1. Abnormal Uterine Bleeding
A new classification system

2. Abnormal Uterine Bleeding
Overarching term for the symptom of disturbed menstral bleeding
Discarded terms
DUB
Menorrhagia
AUB will be subdivided by causes such as polyps, ovulation disorders, etc

3. PALM-COEIN P A L Polyps either endometrial or endocervical AUB-P
Adenomyosis
AUB-A L
Leiomyoma
AUB-L

4. PALM-COEIN M C O Malignancy/hyperplasia AUB-M
Coagulopathy either from clinical disorder or from anticoagulant medication
AUB-C O
Ovulatory disorders
AUB-O

5. PALM-COEIN E I N Endometrial disorders AUB-E Iatrogenic AUB-I
Non yet classified
AUB-N

6. Patient with AUB Could they be anemic
Are they on a drug that could cause AUB
Are they ovulatory
Are they at risk of hyperplasia/malignancy

7. Chronic AUB: =3 months of disturbed menstrual bleeding
Could they be anemic?
CBC No
Yes
Are they on a drug that could cause AUB?
AUB-I
AUB-C
Are they ovulatory No
Yes
Are they at risk for malignancy/hyperplasia
yes
AUB-O
Evaluate the uterus
Endometrial sampling
Ultrasound, sonohysterogram, hysteroscopy
AUB-M
negative
AUB-A
Positive
AUB-P
AUB-E
AUB-L

8. AUB-I Hormonal contraception IUD
Tricyclic antidepressants, phenothiazines

9. AUB-C
Anticoagulant meds
coagulopathies

10. Chronic AUB: =3 months of disturbed menstrual bleeding
Could they be anemic?
CBC No
Yes
Are they on a drug that could cause AUB?
AUB-I
AUB-C
Are they ovulatory No
Yes
Are they at risk for malignancy/hyperplasia
yes
AUB-O
Evaluate the uterus
Endometrial sampling
Ultrasound, sonohysterogram, hysteroscopy
AUB-M
negative
AUB-A
Positive
AUB-P
AUB-E
AUB-L

11. AUB-O Most of the time no etiology PCOS Hypothyroid Hyperprolactinemia
Mental stress
Extreme changes in weight or exercise

12. Chronic AUB: =3 months of disturbed menstrual bleeding
Could they be anemic?
CBC No
Yes
Are they on a drug that could cause AUB?
AUB-I
AUB-C
Are they ovulatory No
Yes
Are they at risk for malignancy/hyperplasia
yes
AUB-O
Evaluate the uterus
Endometrial sampling
Ultrasound, sonohysterogram, hysteroscopy
AUB-M
negative
AUB-A
Positive
AUB-P
AUB-E
AUB-L

13. Posterior Fibroid Slide courtesy of Linda Darlene Bradley, MD.
This slide shows a TVS image of a posterior fibroid.
Slide courtesy of Linda Darlene Bradley, MD.
Slide courtesy of Linda Darlene Bradley, MD.

14. Saline Infusion Sonography

15. Posterior Class 3 Fibroid
This slide shows a SIS image of a posterior Class 3 fibroid abutting the posterior endometrium.
Slide courtesy of Linda Darlene Bradley, MD.
Slide courtesy of Linda Darlene Bradley, MD.

16. Endometrial Polyps Slide courtesy of Linda Darlene Bradley, MD.
This slide shows an SIS image of endometrial polyps.
Slide courtesy of Linda Darlene Bradley, MD.
Slide courtesy of Linda Darlene Bradley, MD.

17. Endometrial Polyps Slide courtesy of Linda Darlene Bradley, MD.
This slide shows a hysteroscopic image of the endometrial polyps seen on the SIS in the previous slide.
Slide courtesy of Linda Darlene Bradley, MD.
Slide courtesy of Linda Darlene Bradley, MD.

18. Chronic AUB: =3 months of disturbed menstrual bleeding
Could they be anemic?
CBC No
Yes
Are they on a drug that could cause AUB?
AUB-I
AUB-C
Are they ovulatory No
Yes
Are they at risk for malignancy/hyperplasia
yes
AUB-O
Evaluate the uterus
Endometrial sampling
Ultrasound, sonohysterogram, hysteroscopy
AUB-M
negative
AUB-A
Positive
AUB-P
AUB-E
AUB-L

21. Possible Endometrial Biopsy Findings
Proliferative, secretory, benign, or atrophic endometrium
Inactive endometrium
Tissue insufficient for analysis
No endometrial tissue seen
Simple or complex hyperplasia without atypia
Simple or complex hyperplasia with atypia
Endometrial adenocarcinoma
The results of most endometrial biopsies fall into one of several categories, shown on this slide.
Atypia is the most important risk factor for endometrial cancer. Approximately 25% of patients with atypia have been reported to develop endometrial cancer, compared with only 2% of patients without atypia. A finding on biopsy of normal secretory endometrium indicates that the patient is having ovulatory cycles, and abnormal uterine bleeding is therefore most likely due to a cause other than anovulation.

22. Chronic AUB: =3 months of disturbed menstrual bleeding
Could they be anemic?
CBC No
Yes
Are they on a drug that could cause AUB?
AUB-I
AUB-C
Are they ovulatory No
Yes
Are they at risk for malignancy/hyperplasia
yes
AUB-O
Evaluate the uterus
Endometrial sampling
Ultrasound, sonohysterogram, hysteroscopy
AUB-M
negative
AUB-A
Positive
AUB-P
AUB-E
AUB-L

23. AUB-A
Adenomyosis usually found on hysterectomy specimen
MRI

25. AUB-E
Problem with prostiglandins
Receptor problems
Areas for research