Guideline sources The following summarized guidelines for the evaluation and management of abnormal uterine bleeding (AUB) are prepared by our editorial team based on guidelines from the American College of Radiology (ACR 2020), the American Association of Family Physicians (AAFP 2019), the American College of Obstetricians and Gynecologists (ACOG 2019; 2013; 2012), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2019; 2018; 2015), and the Society of Gynecologic Surgeons (SGS 2012). 1 2 3 4 5 6 7 8 9 10 Guidelines 1. Classification and risk stratification Classification: As per AAFP 2019 guidelines, use the International Federation of Gynecology and Obstetrics classification system to characterize AUB. B As per SOGC 2018 guidelines, consider adopting standardized international terminology for AUB. C As per ACOG 2013 guidelines, classify etiologies of AUB based on the PALM-COEIN system: https://web.pathway.md/diseases/recyVq825NSm4QU51 1/7 6/23/23, 1:24 AM Abnormal uterine bleeding Pathway s pe COG 0 3 gu de es, c ass y et o og es o U based o t e CO syste polyp adenomyosis leiomyoma malignancy and hyperplasia coagulopathy ovulatory dysfunction endometrial iatrogenic not otherwise classified. E 2. Diagnostic investigations History and physical examination: elicit history and perform physical examination to determine the cause of AUB and direct the need for further investigation and treatment. B Pregnancy testing: As per AAFP 2019 guidelines, obtain pregnancy testing in all patients with AUB. B As per SOGC 2018 guidelines, obtain a sensitive urine or serum pregnancy test in patients with AUB if there is any possibility of pregnancy. B Ultrasound: As per ACR 2020 guidelines, obtain transabdominal and transvaginal ultrasound (including Doppler ultrasound) as initial imaging in patients with AUB. B Show 2 more As per AAFP 2019 guidelines, obtain transvaginal ultrasound as first-line imaging for the evaluation of AUB in most patients. B As per SOGC 2018 guidelines, obtain imaging to acquire additional information to assist in patient assessment and treatment in indicated circumstances. A Show 2 more Magnetic resonance imaging: As per ACR 2020 guidelines: Obtain contrast-enhanced pelvic MRI for subsequent imaging of AUB if the initial ultrasound is inconclusive or further imaging characterization is needed. B Obtain contrast-enhanced pelvic MRI for follow-up imaging of AUB when surveillance is appropriate given findings from the initial ultrasound. B Laboratory testing: As per AAFP 2019 guidelines, obtain testing for anemia in all patients with AUB. B As per SOGC 2018 guidelines, obtain a CBC in patients with heavy or prolonged bleeding. B Show 2 more https://web.pathway.md/diseases/recyVq825NSm4QU51 2/7 6/23/23, 1:24 AM Abnormal uterine bleeding Pathway 3. Diagnostic procedures Hysteroscopy: Perform hysteroscopy to acquire additional information to assist in patient assessment and treatment in indicated circumstances. A Perform hysteroscopy for the diagnosis and characterization of discrete intrauterine abnormalities, such as submucosal fibroids. A Endometrial biopsy: As per AAFP 2019 guidelines, perform endometrial biopsy in all patients with AUB with any of the following: age 45 years younger patients with a significant history of unopposed estrogen exposure persistent bleeding failed medical management. B As per SOGC 2018 guidelines, consider performing endometrial biopsy in patients with AUB with any of the following: age > 40 years bleeding not responsive to medical therapy younger patients with risk factors from endometrial cancer. B Show 2 more 4. Medical management General principles: Initiate medical treatment as first-line therapy in patients with AUB once malignancy and significant pelvic pathology is ruled out. A Tailor medical treatment to individual patient's therapeutic goals, desire for contraception, underlying medical conditions and tolerance of side effects to encourage compliance and maximize the likelihood of treatment success. B Initiate medical management with the following agents as the initial treatment in most patients with AUB, if clinically appropriate, with choice of agent based on the patient's medical history and contraindications to therapies: IV conjugated equine estrogen multi-dose regimens of oral contraceptives or oral progestins tranexamic acid. E Consider offering any of the following treatment options in patients with AUB presumed caused by predominately ovulatory disorders or endometrial hemostatic disorders, with choice of treatment based on the patient's values and preferences: hysterectomy https://web.pathway.md/diseases/recyVq825NSm4QU51 3/7 6/23/23, 1:24 AM Abnormal uterine bleeding Pathway endometrial ablation systemically administered medical therapies levonorgestrel intrauterine system. C Show 2 more Management of acute bleeding: As per SOGC 2018 guidelines, recognize that acute heavy menstrual bleeding may result in significant anemia and require emergent care. B Show 2 more As per ACOG 2013 guidelines, initiate long-term maintenance therapy once acute bleeding episode has been controlled. E Hormone therapy: as per SOGC 2018 guidelines, offer combined oral contraceptive pills, depot medroxyprogesterone acetate, or levonorgestrel-releasing intrauterine systems to reduce menstrual bleeding in patients with AUB desiring effective contraception. A Show 3 more Antifibrinolytics: consider offering antifibrinolytics for the treatment of patients with heavy menstrual bleeding being mainly cyclic or predictable in timing. B Nonsteroidal anti-inflammatory drugs: consider offering NSAIDs for the treatment of patients with heavy menstrual bleeding being mainly cyclic or predictable in timing. B 5. Therapeutic procedures Intrauterine devices: As per AAFP 2019 guidelines, offer 20 g/day formulation of the levonorgestrel releasing intrauterine system over other medical therapies for reducing heavy menstrual bleeding. A As per SOGC 2018 guidelines, consider placing progestin intrauterine system before surgical intervention in patients with heavy menstrual bleeding due to outcomes similar to endometrial ablation. B As per SGS 2012 guidelines: Consider placing levonorgestrel intrauterine system rather than performing hysterectomy if the patient's main preference is to avoid adverse events. C Consider either performing hysterectomy or placing levonorgestrel intrauterine system if the patient's main preference is improvement in overall quality of life or sexual health, with choice of treatment based on additional patient preferences. C Endometrial ablation: As per SOGC 2018 guidelines, prefer non-hysteroscopic ablation techniques over traditional hysteroscopic ablation due to similar patient satisfaction results with fewer risks of complications, less anesthetic requirement, and higher efficacy and safety. A As per SOGC 2015 guidelines, obtain comprehensive preoperative assessment to rule out any contraindication to endometrial ablation. B https://web.pathway.md/diseases/recyVq825NSm4QU51 4/7 6/23/23, 1:24 AM Abnormal uterine bleeding Pathway Show 8 more As per SGS 2012 guidelines: Consider performing endometrial ablation rather than hysterectomy if the patient's main preference is for shorter hospitalization and for lower operative and postoperative procedural risk. C Consider performing either hysterectomy or endometrial ablation if the patient's main preference is for improvement in overall quality of life or sexual health, with choice of treatment based on additional patient preferences. C 6. Surgical interventions General principles: Decide on performing surgery based on the following factors: clinical stability severity of bleeding contraindications to medical management lack of response to medical management underlying medical condition patient's desire for future fertility. E Hysterectomy: As per AAFP 2019 guidelines, perform hysterectomy as the most effective treatment for reducing heavy menstrual bleeding. A As per SOGC 2018 guidelines, perform hysterectomy as the definitive treatment in patients with AUB. A As per SGS 2012 guidelines, consider performing hysterectomy rather than endometrial ablation if the patient's main preference is for amenorrhea or avoiding additional therapy or experiencing less pain. C Show 5 more Myomectomy: consider performing hysteroscopic myomectomy in patients with AUB secondary to submucosal fibroids. B 7. Specific circumstances Adolescent patients, evaluation: As per ACOG 2019 guidelines, recognize that heavy menstrual bleeding at menarche and in adolescence may be an important sentinel for an underlying bleeding disorder. E Show 6 more As per SOGC 2018 guidelines: Recognize that AUB in adolescents most commonly represents ovulatory dysfunction related to immaturity of the hypothalamic-pituitary-ovarian axis. B https://web.pathway.md/diseases/recyVq825NSm4QU51 5/7 6/23/23, 1:24 AM Abnormal uterine bleeding Pathway Obtain assessment for an underlying bleeding disorder in adolescent patients presenting with heavy menstrual bleeding at or in close approximation to menarche. B Adolescent patients (management): initiate medical management as first-line approach to acute bleeding in the adolescent patients. Reserve surgery for patients not responding to medical therapy. E Show 9 more Patients with inherited bleeding disorders: recognize that inherited bleeding disorders may be an underlying cause of AUB, with von Willebrand's disease present in the majority of cases. B Show 3 more Patients undergoing cancer treatment: Consider obtaining a gynecologic consultation before initiation of treatment in all premenopausal patients at risk for AUB from chemotherapy. B Consider offering leuprolide acetate or combined hormonal contraceptives before cancer treatment to preven AUB in premenopausal patients at risk for thrombocytopenia. B References 1. No authors listed. ACOG committee opinion no. 557 Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol. 2013 Apr;121 4 891 896. Open 2. Sukhbir Singh, Carolyn Best, Sheila Dunn et al. No. 292 Abnormal Uterine Bleeding in Pre-Menopausal Women. J Obstet Gynaecol Can. 2018 May;40 5):e391-e415. Open 3. No authors listed. Practice bulletin no. 136 management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol. 2013 Jul;122 1 176 185. Open 4. Philippe Laberge, Nicholas Leyland, Ally Murji et al. Endometrial ablation in the management of abnormal uterine bleeding. J Obstet Gynaecol Can. 2015 Apr;37 4 362 79. Open 5. Committee on Practice Bulletins Gynecology. Practice bulletin no. 128 diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012 Jul;120 1 197 206. Open 6. Noah Wouk, Margaret Helton. Abnormal Uterine Bleeding in Premenopausal Women. Am Fam Physician. 2019 Apr 1;99 7 435 443. Open 7. Thomas L Wheeler nd, Miles Murphy, Rebecca G Rogers et al. Clinical practice guideline for abnormal uterine bleeding: hysterectomy versus alternative therapy. J Minim Invasive Gynecol. Jan-Feb 2012;19 1 81 8. Open 8. Expert Panel on GYN and OB Imaging, Jessica B Robbins, Elizabeth A Sadowski et al. ACR Appropriateness Criteria Abnormal Uterine Bleeding. J Am Coll Radiol. 2020 Nov;17 11S S336 S345. Open 9. No authors listed. Screening and Management of Bleeding Disorders in Adolescents With Heavy Menstrual Bleeding: ACOG COMMITTEE OPINION, Number 785. Obstet Gynecol. 2019 Sep;134 3):e71-e83. Open https://web.pathway.md/diseases/recyVq825NSm4QU51 6/7 6/23/23, 1:24 AM Abnormal uterine bleeding Pathway 10. Yolanda A Kirkham, Melanie P Ornstein, Anjali Aggarwal et al. No. 313 Menstrual Suppression in Special Circumstances. J Obstet Gynaecol Can. 2019 Feb;41 2):e7-e17. Open https://web.pathway.md/diseases/recyVq825NSm4QU51 7/7