The classification system for abnormal uterine bleeding uses nine basic categories, separated into structural and non structural conditions: (PALM-COEIN) Polyp, Adenomyosis, Leiomyoma, Malignancy–Coagulopathy, Ovulatory disorders, Endometrium, Iatrogenic and Not otherwise specified.
FEDERATION OF GYNAECOLOGY AND OBSTETRICS, 2011
Abnormal uterine bleeding is a common problem encountered in general practice. Heavy menstrual bleeding is the commonest cause of iron-deficiency anaemia in the Western world. A classification of abnormal uterine bleeding is presented in TABLE 102.1.
Table 102.1Classification of abnormal uterine bleeding ||Download (.pdf) Table 102.1 Classification of abnormal uterine bleeding
Irregularity of cycle
Intermenstrual bleeding (metrorrhagia)
Increased amount = menorrhagia/heavy menstrual bleeding
Decreased amount = hypomenorrhoea
Combination (rhythm and amount)
Irregular and heavy periods = metromenorrhagia
Irregular and light periods = oligomenorrhoea
Absence of periods = amenorrhoea
Key facts and checkpoints
Up to 20% of women in the reproductive age group complain of increased menstrual loss.1
At least 4% of consultations in general practice deal with abnormal uterine bleeding.
Up to 50% of patients who present with perceived menorrhagia (or excessive blood loss) have a normal blood loss when investigated.1
The possibility of pregnancy and its complications, such as ectopic pregnancy, miscarriage (threatened, complete or incomplete), hydatidiform mole or choriocarcinoma should be kept in mind.2
A menstrual record is a useful way to calculate blood loss.
The mean blood loss in a menstrual cycle is 30–40 mL.
Blood loss is normally less than 80 mL.
Heavy menstrual bleeding (menorrhagia)—HMB—is a menstrual loss of more than 80 mL per menstruation.
HMB disposes women to iron-deficiency anaemia.
Two common organic causes of HMB are fibroids and adenomyosis (presence of endometrium in the uterine myometrium).3
Various drugs can alter menstrual bleeding (e.g. anticoagulants, cannabis, steroids).
DEFINING WHAT IS NORMAL AND WHAT IS ABNORMAL
This feature is based on a meticulous history, an understanding of the physiology and physiopathology of the menstrual cycle and a clear understanding of what is normal. Most girls reach menarche by the age of 13 (range 10–16 years).1 Dysfunctional bleeding is common in the first 2–3 years after menarche due to many anovulatory cycles resulting in irregular periods, heavy menses and probably dysmenorrhoea.
Once ovulation and regular menstruation are established the cycle usually follows a predictable pattern and any deviation can be considered as abnormal uterine bleeding (see TABLE 102.2). It is abnormal if the cycle is less than 21 days, the duration of loss is more than 7 days, or the volume of loss is such that menstrual pads of adequate absorbency cannot cope with the flow or clots.4
Table 102.2Normal menstruation in the reproductive ...