin, day-21 progesterone, coagulation screen as indicated. Postmenopausal bleeding + endometrial thickness ≥4 mm = mandatory biopsy. Management: LNG-IUS (most effective medical — 80–90% reduction), tranexamic acid (40–50%), NSAIDs, COCP, cyclical progestogens; surgical: hysteroscopic polypectomy/myomectomy, endometrial ablation (completed family), hysterectomy (definitive). Cause-specific: GnRH for AUB-O/hypothyroidism; cabergoline for hyperprolactinaemia; hysteroscopic resection for AUB-P and AUB-L type 0–2.

REFLECT

You are consulting with a 38-year-old teacher who has had heavy periods for two years, now missing work on heavy flow days. She has a haemoglobin of 9.8 g/dL and a 3 cm submucosal fibroid on ultrasound. She tells you she has 'heard hysterectomy is the only real cure' and is ready for surgery. How do you counsel her about the full spectrum of options — from LNG-IUS and hysteroscopic myomectomy through to hysterectomy? What factors in her history and values would shift your recommendation? Reflect on how the evidence-based hierarchy of management sometimes conflicts with a well-informed patient's preference — and how you navigate that tension.