Chapter 28: Abnormal Uterine Bleeding

Welcome to Last Minute Lecture.

This free chapter overview is designed to help students review and understand key concepts.

These summaries supplement not replaced the original textbook and may not be redistributed or resold.

For complete coverage, always consult the official text.

You know, usually when we talk about a medical diagnosis, there's this expectation of absolute precision, almost like structural engineering or something.

Absolutely.

Like, break your arm,

the x -ray shows that jagged white line, and the doctor just points to the screen and says, well, there it is, broken.

Right.

It's binary.

It's clean.

We naturally like things to be visible and neatly categorized.

But then you step into the world of women's health, specifically menstrual health, and suddenly that x -ray machine feels, you know, completely useless.

Oh, entirely.

Yeah.

We're looking at a diagnostic landscape that is, honestly,

incredibly murky.

The old rules don't always apply, and just the terminology alone can make your head spin.

It is the absolute definition of diagnostic muddy water.

I mean, for a long time, the medical community didn't even have a unified language for it.

Which is exactly why we're here today.

So welcome to this deep dive.

Today, we're giving you a shortcut through chapter 28 of your textbook, Advanced Health Assessment of Women.

It's going to be a good one.

We are going to take the murky, confusing world of abnormal uterine bleeding, where the old diagnostic rule book has literally been thrown out, and give you a foolproof blueprint to use in your clinicals.

Right.

We'll trace the logic all the way from the patient's first complaint straight through to targeted relief.

Because it's really essential material for any nursing or advanced practice student.

It really is.

And the best place to start is simply defining the problem.

Like, what actually constitutes abnormal uterine bleeding, or AUB?

Right.

Because to a patient, what feels normal or abnormal can be, well, incredibly subjective.

Exactly.

If a patient says, my periods are crazy, we need to anchor that to something concrete.

So clinically, AUB is any uterine bleeding that occurs outside of normal menstrual boundaries, right?

Yes.

And we measure those boundaries using four specific parameters.

We look at duration, volume, cycle length, and Okay, let's break those down.

So for duration, a normal period lasts between two and seven days.

Anything less than two or more than seven is abnormal.

Makes sense.

Then for volume, normal is under 80 milliliters of blood loss per cycle.

Okay, let's pause on the 80 milliliters for a second, because we definitely need to come back to how to measure that.

But keep going with the parameters.

Sure.

Next is cycle length.

A normal interval is anywhere between 21 and 38 days.

Right.

And finally, timing.

Any bleeding that happens between periods, so intermenstrual bleeding, or postcoital spotting after sex, or any unscheduled bleeding if a patient is on hormone therapy, that automatically flags as AUB.

Okay, let's unpack this.

Because if you're reviewing older medical charts, you're going to see an absolute alphabet soup of terms.

Oh, it's a mess.

You'll see menorrhagia, metroragia, dysfunctional uterine bleeding.

I mean, it sounds like a dead language.

And thankfully, it is a dead language now.

The textbook points out that in 2011 and updated again in 2018, the International Federation of Gynecology and Obstetrics, or FIGO, officially retired those old confusing terms.

Oh, okay.

Good riddance.

Yeah, they were used so inconsistently by providers that they actually hindered patient care.

So FIGO threw them out and replaced them with a much clearer classification system using the acronym PALL -M -COTAON.

Which we are going to break down in detail shortly.

But first, let's talk about why we care so much about this.

And that's a bigger picture.

Yeah.

Why does AUB take up an entire chapter?

And why is it such a massive focus in women's health?

The stats in the text are wild.

They really are staggering.

Approximately 1 .4 million women report AUB annually.

It accounts for 30 % of all outpatient gynecology visits.

A huge portion of visits, yeah.

And the incidence really spikes during two key transitional phases, right?

Adolescents, when the reproductive system is waking up, and perimenopause, when it's winding down.

Exactly.

And if we connect this to the bigger picture, AUB is not just a monthly inconvenience for these patients.

The health -related complications are severe.

Right.

It's not just a nuisance.

No, not at all.

When a patient is losing more than 80 milliliters of blood per cycle, they are at a very high risk for anemia.

Which makes sense.

But even beyond the lab values, AUB significantly lowers both physical and mental quality of life.

It causes miswork,

massive anxiety, increased healthcare costs, and crucially, AUB is responsible for approximately two -thirds of all hysterectomies.

Wait, two -thirds?

That's incredible.

But, okay, I have to stop you there.

I am having a really hard time visualizing how we actually enforce that 80 -milliliter volume limit in the real world.

It's tricky, for sure.

Because in a clinical setting, when you're sitting across from a patient,

you can't exactly ask them to measure their menstrual blood in a beaker.

How do we quantify that?

That is the perfect question.

You're completely right.

We can't objectively measure every drop of blood.

This is why the clinical history is our primary diagnostic tool.

So the history does the heavy lifting here.

Exactly.

The clinical proxy we use to estimate that 80 -milliliter threshold is pad or tampon usage.

Oh, okay.

But you don't just use total because, well, hygiene habits vary wildly from person to person.

You have to ask about the change in their usage.

So looking for a shift from their normal?

Right.

Specifically, an increase of two or more pads or tampons per day is your clinical marker for a significant increase in blood loss.

Oh, that makes so much more sense.

It grounds the clinical data entirely in the patient's lived experience.

You're basically comparing the patient to her own baseline.

Precisely.

And from there, you have to structure your history taking methodically.

First, you establish the pattern in the course.

Meaning acute versus chronic.

Right.

Is this acute or chronic?

If a patient comes in with acute SOB, your immediate priority is stabilization.

Are they hemorrhaging right now?

Do we need to intervene immediately to prevent shock?

Definitely.

But if it's chronic, you are looking for a persistent pattern of abnormal timing, amount or regularity that has lasted for the majority of a six -month period.

So you're asking questions like, are your cycles getting longer or shorter?

Are you passing clots?

And if so, are they the size of a dime or the size of a golf ball?

Yes, exactly.

And you also need to confirm where the blood is actually coming from, right?

Right.

Like is it definitively from the uterus or is it coming from the cervix, the vaginal wall, or the vulva?

That is a crucial distinction to make early on.

And once you have the pattern, you move to the review of systems, the ROS.

The text mentions some specific things to look for here.

It does.

The chapter highlights some very specific red flags.

For example, you need to ask about heat symptoms.

So head, eyes, ears, nose and throat.

Specifically, is she experiencing dizziness or syncope,

especially when she stands up?

Because if she's dizzy when changing positions, that points straight to hypovolemia.

She literally lacks blood volume to maintain her blood pressure because she's bleeding so heavily.

Right.

The symptoms tell a physiological story.

Here's another one.

You must ask about breast symptoms, specifically bilateral nipple discharge, which is known as galactoria.

Wait, how does nipple discharge connect to uterine bleeding?

It connects through the endocrine system.

Galactoria suggests hyperprolactinemia, which means high levels of the hormone prolactin.

High prolactin tricks the brain into thinking the body is nursing a baby.

And when the brain thinks it's nursing, it suppresses the hormones needed to trigger regular ovulation.

Wow.

So a problem in the pituitary gland up in the brain ends up presenting as irregular bleeding down in the uterus.

That is fascinating.

The body is so interconnected.

And of course, you absolutely cannot skip the full gynecologic and sexual history.

You never skip that.

You need to ask about sexually transmitted infections, which can inflame the cervix and cause bleeding.

You have to ask about the consistency of their contraceptive use.

Right.

User error is a huge factor.

You even need to ask about personal hygiene habits.

I mean, a retained tampon or an allergic reaction to a new feminine hygiene product can absolutely be the culprit.

Absolutely.

And then you dig into the medical and family history.

This is where students sometimes get tripped up because you have to ask seemingly unrelated questions.

Like what?

For instance, you should ask, have you ever had heavy bleeding after a dental procedure or a minor surgery?

Okay.

I have to admit, if I'm a patient sitting in a gynecology clinic because of heavy periods and you ask me about my last trip to the dentist,

I'm going to be very confused.

Why are we asking about dental work?

It seems completely out of the field.

I know,

but it's actually a crucial screening tool for underlying undiagnosed bleeding disorders like von Willebrand disease.

Oh, right.

Because bleeding is bleeding.

Exactly.

If her blood doesn't clot well when a dentist pulls a tooth, it's not going to clot well when the endometrial lining sheds.

That makes total sense.

You also need to ask about a family history of bleeding disorders or polycystic ovary syndrome or even endometrial and colon cancer.

Because those cancers have genetic links like Lynch syndrome that can present with irregular uterine bleeding as an early warning sign.

Exactly.

The history gives us our suspect list.

And once we have our suspects, we have to gather the hard evidence.

We move from the patient's story to the focused physical examination.

And the rule of thumb here is always systemic to specific.

You start with the vitals.

As we mentioned, check those orthostatic blood pressures and pulses to confirm if she's volume depleted.

Always check vitals first.

Then check the BMI.

Because obesity is a known risk factor for certain types of AUB, partly because excess adipose tissue can actually produce estrogen, which thickens the uterine lining.

That's a great point.

After vitals, you look for visual clues on the skin.

You're looking for hirsutism, which is excess male pattern hair growth,

or acanthesis nigricans, which are those dark, velvety, hyperpigmented patches of skin.

Usually found on the back of the neck or

Exactly.

And why do we care about a velvety patch of skin on the neck in this context?

Because acanthesis nigricans is a classic physical marker for severe insulin resistance.

Both that and the excess hair growth point straight to endocrine issues like PCOS.

You also want to scan the skin for pallor, patechia, or ecumosis, which are essentially tiny pinpoint bleeds or larger bruises.

That points back to our suspicion of a systemic bleeding disorder.

Okay, so then we finally get to the pelvic exam.

The text is very clear on the steps here.

It is.

First, you visualize the external genitalia, the vagina, and the cervix.

You are trying to identify the exact source of the blood.

Then you check for cervical motion tenderness.

Right, CMT.

If moving the cervix causes severe pain, that could indicate an active pelvic infection, like pelvic inflammatory disease.

And then comes the bimanual exam, where the provider uses both hands, one internally and one pressing on the abdomen to physically assess the internal organs.

Right.

You are assessing the uterus for its size, shape, and firmness.

You're also checking the adnexa, which is the medical term for the appendages of the uterus, meaning the ovaries and the fallopian tubes.

Making sure there are no painful cysts or masses there.

Exactly.

I like to use an analogy here for the bimanual exam.

If we think about the uterus, we are feeling for its structure, like checking a piece of fruit.

Oh, I like that.

Is it smooth and firm, the way it should be?

Or are there hard, lumpy masses on it, which could be gliomyomas, also known as fibroids?

Or maybe it feels generally enlarged and incredibly boggy, which might suggest a condition like adenomyosis, where the lining grows deep into the muscle wall.

That physical assessment is crucial, because once you've felt the structure of the uterus, and once you have your comprehensive history,

you need a framework to organize all these clues.

And here's where it gets really interesting, because earlier we mentioned the Figo -Palm -Coeing classification system.

We did.

It's not just a random assortment of letters to memorize.

It's actually divided into two very distinct categories,

palm and co -eon.

Right.

I've heard a great analogy for this.

Think of the reproductive system like a house.

Okay, I like where this is going.

So, Palm stands for polyps, adenomyosis, gliomyoma,

and malignancy or hyperplasia.

These are the structural issues.

This is the house's physical architecture.

Right, the tangible stuff.

Exactly.

A hole in the roof, a broken pipe in the wall, a sagging floorboard.

You can physically see these things.

If you do an ultrasound, you can see a polyp.

If you do an exam, you can feel a fibroid.

That's a brilliant way to frame it.

The Palm entities are physical anomalies you can touch or see on imaging, which means the second bucket, co -eon, represents the non -structural problems.

Right.

Co -eon stands for coagulopathy, ovulatory disorders,

endometrial disorders, iatrogenic causes, meaning caused by medical treatment or medications,

and not classified.

The invisible issues.

Yeah.

If Palm is the structure of the house, co -eon is the invisible systems running through it.

The Wi -Fi is down, the thermostat is broken, the electrical grid is failing.

Exactly.

You can't see an ovulatory disorder on a standard ultrasound, just like you can't see a Wi -Fi signal.

These are systemic hematologic or hormonal issues that disrupt the HPO axis, the hypothalamic -pituitary ovarian axis.

And keeping that distinction clear helps you drastically narrow down your diagnosis.

But there's another major factor.

The text provides table 28 .1, which delivers a massive clinical pearl.

Your differential diagnoses completely change depending on the patient's age.

Age dictates which broken system in the house is most likely.

How predictive is age?

Extremely.

In an adolescent, you're primarily thinking about a nobulation because their HPO axis, you know, the communication between the brain and the ovaries is immature.

Like a brand new electrical system that hasn't quite synced up yet.

Perfect analogy, yes.

Or it could be an underlying coagulation disorder rearing its head with their first few periods.

Makes sense.

But in the reproductive years, your first thought always has to include pregnancy -related complications alongside polyps or fibroids.

But there is one crucial rule regarding age that every single student needs to highlight in their textbook.

Yes, there is.

Any bleeding.

Even a single scant drop of spotting in a postmenopausal woman is considered malignant until proven otherwise.

Malignant until proven otherwise.

You do not wait and see with postmenopausal bleeding.

Ever.

Which perfectly sets up our next step.

If the physical exam is normal, so if the walls of the house are structurally sound, what's our next move?

How do we prove what's causing the bleeding?

Well, we have to order diagnostic testing.

Right.

And knowing whether your suspect is a polym structural issue or a coagulant non -structural issue tells you exactly which diagnostic tools to pull out of your bag.

Exactly.

Let's start with the labs, which are primarily going to help us identify those COEI or system level issues.

Okay, what are we ordering?

For serology, a complete blood count or CBC with platelets is your absolute baseline to check for anemia and platelet deficiencies.

But you cannot stop there.

You also need a ferritin level.

Why ferritin specifically?

Why isn't a CBC enough?

Because ferritin measures the body's stored iron.

A patient might have a totally normal hemoglobin on their CBC today, but their ferritin could be in the basement.

Oh, wow.

Yeah, it identifies depleted iron stores in patients who aren't quite anemic yet, but are absolutely on their way.

It gives you a head start.

That's super helpful.

We also order a TSH, thyroid stimulating hormone, because an underactive or overactive thyroid can completely derail the menstrual cycle.

Right.

Plus, we screen for those bleeding disorders with specific coagulation studies if they have a history of heavy bleeding since their very first period, or if they answered yes to those screening questions we talked about earlier.

Like the bleeding gums at the dentist or frequent nosebleeds?

Yes, exactly.

So that covers the invisible systemic co -orient stuff.

Yeah.

But how do we find the palm?

How do we look for the structural issues inside the uterus?

For that, we rely on imaging and biopsy.

Transvaginal ultrasound, or TDUS, is the gold standard here.

It really is.

The probe is inserted vaginally, which gets the ultrasound waves much closer to the uterus than a traditional abdominal scan.

It's fantastic for identifying structural abnormalities like polyps or fibroids, and for measuring the exact thickness of the endometrial lining, which is known as the endometrial stripe.

And there is a very specific, highly testable clinical pearl here regarding that measurement.

An endometrial stripe of 4 millimeters or less correlates with the profoundly low risk of endometrial cancer.

We're talking about 1 in 917.

Wow, that is specific.

Yes.

If the stripe is that thin, an invasive endometrial biopsy might not be needed because the tissue is simply too thin to harbor a significant malignancy.

But we have to be careful, because there are strict clinical rules for when a biopsy is required, regardless of the ultrasound.

All right.

An endometrial biopsy is absolutely required for all post -menopausal women presenting with bleeding.

It is also required for women over the age of 40 with AUB, and for younger women if they have specific risk factors like obesity or chronic inovulation.

And there's a statistical reason for that age cutoff.

The textbook points out that the incidence of endometrial cancer for women age 19 to 34 is quite rare, about 2 .3 out of 100 ,000.

Right.

But once a woman enters the 40 to 49 age bracket, that incidence jumps dramatically to 36 .0 out of 100 ,000.

That's a massive leap.

It is, which is why turning 40 automatically triggers the biopsy protocol if abnormal bleeding is present.

Okay, so we've taken the history, done the exam, and pulled our labs and imaging.

We've caught the culprit.

Now we have to fix the problem.

Clinical management.

What is our ultimate goal here?

The first thing to clarify is that management only begins once you have definitively ruled out pregnancy and malignancy.

Right, that's up one.

Once you know it's neither of those, your goal is straightforward.

Restore normal menstrual cycles, minimize blood loss, and reduce the disruption to the woman's daily life.

And the beauty of the textbook's breakdown, specifically tables 28 .3, 28 .4, and 28 .5, is how clearly it tailors the treatment to the specific cause.

Yeah, those tables are great.

Let's look at heavy menstrual bleeding first.

The hormonal options include combination, oral contraceptive pills, vaginal rings, and the levonar gastral IUD.

And I want to point out the nuance here.

Why might a clinician recommend an IUD over a standard daily pill for heavy bleeding?

It really comes down to the mechanism of action.

An oral contraceptive is systemic.

It enters the bloodstream and enforces a chemical schedule on the whole body, which is great for regulating cycles.

Sure.

But a levonar gestural IUD sits directly inside the uterus.

It secretes progestin locally, right onto the endometrial lining.

This causes that lining to thin out dramatically, which means there's simply less tissue to shed each month.

Oh, that makes perfect sense.

It's incredibly effective for volume reduction.

And the text notes the specific brand ranges.

Marina is 52 milligrams of medication approved for up to eight years, Kailena is 19 .5 milligrams for five years, and Skyla is 13 .5 milligrams for three years.

Good to know those specifics.

But what if the patient doesn't want hormones, or what if they are actively hemorrhaging in front of you?

That's where tranexamic acid is vital.

It's a non -hormonal pill taken only during the days of heavy bleeding.

How does that actually work?

Does it just make the blood thicker?

Not exactly.

It's an anti -fibrinolytic.

Normally, when you bleed, your body forms a clot to stop it.

Then your body sends out enzymes to break that clot down so it doesn't get too big.

Okay, fall by.

Tranexamic acid blocks those clot -busting enzymes.

It preserves the clots the body has naturally formed inside the uterus, drastically slowing the bleeding.

Oh.

However, the text warns that because it affects kidney clearance, you must obtain a baseline creatinine lab level before prescribing it to ensure the patient's kidneys are functioning properly.

That's a really great mechanical explanation.

Moving on to an ovulatory bleeding.

When the ovary isn't releasing an egg, treatments include cyclic oral contraceptives or progestin -only regimens to force a withdrawal bleed.

Right.

But here's a specific callout from the chapter.

If the inobulation is driven by insulin resistance, like in PCOS,

the diabetes medication metformin is specifically indicated to help restore ovulatory function by making the body more sensitive to insulin.

That's a key connection to make.

Finally, for the structural causes, the polym side, like polyps and leiomyomas, we can try to manage the bleeding symptoms with oral contraceptives or the IUD, but ultimately, these are physical structures in the house.

Right.

The broken pipes.

Yes.

If medical management fails, they require physical removal.

That means surgical excision, like a mitomectomy to cut out a fibroid, or endometrial ablation to burn away the lining.

And a hysterectomy, removing the uterus entirely, is always considered the absolute last resort.

Okay.

We've covered a massive amount of ground here.

Let's take all this theory and put it into practice.

Imagine we are on clinical rounds sitting in the break room discussing a real patient.

I love this.

Let's walk through the case study from the chapter.

Okay.

Here is the patient presentation.

A 46 -year -old black cisgender female.

She complains of bleeding every two weeks for the past four to six months.

Okay.

Her flow is very heavy.

She's currently using five to six pads a day, which she notes is up from her usual three pads a day.

She is passing grape -sized blood clots.

That's significant.

She's also experiencing increased pelvic pressure and dysmenorrhea, which is the clinical term for painful menstrual cramping.

Her BMI is 32, and she has a history of hypertension.

Okay.

So let's break this down methodically.

First,

why is this abnormal based on our parameters?

Well, her interval is way too short.

She's bleeding every 14 days, and we know normal is 24 to 35 days.

Exactly.

And her volume is too high.

She's doubled her pad usage to five or six a day, which is our clinical proxy for exceeding that 80 -milliliter mark, and passing grape -sized clots confirms the heavy flow.

Perfect.

So what are the top differentials on our suspect list?

We look at her age.

She's 46, so she's in midlife.

We note her race, the heavy bleeding, and crucially the feeling of pelvic pressure.

Right.

All of this strongly suggests a structural issue, specifically a leomaoma or a uterine fibroid, because she's perimenopausal, we also have to consider an ovulatory cycles as her HPO axis winds down.

And as always, pregnancy must be ruled out.

Following our blueprint, what diagnostics do we order?

First, a urine HCG to rule out pregnancy.

We do a cervical cytology or PAP smear to ensure there are no cervical lesions causing the bleeding.

Spot on.

We pull a CBC in a ferritin level to check her anemia status from all those clots.

We run a TSH for her thyroid, and crucially, we order a pelvic ultrasound to look for that structural abnormality.

Yes.

Let's say the ultrasound comes back and confirms our suspicion.

It reveals a small leomaoma located in the uterine wall.

Her endometrial stripe is thin, and all other labs are normal.

What is the clinical management plan?

The plan targets her specific symptoms.

For the dysmenorrhea and cramping, we prescribe naproxen sodium, an NSEID, instructing her to start taking it two to three days prior to the onset of menses to proactively block the prostaglandins causing the pain.

Good call.

To reduce the heavy bleeding and provide ongoing pregnancy prevention, we recommend the placement of a levendor to gestural IUD.

And we don't just send her on her way.

We schedule a follow -up in two to three months to ensure the bleeding and pain are actually controlled by the IUD.

It's a textbook, evidence -based plan.

You move seamlessly from the subjective history to the palm -kawaiian framework,

use targeted diagnostics, and arrived at a management plan that improves her quality of life.

It really highlights how logical this process is once you have the right framework.

It really does.

But before we wrap up, I want to leave you with one final thought.

We spent this entire time heavily focused on the clinical science, but I want you to think about the social history for a moment.

Think about how heavy bleeding is so often normalized within families.

That is such a profound point.

A patient might sit in your clinic and say, my mother had incredibly heavy periods, and my grandmother had heavy periods, so I just thought passing grape -sized clots and being exhausted all the time was just what happens to women in our family.

Exactly.

That normalization can delay patients from seeking care for years or even decades.

They suffer in silence because they think it's just their biological burden to bear.

It's heartbreaking, really.

But by using this targeted, specific history -taking approach, you as a clinician have the power to break that generational silence.

You can give them the vocabulary to understand that what they're experiencing isn't just bad luck or a family curse.

Right.

It's a medical condition with a name, and much more importantly, with a highly effective treatment.

You aren't just treating a symptom.

You're changing the entire narrative for that patient.

So what does this all mean?

It means mastering abnormal uterine bleeding isn't just about memorizing the Pomco -Wayne acronym or knowing the mechanism of tranexamic acid or remembering that a 4 -millimeter stripe means a low cancer risk.

No, it's bigger than that.

It means taking that messy, murky clinical picture, the one that doesn't show up on a simple x -ray, and using your investigative skills to draft a precise blueprint for healing.

Absolutely.

We want to say a massive thank you to you, the student listener from the Last Minute Lecture team here at the Deep Dive, for joining us today.

You've got this.

Good luck in your clinicals.