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Gynecology

Abnormal Uterine Bleeding (AUB)

Any vaginal bleeding that represents a variation from the normal pattern of regular menstruation in terms of frequency, duration, regularity, or volume.

Also known as: AUB, Irregular Vaginal Bleeding

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Referral and warning signs

When to refer

  • Urgent Referral (RR): Postmenopausal bleeding (assess for endometrial pathology). Suspected cervical/vaginal lesion/growth (assess for malignancy).
  • Referral (H/Specialist): Suspected significant structural pathology (large fibroids, polyps needing removal). Acute heavy bleeding causing instability or severe anaemia. Failure of initial medical management. Need for endometrial biopsy or advanced investigations. Desire for surgical management.
  • Referral (HC4): Positive pregnancy test with bleeding (manage as potential abortion/ectopic - see Obs chapter).
  • Referral (H): Suspected fibroid (for ultrasound scan).

Red flags

  • Postmenopausal bleeding.
  • Acute heavy bleeding with signs of shock (hypotension, tachycardia).
  • Suspicious cervical or vaginal lesion on examination.
  • Significant anaemia.
  • Bleeding associated with positive pregnancy test.

Signs and symptoms

  • Bleeding between periods (intermenstrual bleeding).
  • Heavy menstrual bleeding (menorrhagia).
  • Prolonged menstrual bleeding (>7 days).
  • Frequent bleeding (cycle <21 days).
  • Infrequent bleeding (cycle >35 days).
  • Irregular bleeding pattern.
  • Postcoital bleeding.
  • Postmenopausal bleeding.

Risk factors

  • Age (adolescence, perimenopause).
  • Obesity.
  • Polycystic ovary syndrome (PCOS).
  • Thyroid dysfunction.
  • Use of certain medications (anticoagulants, hormonal contraception).
  • Uterine fibroids, polyps.
  • Endometrial hyperplasia/cancer.
  • Cervical cancer.
  • STIs/PID.

Diagnosis

Clinical assessment

Detailed history of bleeding pattern, associated symptoms (pain, discharge), contraceptive use, medical history, medications. Pelvic examination (speculum and bimanual) to assess for cervical/vaginal lesions, uterine size/shape/tenderness. Determine if bleeding is acute/heavy or chronic/irregular.

Differential diagnosis

  • Pregnancy-related bleeding (abortion, ectopic pregnancy, molar pregnancy)
  • Hormonal dysfunction (anovulation - common in adolescents/perimenopause)
  • Uterine structural causes (fibroids, polyps, adenomyosis)
  • Endometrial hyperplasia or cancer (especially postmenopausal or high risk)
  • Cervical causes (cancer, polyp, cervicitis)
  • Vaginal causes (cancer, trauma, atrophy)
  • Infections (PID, cervicitis)
  • Coagulation disorders
  • Thyroid disease
  • Iatrogenic (IUD, hormonal contraception side effect)

Investigations

  • Pregnancy test (URGENTLY exclude pregnancy-related causes).
  • Full Blood Count (FBC): Assess Haemoglobin level for anaemia.
  • Speculum Examination: Visualize cervix/vagina.
  • Pelvic Ultrasound (Transvaginal preferred if available): Assess uterine lining (endometrial thickness), identify fibroids, polyps, ovarian pathology.
  • STI screening (swabs for GC/Chlamydia, HVS) if infection suspected.
  • Thyroid Function Tests (TSH).
  • Coagulation screen (if history suggests bleeding disorder).
  • Endometrial biopsy (especially >45 yrs, postmenopausal bleeding, or risk factors for endometrial cancer).

Diagnostic criteria

Diagnosis based on history, examination, and investigations to identify the underlying cause (using PALM-COEIN classification system internationally: Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia - Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified).

Management

Non-pharmacological management

  • Reassurance if cause is benign/physiological.
  • Iron supplementation (Ferrous sulphate or Fefol 1 tab OD/BID) if anaemic. (LOC: HC2)
  • Address underlying cause (e.g., treat infection, manage thyroid disease).

Pharmacological treatment

  • Management depends heavily on the identified cause, patient age, and desire for fertility.
  • Acute Heavy Bleeding:
  • - Hormonal options (e.g., high-dose combined oral contraceptives, progestins - specialist guidance).
  • - Tranexamic acid (antifibrinolytic - less available).
  • - Urgent referral if haemodynamically unstable.
  • Chronic AUB (Ovulatory Dysfunction):
  • - Combined Oral Contraceptives (COCs).
  • - Progestin-only methods (pills, depot injection, implant, hormonal IUD).
  • - Cyclic progestins.
  • Structural Lesions (Fibroids, Polyps):
  • - Medical management (hormonal therapies) may help symptoms.
  • - Surgical management (myomectomy, polypectomy, hysterectomy) - Refer to specialist.
  • Infection (PID): Treat as per PID guidelines (See GYN002). (LOC: HC3)
  • Contraceptive Side Effect: Counsel, consider alternative method (See Family Planning Chapter). (LOC: HC2)

Monitoring

Monitor bleeding pattern, haemoglobin levels. Follow up based on underlying cause and treatment plan. Monitor side effects of hormonal therapy.

Complications

  • Anaemia.
  • Reduced quality of life.
  • Haemodynamic instability (acute heavy bleeding).
  • Complications related to underlying pathology (e.g., infertility, malignancy).

Prevention

  • Maintain healthy weight.
  • Manage chronic conditions (PCOS, thyroid).
  • Appropriate use of contraception.

Patient education

  • Explanation of potential causes of AUB.
  • Importance of investigations (pregnancy test, Hb, ultrasound).
  • Treatment options based on cause.
  • Information on iron supplementation if anaemic.
  • Side effects and benefits of hormonal treatments if used.
  • When to seek urgent review (heavy bleeding, dizziness).

Uganda-specific notes

Exclude pregnancy and infection promptly. Anaemia due to AUB is common. Ultrasound access is variable. Be highly suspicious of cervical cancer with contact bleeding or visible lesions. Postmenopausal bleeding requires urgent referral for endometrial assessment where feasible.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 14, Section 14.1.3

For learning and professional reference. Use current local guidance and clinical judgement.

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