3.1.2: Abnormal Uterine Bleeding (AUB)
- Page ID
- 94911
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- Abnormal uterine bleeding: Non-gestational bleeding during the reproductive years. Involves any alteration in the normal frequency, regularity, duration, or volume of menstrual bleeding (heavy menstrual bleeding) as well as intermenstrual bleeding and unscheduled bleeding with pharmaceutical agents designed to suppress menstrual function
- Heavy menstrual bleeding (menorrhagia): An AUB symptom—excessive menstrual blood loss that interferes with a woman’s physical, social, emotional and/ or material quality of life
- Intermenstrual irregular bleeding (metrorrhagia): An AUB symptom—uterine bleeding between regular menstrual periods
- Irregular menstruation: An AUB symptom—menstrual cycle lengths that vary by more than 7 (ages of 18–25 and 42–45 years) to 9 days (ages of 26–41 years)
- Prolonged menstrual bleeding: An AUB symptom—a menstrual period lasting more than 8 days
- Frequent menstrual bleeding: An AUB symptom—menstrual cycle of less than 24 days
- Infrequent menstrual bleeding: An AUB symptom—menstrual cycle length of more than 38 days
- Dysfunctional uterine bleeding: A clinical term for uterine bleeding without any underlying structural abnormality, caused mainly by hormonal imbalances4
3.1.2.2 Etiologies
The International Federation of Gynecologists and Obstetricians (FIGO) classification system of AUB (Figure 3.1.3) aimed to facilitate clinical care and research. The system used the “PALM-COEIN” nomenclature (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified). It systematically classifies AUB into groups with distinctively different structural and functional causes.5
-
Structural Uterine Causes
- Polyps
- Adenomyosis
- Leiomyoma
- Malignancy and hyperplasia
-
Non-Structural Causes
- Coagulation disorders
- Ovulatory disorders
- Endometrial disorders
- Iatrogenic
- Not otherwise classified
Figure 3.1.3 FIGO classification of causes of AUB; “PALM-COEIN.”
Image Source: Chodankar, Rohan, Hilary O.D. Critchley, and Carlos Simón. “Biomarkers in Abnormal Uterine Bleeding.” Biology of Reproduction 101, no. 6 (2019). This work is openly licensed via CC BY 4.0. license. doi.org/10.1093/biolre/ioy231
FIGO developed a new classification of ovulatory disorders (Figures 3.1.4 and 3.1.5) using a three-level multi-tiered system. The primary level of the system is based on an anatomic model (Hypothalamus, Pituitary, Ovary) that is completed with a separate category for polycystic ovary syndrome (PCOS). The system uses the acronym HyPO-P. Each anatomic category is stratified in the second layer of the system to provide granularity for investigators, clinicians, and trainees using the "GAIN-FIT-PIE" mnemonic (Genetic, Autoimmune, Iatrogenic, Neoplasm; Functional, Infectious and Inflammatory, Trauma and Vascular; Physiological, Idiopathic, Endocrine). The tertiary level of the system allows for specific diagnostic entities
Figure 3.1.4 Graphical depiction of the proposed FIGO Ovulatory Disorders Classification System. Note: After the individual is diagnosed with an ovulatory disorder, the core or first level of the system is allocation to type I, II, or III disorders according to their presumed primary source: hypothalamus, pituitary gland, or ovary, respectively. PCOS comprises the type IV category, and the criteria proposed by WHO are to be used to determine this categorization. The second level stratifies each anatomic category (types I–III) into the known or presumed mechanism according to the ‘GAIN-FIT-PIE’ mnemonic as appropriate and applicable. FIGO, International Federation of Gynecology and Obstetrics; GAIN-FIT-PIE, Genetic, Autoimmune, Iatrogenic, Neoplasm; Functional, Infectious and Inflammatory, Trauma and Vascular; Physiological, Idiopathic, Endocrine; PCOS, polycystic ovary syndrome; WHO, World Health Organization.
Image Source: Munro, Malcolm G, Adam H Balen, SiHyun Cho, Hilary O D Critchley, Ivonne Díaz, Rui Ferriani, Laurie Henry, Edgar Mocanu, and Zephne M van der Spuy. FIGO Committee on Menstrual Disorders and Related Health Impacts, and FIGO Committee on Reproductive Medicine, Endocrinology, and Infertility. "The FIGO Ovulatory Disorders Classification System," Human Reproduction, 37, No. 10 (October 2022):2446–2464. Distributed under the terms of the Creative Commons CC BY license. doi.org/10.1093/humrep/deac180
Figure 3.1.5 Disorders of ovulation exist on a spectrum that ranges from occasional failure to ovulate to chronic anovulation. Note: Typically, but not always these disorders manifest abnormalities in menstrual parameters, such as frequency, regularity, duration and volume of bleeding, and, in the case of chronic anovulation with amenorrhea. It is apparent that the luteinized unruptured follicle (LUF) and luteal out of phase (LOOP) disorders exist on a similar spectrum of varying frequency.
Image Source: Munro, Malcolm G, Adam H Balen, SiHyun Cho, Hilary O D Critchley, Ivonne Díaz, Rui Ferriani, Laurie Henry, Edgar Mocanu, and Zephne M van der Spuy. FIGO Committee on Menstrual Disorders and Related Health Impacts, and FIGO Committee on Reproductive Medicine, Endocrinology, and Infertility. "The FIGO Ovulatory Disorders Classification System," Human Reproduction, 37, No. 10 (October 2022):2446–2464. Distributed under the terms of the Creative Commons CC BY license. doi.org/10.1093/humrep/deac180
Glossary Terms
- Adenomyosis
-
Relating to, affecting, or consisting of a vessel or vessels, especially those which carry blood.
- Autoimmune
- Disorders in which the immune system overreacts and begins to attack itself
- Coagulopathy
- (also called a bleeding disorder) A condition in which the blood's ability to coagulate (form clots) is impaired
- Endocrine
- Cells, tissues, and organs that secrete hormones as a primary or secondary function and play an integral role in normal bodily processes
- Endometrial
- Related to the inner lining of the uterus, part of which builds up during the secretory phase of the menstrual cycle and then sheds with menses
- Hyperplasia
- Abnormal growth due to the production of cells
- Hypothalamus
- Major region of the diencephalon that is responsible for coordinating autonomic and endocrine control of homeostasis
- Iatrogenic
- Relating to illness caused by medical examination or treatment (e.g., "Drugs may cause side effects which can lead to iatrogenic disease")
- Idiopathic
- something that is unknown
- Infectious
- transmission of infectious disease or pathogens. When transmission is within the same species, the mode can be horizontal or vertical (infectious disease transmission, vertical)
- Inflammatory
- Basic innate immune response characterized by heat, redness, pain, and swelling
- Leiomyoma
- Benign tumor derived from smooth muscle tissue, also known as a fibroid tumor. They rarely occur outside of the uterus and the gastrointestinal tract but can occur in the skin and subcutaneous tissue, probably arising from the smooth muscle of small blood vessels in these tissues
- Malignancy
- Cancerous
- Neoplasm
- New abnormal growth of tissue. Malignant neoplasms show a greater degree of anaplasia and have the properties of invasion and metastasis, compared to benign neoplasms
- Ovary
- female gonad that produces oocytes and sex steroid hormones (notably estrogen and progesterone)
- Ovulatory dysfunction
- Regular, infrequent (less than nine per year) menstrual periods or does not ovulate at all, she is said to have ovulatory dysfunction
- Physiological
- relating to the way in which a living organism or bodily part functions
- Pituitary
- Bean-sized organ suspended from the hypothalamus that produces, stores, and secretes hormones in response to hypothalamic stimulation (also called hypophysis)
- Polyp
- Growth that protrudes from a mucous membrane (National Cancer Institute)
- Trauma
- Physical injury
- Vascular
- Relating to, affecting, or consisting of a vessel or vessels, especially those which carry blood
Footnotes
- Munro, Malcolm G, Adam H Balen, SiHyun Cho, Hilary O D Critchley, Ivonne Díaz, Rui Ferriani, Laurie Henry, Edgar Mocanu, and Zephne M van der Spuy. FIGO Committee on Menstrual Disorders and Related Health Impacts, and FIGO Committee on Reproductive Medicine, Endocrinology, and Infertility. "The FIGO Ovulatory Disorders Classification System," Human Reproduction, 37, No. 10 (October 2022):2446–2464. Distributed under the terms of the Creative Commons CC BY license. doi.org/10.1093/humrep/deac180
- Munro et al, 2022
- Munro et al, 2022
Image Acknowledgements
- Chodankar, Rohan, Hilary O.D. Critchley, and Carlos Simón. “Biomarkers in Abnormal Uterine Bleeding.” Biology of Reproduction 101, no. 6 (2019). This work is openly licensed via CC BY 4.0. license. doi.org/10.1093/biolre/ioy231
- Munro, Malcolm G, Adam H Balen, SiHyun Cho, Hilary O D Critchley, Ivonne Díaz, Rui Ferriani, Laurie Henry, Edgar Mocanu, and Zephne M van der Spuy. FIGO Committee on Menstrual Disorders and Related Health Impacts, and FIGO Committee on Reproductive Medicine, Endocrinology, and Infertility. "The FIGO Ovulatory Disorders Classification System," Human Reproduction, 37, No. 10 (October 2022):2446–2464. Distributed under the terms of the Creative Commons CC BY license. doi.org/10.1093/humrep/deac180