Classify the causes of abnormal uterine bleeding
Menstrual disorders are a common cause for office visits. In a national study, menstrual disorders accounted for 19.1% of 20.1 million visits to physician offices for gynecologic conditions over a two-year period.1 Before implementing treatment strategies, clinicians must check their approach to diagnosing causes of bleeding.
A normal menstrual cycle typically lasts between 21 and 35 days, with menstruation generally lasting for five days. With abnormal uterine bleeding (AUB), clinicians are looking at bleeding that is more or less frequent or heavier than normal, or menstrual cycles that are shorter or longer than average. In reproductive-age women, causes of AUB can vary greatly and might include uterine fibroids or polyps, irregular ovulation, endometrial problems, underlying bleeding disorders such as von Willebrand disease, or cancer.
Abnormal uterine bleeding also can be caused by a wide variety of local and systemic diseases, such as leukemia and liver failure, or can be related to medications, such as anticoagulants or chemotherapeutic agents, notes Andrew Kaunitz, MD, professor and associate chair in the Obstetrics and Gynecology Department at the University of Florida College of Medicine — Jacksonville.
There are many definitions of heavy menstrual bleeding (HMB). In their chapter on menstrual disorders in Contraceptive Technology, authors Anita Nelson, MD, and Susie Baldwin, MD, MPH, simplify this complex issue.2
"A practical new definition of HMB advances the idea that a woman’s blood loss is excessive when she says it is excessive," the authors state. "This definition illustrates that the key factor in making a diagnosis of HMB is not the amount of blood the woman loses, which is difficult to ascertain, but how a woman’s HMB disrupts her life."
Classify the causes
The London-based International Federation of Gynecology and Obstetrics (FIGO) has developed a revised classification system for causes of abnormal uterine bleeding in nongravid reproductive-age women.3 Introduced in 2011 following an international consensus process, the etiologies of AUB are classified as "related to uterine structural abnormalities" and "unrelated to uterine structural abnormalities" and categorized following the acronym PALMCOEIN:
• malignancy and hyperplasia;
• ovulatory dysfunction;
• not otherwise classified.
The PALM-COEIN classification is a systematic approach that is translatable to multiple languages, says Malcolm Munro, MD, co-chair of the FIGO Menstrual Disorders Committee, professor in the David Geffen School of Medicine at the University of California, Los Angeles, and director of gynecological services at Kaiser Permanente, Los Angeles Medical Center. It seeks to remove such outdated terms as dysfunctional uterine bleeding, menorrhagia, and menometrorrhagia to create consistency in research, help define roles in diagnosis and treatment, and aid to standardize the approach to diagnosis and treatment. Coagulopathy, endometrial dysfunction, and ovulatory disorders now replace the collection of disorders previously encompassed under dysfunctional uterine bleeding. Heavy menstrual bleeding now describes excess menstrual bleeding, instead of menorrhagia. Intermenstrual bleeding that occurs between clearly defined cyclic and predictable menses now replaces the outdated term "metrorrhagia."3
In FIGO meetings, experts agreed that chronic abnormal uterine bleeding is classified as bleeding from the uterine corpus that is abnormal in volume, regularity, and/or timing, and has been present for most of the past six months.2 Acute AUB is defined as an episode of heavy bleeding that, in the opinion of the clinician, is of sufficient quantity to require immediate treatment.3
The American College of Obstetricians and Gynecologists has adopted the PALM-COEIN system. It issued a Practice Bulletin on diagnosis of AUB in 2012 and a Committee Opinion on management of acute abnormal uterine bleeding in nonpregnant reproductive-age women in 2013.4,5 It also released a Practice Bulletin in 2013 on management of abnormal uterine bleeding associated with ovulatory dysfunction.6
Look at method options
Several options are available for long-term treatment of chronic AUB. Effective medical therapies include the levonorgestrel intrauterine system (Mirena, Bayer HealthCare Pharmaceuticals, Wayne, NJ), oral contraceptives (monthly or extended cycles), progestin therapy (oral or intramuscular), tranexamic acid, and nonsteroidal anti-inflammatory drugs (NSAIDs).5
For the reduction in mean blood loss in women with heavy menstrual bleeding presumed secondary to abnormal uterine bleeding presumed secondary to endometrial dysfunction, results of a recent analysis of available data suggest that use of the levonorgestrel intrauterine system is indicated over oral contraceptives, luteal-phase progestins, and NSAIDs.7
The levonorgestrel intrauterine system appears to be a highly effective treatment option in women with heavy menstrual bleeding, including those with organic causes and bleeding disorders, notes Kaunitz.
- Nicholson WK, Ellison SA, Grason H, et al. Patterns of ambulatory care use for gynecologic conditions: A national study. Am J Obstet Gynecol 2001;184(4):523-30.
- Nelson AL, Baldwin SB. Menstrual disorders. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.
- Munro MG, Critchley HO, Broder MS, et al. FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011; 113:3-13.
- Committee on Practice Bulletins — Gynecology. Practice bulletin no. 128: Diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol 2012; 120(1):197-206.
- American College of Obstetricians and Gynecologists. ACOG committee opinion no. 557: Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol 2013;121(4):891-896. Accessed at http://bit.ly/1dbIXo6.
- Committee on Practice Bulletins — Gynecology. Practice bulletin no. 136: Management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol 2013; 122(1):176-185.
- Matteson KA, Rahn DD, Wheeler TL 2nd, et al. Nonsurgical management of heavy menstrual bleeding: a systematic review. Obstet Gynecol 2013; 121(3):632-643. n