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Abnormal uterine bleeding and fibroids
Abnormal uterine bleeding is classified by PALM-COEIN — structural causes (polyp, adenomyosis, leiomyoma, malignancy) and non-structural causes (coagulopathy, ovulatory, endometrial, iatrogenic); the work-up always starts with a pregnancy test, and endometrial sampling is needed from age 45 or with risk factors.
Why it matters in the exam
Exam questions present a woman with heavy or irregular periods and ask for the next step. The order is fixed: a pregnancy test, a blood count, TSH, and in a girl with heavy bleeding since menarche — a coagulation work-up (mainly von Willebrand disease). Transvaginal ultrasound looks for a structural cause. Endometrial sampling is needed from age 45, and also at a younger age with prolonged unopposed oestrogen exposure (obesity, PCOS) or when treatment fails. In acute heavy bleeding the woman is stabilised first, then the bleeding is stopped with high-dose hormones, tranexamic acid or curettage.
Fibroids (leiomyomas) are the most common benign tumour of the uterus. Most cause no symptoms; they cause heavy bleeding, pelvic pressure and sometimes infertility — mainly submucous fibroids that distort the cavity. Treatment is chosen by symptoms, size, location and the wish for pregnancy: drugs to reduce bleeding, a combined GnRH antagonist (relugolix) or a GnRH agonist before surgery, hysteroscopic myomectomy for a submucous fibroid, surgical myomectomy for a woman who wants to conceive, uterine artery embolisation, and hysterectomy as definitive treatment. A fibroid that grows rapidly after menopause raises suspicion of sarcoma. In pregnancy a fibroid may undergo "red" degeneration with sharp pain, treated with analgesia.
Key points
- PALM-COEIN: structural versus non-structural.
- Work-up: pregnancy, blood count, TSH; coagulation in a girl with heavy bleeding.
- Endometrial biopsy from age 45 or with risk factors.
- Chronic heavy bleeding → hormonal IUD as first line.
- Fibroids: submucous → hysteroscopy; wish for pregnancy → myomectomy; definitive → hysterectomy.
Summary table
| Situation | Finding | Work-up | Treatment |
|---|---|---|---|
| Acute heavy bleeding | Instability or severe anaemia | Pregnancy test, blood count, group, coagulation | Stabilise; IV oestrogen or high-dose hormones, tranexamic acid; curettage if no response |
| Chronic heavy menstrual bleeding | Heavy, regular periods | Blood count, ferritin, TSH, ultrasound | Hormonal IUD (first line), tranexamic acid, NSAIDs, the pill; ablation once childbearing is complete |
| Ovulatory dysfunction (O in COEIN) | Irregular cycles, PCOS, early or late reproductive years | Hormones, TSH, prolactin | Cyclical progestin or the pill; endometrial protection |
| Endometrial sampling | Age 45 or more, or younger with risk | Biopsy (Pipelle) | Exclude hyperplasia and cancer |
| Submucous fibroid | Distorts the cavity; bleeding and infertility | Ultrasound, hysteroscopy | Hysteroscopic resection |
| Intramural or subserosal fibroids | Heavy bleeding, pressure | Ultrasound or MRI | Combined relugolix, myomectomy, uterine artery embolisation, hysterectomy |
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Sources
- FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding, 2018 revision — PALM-COEIN
- ACOG Committee Opinion No. 557, 2013, reaffirmed — Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women
- ACOG Practice Bulletin No. 228, 2021 — Management of Symptomatic Uterine Leiomyomas
- Berek and Novak's Gynecology, 16th edition (2019) — Abnormal Uterine Bleeding; Uterine Fibroids
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.