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Abnormal uterine bleeding (AUB) is a common gynecological symptom and sign. As a general term, it refers to any one of the abnormal bleeding from the uterine cavity that does not match any of the cycle frequency, regularity, length of menstruation, and menstrual bleeding volume of normal menstruation. . The AUB described in this guide is restricted to women of childbearing age who are not pregnant. Therefore, it is necessary to exclude bleeding associated with pregnancy and puerperium, and it does not include prepubertal and postmenopausal bleeding. The medical terms and definitions describing AUB in countries around the world are confusing. To this end, the International Federation of Obstetrics and Gynecology (FIGO) published a consensus on "terms related to normal and abnormal uterine bleeding" in 2007, and in 2011 published "non-pregnancy in childbearing age New classification of women's AUB etiology PALM-COEIN system ", unified terminology to guide clinical treatment and research. There are also some confusions in the gynecological community in China. For example, the three terms AUB, dysfunctional uterine bleeding (dysfunction), and menstruation are used indiscriminately. Therefore, in October 2014, the Gynecological Endocrinology Group of the Obstetrics and Gynecology Branch of the Chinese Medical Association formulated the Guidelines for the Diagnosis and Treatment of Abnormal Uterine Bleeding.

Basic Information

English name

abnormal uterine bleeding, AUB

Visiting department

Gynecology

Multiple groups

Non-pregnant women of childbearing age

Common symptoms

Excessive menstruation, irregular bleeding, infertility

Causes, classification and terminology of abnormal uterine bleeding

FIGO's new classification system for terms and causes related to normal and abnormal uterine bleeding is as follows:

1. Normal Uterine Bleeding and Recommended AUB Terms

Normal uterine bleeding is menstruation, and the standard menstrual indicators include at least four factors: the frequency and regularity of the cycle, the length of the menstrual period, and the amount of menstrual bleeding. The tentative terminology standards in China are shown in Table 1. , Backache, falling.

2. Obsolete and reserved terminology

The term "function blood" was discarded because the definitions in different regions and the resources used for diagnostic tests were different, so the connotation was inconsistent.

(1) Discontinued terms Metrorrhagia (menorrhagia), menorrhagia (menorrhagia) and other terms with Greek or Latin roots, because the definitions are vague and different in understanding.

(2) Reserved terms intermenstrual bleeding (IMB); irregular uterine bleeding; breakthrough bleeding (BTB): bleeding is more bleeding, drip bleeding.

3. New term proposed

(1) Chronic AUB refers to AUB that has occurred at least 3 times in the past 6 months. The physician believes that AUB does not require urgent clinical treatment but requires standardized diagnosis and treatment.

(2) Acute AUB refers to AUB with severe severe bleeding. The doctor believes that urgent treatment is needed to prevent further blood loss. It can be seen in patients with or without a history of chronic AUB.

4. FIGO's new AUB etiology classification system-PALMCOEIN system

In the past, the causes of AUB were divided into three categories: organic diseases, dysfunction and iatrogenic causes. FIGO divides the etiology of AUB into two categories and nine types, which are abbreviated as "PALM-COEIN" according to the English acronym. "PALM" has structural changes, which can be clearly diagnosed by imaging techniques and / or histopathological methods. "COEIN" has no structural changes in the uterus. Specifically:

PALM: AUB (abbreviation: AUB-P) caused by endometrial polyps, AUB (abbreviation: AUB-A) caused by adenomyosis, AUB (abbreviation: AUB-L) caused by uterine leiomyoma -L fibroids include submucosal (SM) and other sites (O). AUB caused by malignant endometrium and atypical hyperplasia (abbreviation: AUB-M);

COEIN: AUB caused by systemic coagulation-related diseases (abbreviated as AUB-C), AUB associated with ovulation disorder (abbreviated as AUB-O), AUB caused by local endometrial abnormalities (abbreviated as AUB-E), iatrogenic AUB (Abbreviation: AUB-I), unclassified AUB (abbreviation: AUB-N).

Any patient may have one or more etiology that causes or is associated with AUB. The diagnosis is expressed as:

Single causes, such as: abnormal uterine bleeding-uterine fibroids (submucosal), multiple causes, such as: abnormal uterine bleeding-uterine fibroids, ovulation disorders; on the other hand, diseases that have been found, such as subserosal uterine fibroids are not At present, the cause of AUB needs to be diagnosed in parallel. The diagnosis is expressed as: abnormal uterine bleeding-ovulation disorder, uterine fibroids (subserosal).

5.Comparison of PALM-COEIN system and original AUB etiology classification in China

In the previous AUB etiology classification in China, organic diseases refer to P, A, L, M, C and some E, N in the PALM-COEIN system; however, organic diseases not included in the PALM-COEIN system include the reproductive tract. Trauma, foreign body, hypothyroidism, liver disease, lupus erythematosus, renal dialysis, etc. Iatrogenic etiology is equivalent to AUB-I in the PALM-COEIN system. Dysfunction emphasizes the elimination of organic diseases. Anovulatory dysfunction is AUB-O, and ovulatory dysfunction involves AUB-O and AUB-E.

AUB AUB etiology diagnosis process of abnormal uterine bleeding

For patients with AUB (that is, menstrual disorders), the first step is to confirm the specific bleeding pattern by asking the history of menstrual changes in detail, which is the main problem of the patient's consultation (that is, the main complaint). Attention should be paid to asking about sexual life and contraceptive measures to exclude bleeding related to pregnancy or puerperium (the blood hCG level should be measured if necessary). Attention should be paid to distinguish between bleeding that resembles normal menstruation and abnormal bleeding, and check on the specific date of nearly 1-3 bleeding The focus should be on natural menstruation rather than drug-induced artificial menstruation. A systemic examination and a gynecological examination are indispensable at the first diagnosis, and relevant signs such as sexual characteristics, height, lactation, body weight, body hair, and abdominal mass can be found in time, which can help determine the source of bleeding, exclude cervical and vaginal lesions, and find Abnormal uterine structure; combined with necessary auxiliary examination to determine the cause of AUB.

1. Determining the AUB bleeding pattern: See Figure 1 for the flow.

2. Diagnosis of frequent menstruation, excessive menstruation, prolonged menstruation, and irregular menstruation: the process is shown in Figure 2.

3. Little menstruation: It is a bleeding pattern of AUB, which is common in the clinic. The etiology can be caused by insufficient secretion of ovarian estrogen, anovulation, or surgical trauma, inflammation, adhesions and other factors that cause the endometrium to not respond to normal amounts of hormones. The diagnosis and treatment process is shown in Figure 3.

4. Thin menstruation: The diagnosis and treatment process is shown in Figure 4.

5. IMB: IMB refers to regular, predictable bleeding between menstruation, including random bleeding and fixed bleeding every cycle. According to the bleeding time can be divided into follicular bleeding, periovulation bleeding, luteal bleeding. The diagnostic process is shown in Figure 5.

AUB Clinical manifestations, diagnosis and management of nine causes of AUB in abnormal uterine bleeding

1.AUB-P

Endometrial polyps can be single or multiple, and 21% to 39% of AUB causes are endometrial polyps. After middle age, obesity, high blood pressure, and women using tamoxifen (other names: tamoxifen) are more likely to occur.

Clinically, 70% to 90% of endometrial polyps have AUB, which is manifested as IMB, excessive menstruation, irregular bleeding, and infertility. A few (0 to 12.9%) have atypical hyperplasia or malignant transformation of the glands; large polyps and high blood pressure are risk factors for malignant transformation. It can usually be found by pelvic B-ultrasound. The best time for examination is before the 10th day of the cycle; the diagnosis needs to be removed under hysteroscopy for pathological examination. If asymptomatic polyps with a diameter of less than 1 cm, the natural disappearance rate is about 27% within one year, and the rate of malignant transformation is low, which can be observed with follow-up. For large and symptomatic polyps, hysteroscopic polyp removal and curettage are recommended. Blind curettage is easy to miss. The risk of postoperative recurrence is 3.7% to 10.0%; short-acting oral administration may be considered for those who have completed or recently unwilling to have children. Birth control pills or levonorgestrel intrauterine sustained release system (LNG-IUS) to reduce the risk of recurrence; for patients who have no reproductive requirements and multiple recurrences, endometrial resection is recommended. Hysterectomy can be considered for those at high risk of malignant transformation.

2.AUB-A

Uterine adenomyosis can be divided into diffuse type and limited type (that is, adenomyoma of the uterus), mainly manifested by menstruation and prolonged menstruation, some patients may have IMB, infertility. Most patients have dysmenorrhea. Pathological examination is needed to confirm the diagnosis, and a preliminary diagnosis can be made clinically based on typical symptoms and signs, and elevated blood CA125 levels. Ultrasound examination of the pelvis can assist diagnosis, and MRI examination is feasible for those who have the condition. Treatment depends on the patient's age, symptoms, and fertility requirements, divided into drug treatment and surgical treatment. For patients with mild symptoms and unwilling to undergo surgery, try short-acting oral contraceptives and gonadotropin-releasing hormone agonists (GnRH-a) for 3 to 6 months. Symptoms will recur after withdrawal and can be re-administered after relapse. LNG-IUS can also be placed in those who have no recent fertility requirements and whose uterine size is less than 8 weeks of gestation; those with uterine size greater than 8 weeks of gestation can consider the combined application of GnRH-a and LNG-IUS. GnRH-a treatment can be used for young people with fertility requirements for 3 to 6 months. Assisted reproductive technology should be given as appropriate. Hysterectomy is feasible for those who have no fertility requirements, severe symptoms, old age, or ineffective drug treatment. Whether the ovaries are retained depends on the presence of ovarian disease and the patient's wishes. Patients with fertility requirements and adenomyoma can consider local lesion resection + GnRH-a treatment and then give assisted reproduction technology.

3.AUB-L

According to the growth site, uterine leiomyomas can be divided into submucosal fibroids and other fibroids that affect the uterine morphology. The former is most likely to cause AUB. Uterine fibroids can be asymptomatic, only found on physical examination, but often manifested as prolonged periods or excessive menstruation. AUB caused by submucosal fibroids is more serious. It can usually be found by pelvic B-ultrasound and hysteroscopy. The diagnosis can be confirmed by postoperative pathological examination. Treatment options depend on the patient's age, severity of symptoms, fibroid size, number, location, and fertility requirements. In women with AUB and submucosal fibroids, hysteroscopy or combined laparoscopic fibroid removal has clear advantages. Short-acting oral contraceptives and LNG-IUS can alleviate symptoms in women who have had more menstrual periods and who have completed childbearing. Women with childbearing requirements can be treated with GnRH-a and mifepristone for 3 to 6 months. After fibroids shrink and bleeding symptoms improve, natural pregnancy or assisted reproductive technology will be used. For uterine fibroids that seriously affect the uterine morphology, hysteroscopy, laparoscopy, or open fibroid removal can be used. However, after these treatments, fibroids may recur, and other treatment methods should be considered as appropriate after the factors such as visual symptoms, tumor size, and growth rate after fertility are completed.

4.AUB-M

Atypical endometrial hyperplasia and malignancy are rare and important causes of AUB. Endometrial atypical hyperplasia is a precancerous lesion, and the canceration rate during follow-up 13.4 years is 8% to 29%. It is common in patients with polycystic ovary syndrome (PCOS), obesity, and tamoxifen. Occasionally, ovulation and inadequate corpus luteum function occur. The clinical manifestations are mainly irregular uterine bleeding, which can alternate with thin menstruation. A few are IMB, and patients often have infertility. A confirmed diagnosis requires endometrial biopsy. For those aged 45 years or older, long-term irregular uterine bleeding, high risk factors for endometrial cancer (such as hypertension, obesity, diabetes, etc.), B-ultrasounds suggest excessive endometrial thickening, uneven echo, and drug treatment effects are not significant Diagnosis and curettage were performed along with pathological examination, and those who had the conditions preferred hysteroscopic biopsy.

Treatment of endometrial atypical hyperplasia requires different treatment options based on the severity of the endometrial disease, the age of the patient, and whether there are fertility requirements. Hysterectomy is recommended for patients> 40 years of age without fertility requirements. For young patients with fertility requirements, after comprehensive evaluation and full consultation, full-cycle continuous and efficient synthesis of progestin can be used for endometrial atrophy treatment, such as medroxyprogesterone and megestrol, etc., after 3 to 6 months Clinic curettage and suction palace (to achieve the purpose of comprehensive materials). If the endometrial disease has not been reversed, the dose should be increased and rechecked after 3 to 6 months. If the endometrial dysplasia disappears, assisted reproductive technology is actively given after the progestin is stopped. While using progestin, cope with the high-risk factors of endometrial hyperplasia, such as obesity and insulin resistance. Diagnosis and treatment of endometrial malignancies refer to relevant clinical guidelines.

5.AUB-C

Including aplastic anemia, various types of leukemia, various coagulation factor abnormalities, thrombocytopenia caused by various reasons and other systemic coagulation mechanism abnormalities. It has been reported that about 13% of women with menorrhagia have systemic coagulopathy. In addition to dysfunction of coagulation, menstruation, IMB and prolonged menstruation. Some women of childbearing age must have lifelong anticoagulation therapy due to thrombotic disease, renal dialysis, or placement of a heart stent, which may cause excessive menstruation. Although this AUB can be classified as iatrogenic, it is more appropriate to classify it as AUB-C. Patients with multiple menstrual periods must be screened for clues to potential coagulation abnormalities and asked about their medical history. Patients who are positive in any of the following 3 items suggest that there may be coagulation abnormalities. Hematologists should be consulted, including: (1) menarche from menarche; (2) One of the following medical histories: previous postpartum, postoperative, or dental-related bleeding; (3) Two or more of the following symptoms: 1 to 2 bruises per month, each Nosebleeds 1-2 times a month, frequent gum bleeding, family history of bleeding tendency.
Treatment should be negotiated with the hematology department and other related departments. In principle, hematology treatment measures should be the main treatment. Gynecology can help control menstrual bleeding. Gynecology is the first choice for drug treatment. The main measures are high-dose and high-efficiency synthetic progesterone endometrial atrophy treatment, and sometimes adding testosterone propionate to reduce pelvic organ congestion. Tranexamic acid, short-acting oral contraceptives may also help. When drug treatment fails or there is no cure for the primary disease, surgical treatment can be considered after controlling the condition in the hematology department and improving the general condition. Surgical treatment includes endometrial resection and total hysterectomy.

6.AUB-O

Ovulation disorders include rare ovulation, anovulation, and inadequate luteal function, which are mainly caused by abnormal hypothalamic-pituitary-ovarian axis function. They are common in adolescence and menopause, and can be caused by PCOS, obesity, hyperprolactinemia, Caused by thyroid disease. Often manifested as irregular menstruation, menstrual flow, menstrual length, cycle frequency, regularity can be abnormal, and sometimes cause major bleeding and severe anemia. The most common method for diagnosing anovulation is basal body temperature measurement (BBT), and it is estimated that the blood progesterone level is measured 5-9 days before the next menstrual period (equivalent to the middle corpus luteum). At the same time, blood LH, FSH, prolactin (PRL), estradiol (E2), testosterone (T), and thyroid stimulating hormone (TSH) levels should be measured in the early follicular phase to understand the cause of anovulation. The principle of treatment is to stop bleeding and correct anemia during hemorrhage, adjust the cycle after hemostasis to prevent endometrial hyperplasia and AUB recurrence, and those who have fertility requirements promote ovulation treatment. Methods of hemostasis include progesterone endometrial shedding, high-dose estrogen endometrial repair, short-acting oral contraceptives or high-efficiency synthetic progesterone endometrial atrophy, and curettage. There are also tranexamic acid drugs to assist hemostasis (see the 2009 "Guide to Blood Function" for details). The method of adjusting the cycle is mainly the second half of progestin therapy. Adolescents and reproductive age patients should choose natural or near-natural progestins (such as dydrogesterone), which is conducive to the establishment or recovery of ovarian axis function. Short-acting oral contraceptives are mainly suitable for women with contraceptive requirements. LNG-IUS can be placed for those who have completed childbirth or have no birth plan for nearly one year, which can reduce the amount of bleeding in patients with anovulation and prevent endometrial hyperplasia. Patients who have completed fertility, failed drug treatment, or have contraindications may consider endometrial resection or hysterectomy. Ovulation-promoting treatment is suitable for patients who have fertility requirements without ovulation, and can correct AUB at the same time, the specific method depends on the cause of anovulation.

7.AUB-E

When AUB occurs in a regular and ovulatory cycle, especially when no other cause can be explained after investigation, it may be caused by local abnormalities in the endometrium. If the symptoms are only menstruation, it may be an abnormal mechanism of regulating the local coagulation and fibrinolysis function of the endometrium. In addition, it may only manifest as IMB or prolonged menstruation, which may be an abnormal molecular mechanism of endometrial repair, including the endometrium. Inflammation, infection, abnormal inflammatory response, and abnormal endometrial angiogenesis. At present, there is no specific method to diagnose local endometrial abnormalities, which is mainly determined based on excluding other definite abnormalities on the basis of ovulated menstruation.

For menorrhagia caused by such non-organic diseases, drug treatment is recommended first. The recommended drug treatment sequence is: (1) LNGIUS, suitable for those who have no fertility requirements for more than 1 year; (2) tranexamic acid resistance Fibrinolytic therapy or non-steroidal anti-inflammatory drugs (NSAID) can be used for those who are unwilling or unable to use sex hormone therapy or want to get pregnant as soon as possible; (3) short-acting oral contraceptives; (4) progestin endometrial atrophy treatment, For example, norethindrone 5mg 3 times a day, starting from the 5th day of the cycle, continuously taking 21d. The curettage is only used for emergency hemostasis and pathological examination. For those without fertility requirements, conservative surgery such as endometrial ablation can be considered.

8.AUB-I

AUB-I refers to AUB caused by factors such as the use of sex hormones, placement of an intrauterine device or traditional Chinese medicine health products that may contain estrogen. BTB refers to unintended uterine bleeding during hormone therapy and is the main cause of AUB-I. The cause of BTB may be related to the improper ratio of estrogen and progesterone used. Missed contraceptive pills cause withdrawal bleeding. Prolonged menstrual period caused by IUD placement may be related to excessive local prostaglandin production or hyperfibrinolysis; women with LNG-IUS or subcutaneous implants for the first time often experience BTB within 6 months. The use of rifampicin, anticonvulsants and antibiotics can also easily lead to the occurrence of AUB-I. The clinical diagnosis needs to be determined by carefully asking the medication history and analyzing the relationship between medication and bleeding time. If necessary, hysteroscopy should be used to rule out other causes.

Regarding bleeding caused by oral contraceptives, missed doses should be ruled out first, and regular use should be emphasized; if there is no missed dose, bleeding can be improved by increasing the dose of ethinylestradiol. Due to the placement of IUDs, antifibrinolytic drugs are preferred for treatment. Bleeding caused by application of LNG-IUS or subcutaneous implants can be treated symptomatically or in anticipation of treatment. Consultation before placement is recommended.

9.AUB-N

Individual patients with AUB may be related to other rare factors, such as arteriovenous malformations, uterine scar defects after cesarean section, and myometrial hypertrophy. However, there is currently no comprehensive examination method as a basis for diagnosis; there may also be some Clarified factors. These factors are temporarily classified as "Unclassified (AUB-N)".

The etiology of AUB caused by arteriovenous malformations is congenital or acquired (uterine trauma, cesarean section, etc.), and most of them are sudden massive uterine bleeding. Transvaginal Doppler ultrasound is preferred for diagnosis, and uterine angiography can confirm the diagnosis. Other auxiliary diagnostic methods include pelvic CT and MRI. In terms of treatment, patients with fertility requirements can use oral contraceptives or anticipatory therapy when the amount of bleeding is small; for patients with severe bleeding, first maintain vital signs stable and use selective uterine artery embolization as soon as possible, but it has been reported that postoperative The pregnancy rate is low. Those without fertility requirements can use hysterectomy.

The high-risk factors for AUB caused by uterine scar defect after cesarean section include improper cesarean incision location, improper cesarean section before the formation of the lower segment of the uterus, and improper surgical operation, which often manifest as prolonged menstruation. The recommended diagnostic method is transvaginal ultrasound or hysteroscopy. In terms of treatment, short-acting oral contraceptives can be used for those who have no fertility requirements, which can shorten the bleeding time; when the drug treatment is not effective, surgical treatment can be considered. For those who have fertility requirements, the risk of uterine rupture during pregnancy should be fully informed before pregnancy. Surgical treatment includes hysteroscopy, laparoscopy, open or transvaginal cesarean section uterine incision diverticulum and peripheral scar removal and repair.