• Nathan Riley, MD

Obgyno Wino Podcast Episode 4 - Management of Acute AUB in Nonpregnant Reproductive-Aged Women

“Someday, somewhere - anywhere, unfailingly, you'll find yourself, and that, and only that, can be the happiest or bitterest hour of your life.” ― Pablo Neruda

2014 Pinot Noir from MacMurray Estate Vineyards (2015 vintage pictured)

CO#557 - Published April 2013

Defining AUB

- acute versus chronic (chronic defined as at least 6 months of disordered bleeding)

- Heavy menstrual bleeding versus intermenstrual bleeding


- when patient presents with severe vaginal bleeding, find the source and determine the severity

- gather detailed medical, surgical, obstetrical, and gynecological histories

- gynecologic history should include length of cycles, duration of bleeding, volume of bleeding, and time frame of any changes to menstrual bleeding patterns

- ask about postpartum bleeding, intraoperative bleeding complications, and bleeding during dental procedures to assess for coagulopathy (13% of patients with heavy menstrual bleeding have some variant of vWD; 20% have an underlying coagulopathy)

- patients to refer to hem/onc for coagulopathy workup:

>patients with HMB since menarche

>postpartum hemorrhage OR surgery-related bleeding OR bleeding associated w/ dental work

>two or more of: bruising 1-2x/month, epistaxis 1-2x/month, frequent gum bleeding, or family history of bleeding symptoms

Physical exam

- start with a physical exam including a bimanual and speculum exam → where is the bleeding coming from?

- vital signs and ROS to determine hemodynamic stability

- labs: hemoglobin and hematocrit in the very least (and pregnancy test!)

- you may also consider clotting studies (INR, PTT, and fibrinogen) depending on severity of bleeding

- down the road, assessment for vWD might include: vW factor antigen, ristocetin cofactor assay, factor VIII level

- likewise: TSH, serum iron, TIBC, and ferritin; LFTs, and Chlamydia trachomatis testing may be helpful

- imaging: not generally useful in the acute setting, but depending on the patient may be helpful

- in the long run, TVUS and MRI/CT may be helpful; for example, MRI to evaluate junctional zone if adenomyosis suspected

Stabilize the patient

- one you’ve determine that the source of the bleeding is uterine, first stabilize the patient

- ensure that they have at least 1 but ideally 2 functioning, large bore IVs in place

- order blood products

- IV resuscitation in the meantime

Determine etiology


- Examples of COEIN

>AUB-C: vWD, hemophilia, platelet dysfunction disorders

>AUB-O: hyperprolactinemia (often presents as amenorrhea), hypothyroidism (heavy, unpredictable bleeding)

>AUB-E: characterized conditions such as increased levels of tissue plasminogen factor

>AUB-I: anticoagulation, IUD (paragard → heavy menstrual bleeding; LNG-IUS → intermenstrual


>AUB-N: AVM, infection

You can find the original article through Google scholar: FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age

Management (COCs and progestins)

- Surgical versus medical

- 1st line medical is hormone therapy in absence of known bleeding disorders

- IV estrogen, COCs, or oral progestins

- IV estrogen is only FDA approved medical management modality

- One RCT showed that IV estrogen resulted in cessation of bleeding in 72% of participants within 8 hrs compared with 38% of participants treated with a placebo

- COCs and progestins also very helpful, though

- One study compared COCs TID for 7 days with oral medroxyprogesterone acetate (Provera) TID for 7 days and found that bleeding stopped in 88% of women who were given the former and 76% of women who were given the latter

Management (TXA) and intrauterine foley

- tranexamic acid has been shown to be effective for chronic AUB (i.e. heavy periods) (55% reduction in bleeding)

- also reduces the need for transfusion when administered prior to major surgery

- likely effective in managing acute AUB, just hasn’t been studied

- could also consider foley bulb to tamponade the bleeding alone or in combination with any of the medical options

- if vWD, desmopressin can be helpful as well as recombinant factor VII and vW factor


- D&C is the standard surgical procedure

- send specimen to path to evaluate for polyps, endometrial hyperplasia or malignancy, or retained POCs

- you can also consider ablation, hysteroscopic polypectomy, myomectomy, or hysterectomy in specific cases

- before ablation, ensure that patient has completed childbearing and that you have ruled out malignancy

What can we do long-term?

- Mirena, COCs, progestins, TXA are all good options

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