Skip to Main Content

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android


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.


Abnormal uterine bleeding (AUB) is a common problem encountered in general practice and refers to any change in the regularity, frequency, heaviness or length of menstruation. Heavy menstrual bleeding (HMB) is the most common presentation of AUB. A careful history is vital, as women who have always experienced heavy bleeding may consider this normal. A classification of abnormal uterine bleeding is presented in TABLE 94.1.

Table 94.1Classification of abnormal uterine bleeding

Key facts and checkpoints

  • Up to 25% of women of reproductive age experience abnormal uterine bleeding (AUB).2

  • At least 4% of consultations in general practice deal with AUB.

  • There is no pathology diagnosed in 50% of women with AUB.

  • 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.3

  • A menstrual record is a useful way to recognise patterns of blood loss.

  • Heavy menstrual bleeding (HMB) accounts for 25–30% of iron-deficiency anaemia.

  • Two common organic causes of HMB are fibroids and adenomyosis (presence of endometrium in the uterine myometrium).4

  • Various drugs can alter menstrual bleeding (e.g. anticoagulants, cannabis, steroids).

  • The possibility of genital tract malignancy should be considered in women who present with intermenstrual bleeding (IMB), postcoital bleeding (PCB) and postmenopausal bleeding.


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).5 Irregular, painful and heavy periods are more common in the first 2–3 years after menarche and during perimenopause due to a higher number of anovulatory cycles.

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 94.2).

Table 94.2Normal menstruation in the reproductive age group

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.