Abnormal Uterine Bleeding

ED Priorities

Overview

        In the ED, AUB is an emergency only if: bleeding is heavy/ongoing, there is
        haemodynamic compromise, pregnancy is possible, or the patient is peri- or post-menopausal.
      

Acute AUB: heavy bleeding requiring urgent intervention to prevent blood loss-related morbidity.
Chronic AUB: abnormal bleeding for >3 months, usually stable and suitable for outpatient management.
Use AUB as a symptom and the PALM-COEIN system to guide your differential diagnosis.

ED Algorithm (Quick Guide)

Flow

Assess ABC, vitals, and visible blood loss. Establish IV access and monitor if bleeding is heavy.
Exclude pregnancy in all reproductive-age patients (urine or serum β-hCG).
Identify red flags: syncope, chest pain, tachycardia, hypotension, Hb very low, post-menopausal bleeding.
Take focused history (cycle, pattern, contraception, medications, coagulopathy, systemic disease).
Perform focused examination: general, abdomen, speculum + bimanual if appropriate and safe.
Order targeted tests (FBC, pregnancy test, coagulation screen, TSH, TVUS if available).
Stabilise and treat:
- Unstable/severe: resuscitate, IV TXA, consider hormonal therapy, urgent gynae consult.
- Stable: start medical therapy (e.g. NSAIDs, TXA, hormonal options), arrange follow-up.
Decide disposition: home with follow-up vs admission/urgent gynae referral.

PALM-COEIN Classification

Etiology

PALM = structural causes. COEIN = non-structural causes. Use this framework to structure your assessment and documentation.

Letter	Group	Example / Notes
P	Polyp	Endometrial or endocervical polyps.
A	Adenomyosis	Globular, tender uterus; dysmenorrhoea, heavy bleeding.
L	Leiomyoma	Fibroids (submucosal, intramural, subserosal).
M	Malignancy / Hyperplasia	Endometrial carcinoma, atypical hyperplasia (especially >40 years or post-menopausal).
C	Coagulopathy	e.g. von Willebrand disease, anticoagulants, thrombocytopenia.
O	Ovulatory dysfunction	Anovulation (PCOS, obesity, thyroid disease, hyperprolactinaemia).
E	Endometrial	Local endometrial dysfunction; infection, chronic endometritis.
I	Iatrogenic	Hormonal contraception, IUCD, anticoagulants, other drugs.
N	Not yet classified	Causes currently unclassified or rare mixing of categories.

Tip: in your note, explicitly state the suspected PALM-COEIN category. This helps gynae and future follow-up.

Assessment in the ED

History & Exam

Focused History

Age, parity, last menstrual period, usual cycle pattern.
Bleeding pattern: onset, duration, clots, flooding, nocturnal changes.
Contraception and sexual history (including STI risk).
Medications: anticoagulants, hormonal therapy, emergency contraception.
History of coagulopathy, liver disease, thyroid disease, PCOS, obesity.
Red-flag symptoms: weight loss, inter-menstrual/post-coital/post-menopausal bleeding, pelvic pain.

Physical Examination

General: pallor, tachycardia, postural hypotension, signs of shock.
Abdomen: uterine size, adnexal masses, tenderness, peritonism.
Thyroid and BMI if relevant to endocrine causes.
Speculum (if appropriate): cervical lesions, polyps, active bleeding source, trauma, discharge.
Bimanual: uterine size/shape, fibroids, adnexal masses, cervical motion tenderness.
Look for bruising, petechiae if coagulopathy suspected.

Investigations

Essentials

β-hCG (urine or serum) in all reproductive-age patients unless clearly not needed.
Full blood count (Hb, platelets) in any moderate–severe bleeding, anaemia symptoms, or chronic AUB.
Coagulation profile if on anticoagulants or bleeding disorder suspected.
TSH, prolactin, +/- glucose/lipids if endocrine/anovulatory cause suspected.
STI swabs if discharge, pelvic pain or risk factors present.
Transvaginal or pelvic ultrasound (if available) for structural causes, endometrial thickness, adnexal masses.
Endometrial sampling is usually outpatient/gynae-led, but consider urgent referral if:
- Age ≥ 40 with persistent AUB or risk factors (obesity, anovulation, tamoxifen).
- Any post-menopausal bleeding.

Management in the ED

Treatment

        Step 1 – Stabilise: ABC, large-bore IV lines, fluids, cross-match if indicated, monitor vitals,
        give oxygen if needed.
      

1. Haemodynamically Unstable / Severe Acute AUB

Resuscitate with IV crystalloids; arrange blood and products if significant loss or anaemia.
Administer tranexamic acid (e.g. 1 g IV) unless contraindicated, as per local protocol.
Consider high-dose hormonal therapy (e.g. IV or high-dose oral estrogen / progestin) according to local guidelines and gynae advice.
If available and trained, mechanical methods (e.g. intra-uterine balloon tamponade) can be life-saving.
Urgent gynae consultation – patient usually requires admission and definitive management.

2. Haemodynamically Stable, Heavy but Controlled Bleeding

Analgesia: avoid NSAIDs if platelet dysfunction/anticoagulants; otherwise NSAIDs reduce bleeding and pain.
Tranexamic acid orally for 3–5 days during heavy bleeding episodes (if no contraindication).
Consider hormonal therapy if no contraindications:
- Combined oral contraceptive pill regimen.
- High-dose oral progestin in anovulatory bleeding.
Optimise comorbidities (thyroid, diabetes, blood pressure).
Iron replacement if anaemic.

3. Chronic / Mild AUB

Ensure no red flags or structural malignancy risk features.
Start non-hormonal and/or hormonal therapy as appropriate and safe.
Arrange outpatient gynae or primary care follow-up for definitive diagnosis and longer-term management (e.g. Mirena IUD, endometrial ablation, surgery).

Special Groups & Disposition

Safety

Adolescents

AUB often due to anovulatory cycles or underlying coagulopathy.
Always exclude pregnancy and sexual assault where appropriate.
Low threshold to screen for bleeding disorders and refer to gynae/haematology if recurrent or severe.

Perimenopausal & Post-menopausal

Any post-menopausal bleeding is endometrial cancer until proven otherwise.
All such patients need urgent gynae follow-up and endometrial assessment, often admission if unstable or high-risk.

Disposition – When to Admit

Haemodynamic instability or need for transfusion.
Ongoing heavy bleeding despite ED measures.
Suspected malignancy with significant bleeding or severe anaemia.
No safe home environment or follow-up not reliable.

Stable, controlled bleeding → Home with follow-up Unstable / transfusion / malignancy risk → Admit Post-menopausal bleeding → Urgent gynae pathway

Patient Counselling

Communication

Explain possible causes using simple language and emphasise that cancer is not the most common cause, but must be excluded in some groups.
Discuss the medication plan: how to take it, duration, common side-effects, and when it is unsafe to miss doses.
Safety-net advice:
- Return immediately if soaking >1 pad per hour, large clots, dizziness, chest pain, or shortness of breath.
- Stress the importance of attending follow-up and any scheduled gynae appointment.

Teamwork: document clearly, communicate with gynae early for complex or high-risk cases, and ensure the patient knows what the next step in their care will be.