By Melissa Crisci
Editor’s Note: The American College of Obstetricians and Gynecologists (ACOG) published its Committee Opinion No. 557 in 2013 to address the management of acute abnormal uterine bleeding in nonpregnant women of reproductive age. [1] Medical student Melissa Crisci was on the FACTS elective when she summarized the committee’s recommendations. The 2013 Committee Opinion was reaffirmed by ACOG in 2019 and remains current to this day.
Introduction
The American College of Obstetricians and Gynecologists (ACOG) Committee Opinion No. 557 defines abnormal uterine bleeding (AUB) as bleeding from the uterus that is unusual in regularity, volume, frequency, and/or duration in the absence of pregnancy. [1] AUB can be acute or chronic. Acute AUB is a sudden and excessive episode of uterine bleeding in a nonpregnant woman of reproductive age that requires immediate medical treatment to prevent blood loss. In contrast, chronic AUB is uterine bleeding in a nonpregnant woman occurring most of the time for at least six months. Although episodes of acute AUB most often occur in women with chronic AUB, the acute bleeding episodes require medical evaluation and treatment to address potential causes, including coagulopathy, endocrine dysfunction, or structural uterine pathology.
“Abnormal uterine bleeding (AUB) is bleeding from the uterus that is unusual in regularity, volume, frequency, and/or duration in the absence of pregnancy.”
The ACOG Committee Opinion No. 557 article [1] summarized below outlines the systematic three-step approach to acute AUB: patient assessment, diagnosis, and appropriate treatment.
Three-step Approach
I. Patient assessment
First, ACOG recommends completing an initial patient assessment to determine if the patient shows signs of hypovolemia or hemodynamic instability, such as tachycardia, orthostasis, or hypotension. This step allows for prompt treatment, if necessary, including intravenous access, administering fluids or blood products, and surgical management. Once the patient is determined to be hemodynamically stable, the physician should investigate the potential underlying etiologies of the uterine bleeding.
II. Diagnosis
When determining possible causes of AUB, ACOG recommends utilizing the International Federation of Gynecology and Obstetrics classification system, which distinguishes between structural and nonstructural uterine abnormalities that may cause AUB. These etiologies are classified by the acronym PALM-COEIN: Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, and Not otherwise classified. [2] ACOG stresses the importance of a comprehensive patient evaluation, including a detailed history, a thorough physical examination including a pelvic exam, and relevant laboratory studies. ACOG recommends screening for underlying disorders of hemostasis through a structured medical history. As indicated, physicians should test for coagulation disorders, particularly von Willebrand disease, in patients with a personal or family history of heavy bleeding episodes or bleeding disorders. Endometrial sampling should be obtained for women over the age of 45 as a first-line test; it should also be obtained for women younger than 45 with a history of unopposed estrogen exposure, persistent uterine bleeding, or previously failed medical management.
“ACOG stresses the importance of a comprehensive patient evaluation, including a detailed history, a thorough physical examination including a pelvic exam, and relevant laboratory studies.”
III. Treatment
The third step involves treatment of the acute bleeding episode and long-term maintenance to prevent recurrence. ACOG recommends medical management as the first-line therapy for hemodynamically stable patients. Medical therapies such as high dose combined oral contraceptives, oral progestins, or antifibrinolytic agents such as tranexamic acid may be administered to stop uterine bleeding. Additionally, intravenous conjugated equine estrogen has been shown to rapidly stop uterine bleeding. For refractory bleeding, intrauterine tamponade with a Foley catheter balloon may be considered.
If attempts at medical management fail or contraindications preclude it, surgical intervention may be necessary. Surgical management for AUB includes dilation and curettage (D&C), polypectomy, myomectomy, uterine artery embolization, endometrial ablation, or hysterectomy. [1] The type of surgical procedure chosen depends on the etiology of AUB, the patient’s hemodynamic status, and future fertility goals. Following stabilization with initial medical or surgical management, patients should transition to maintenance therapy, such as hormonal contraception, cyclic or continuous progestins, hormonal intrauterine device, NSAIDs, or continued use of antifibrinolytics if needed.
Discussion
When reviewing the ACOG Committee Opinion on acute AUB management through the lens of fertility awareness-based methods (FABMs), the article [1] provides useful insight into how medical professionals can treat acute AUB while preserving fertility. Women who track their cycles with FABMs can more readily detect deviations from their normal menstrual bleeding patterns, such as intermenstrual spotting or unusually heavy bleeding. When considering the PALM-COEIN acronym, ovulatory dysfunction can manifest as irregular or prolonged menstrual cycles — both easy to recognize when charting with FABMs. By being intimately aware of their cycles through practicing FABMs, women can quickly recognize AUB and seek medical evaluation before an acute bleeding episode occurs.
Additionally, cycle tracking data can supplement medical evaluation by providing longitudinal information that reflects a woman’s hormonal patterns and ovulatory function. Although FABMs do not directly treat acute AUB, the emphasis on female cycle literacy empowers a woman to know her body enough to confidently recognize abnormal uterine bleeding patterns that might otherwise be dismissed or seen as normal.
“Cycle tracking data can supplement medical evaluation by providing longitudinal information that reflects a woman’s hormonal patterns and ovulatory function.”
The ACOG Committee Opinion also discusses the importance of aligning the management of AUB with patients’ fertility goals, as AUB treatment can either preserve fertility, impair fertility, or lead to permanent infertility. Surgical procedures such as myomectomy or polypectomy can treat structural causes of AUB while maintaining the integrity of the uterus and allowing for future fertility. In contrast, endometrial ablation strips the inner lining of the uterus, causing an unfavorable environment for a future pregnancy. When counseling patients, physicians can integrate this perspective of fertility-preserving vs. fertility-ending approaches to treatment to provide informed consent by presenting all management options and their long-term implications on fertility.
In summary, the article discusses the management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women through a systematic approach consisting of three important steps: stabilization, diagnosis, and treatment. ACOG’s Committee Opinion recommendations reinforce the importance of incorporating patients’ values and reproductive goals when considering medical management for AUB, advice which aligns with the use of FABMs. By practicing evidence-based, patient-centered medicine, physicians can simultaneously understand and effectively treat AUB while encouraging women to learn about their cycles and supporting their individual reproductive goals.
References
[1] Committee Opinion No. 557: Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women. Obstetrics & Gynecology 121(4):p 891-896, April 2013. | DOI: 10.1097/01.AOG.0000428646.67925.9a
[2] Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. FIGO Working Group on Menstrual Disorders. Int J Gynaecol Obstet 2011;113:3–13.
ABOUT THE AUTHOR
Melissa Crisci
Melissa Crisci is a fourth-year medical student at Rowan-Virtua School of Osteopathic Medicine in Stratford, New Jersey. She completed her undergraduate education at Saint Joseph’s University in Philadelphia, PA. She plans to pursue residency in obstetrics and gynecology and is interested in providing women’s health for underserved communities. She enrolled in the FACTS elective to deepen her understanding of fertility awareness–based methods and explore how cycle tracking can enhance patient education, promote reproductive autonomy, and strengthen the patient–physician relationship.
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