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# Abnormal uterine bleeding

Abnormal uterine bleeding is bleeding from the uterus that is too heavy, too long, irregular or between periods, outside pregnancy; it has many causes.

Updated 2026-10-29

## Structures involved

Tap one to see what it is and open it in 3D.

- [Endometrium](https://durgical.com/en/anatomy/endometrium/)
- [Body of uterus](https://durgical.com/en/anatomy/body-of-uterus/)
- [Myometrium](https://durgical.com/en/anatomy/myometrium/)
- [Cervix](https://durgical.com/en/anatomy/cervix-of-uterus/)
- [Ovaries](https://durgical.com/en/anatomy/ovary/)
- [Uterine artery](https://durgical.com/en/anatomy/uterine-artery/)
- [Vagina](https://durgical.com/en/anatomy/vagina/)

## In embryology

- [Ovarian cycle, ovulation and the corpus luteum](https://durgical.com/en/embryology/ovarian-cycle-ovulation-and-the-corpus-luteum/)

## In the clinical exam

- [Gynecologic and obstetric history](https://durgical.com/en/clinical-exam/gynecologic-and-obstetric-history/)

## In physiology

- [Primary hemostasis and platelets](https://durgical.com/en/physiology/primary-hemostasis-and-platelets/)
- [Body iron balance](https://durgical.com/en/physiology/body-iron-balance/)
- [The menstrual cycle: ovary and endometrium](https://durgical.com/en/physiology/the-menstrual-cycle-ovary-and-endometrium/)
- [Menopause](https://durgical.com/en/physiology/menopause/)

## Why it happens

- [Actions of estrogen and progesterone](https://durgical.com/en/physiology/actions-of-estrogen-and-progesterone/)
- [Uterus and the endometrial cycle](https://durgical.com/en/histology/uterus-and-the-endometrial-cycle/)

## What it is

Bleeding from the uterus that is abnormal in frequency, regularity, duration or volume, or that occurs between periods, in a woman who is not pregnant. It is a symptom with many causes, sorted with the FIGO PALM-COEIN system.

## Who gets it

One of the most common reasons for gynaecological consultation, from adolescence to perimenopause. Heavy menstrual bleeding is a frequent cause of iron deficiency anaemia in women in Colombia and worldwide.

## Causes

- Structural (PALM): polyp, adenomyosis, leiomyoma (fibroid), malignancy or hyperplasia
- Non-structural (COEIN): coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified
- Ovulatory dysfunction is common at the extremes of reproductive life and in polycystic [ovary](https://durgical.com/en/anatomy/ovary/) syndrome

## Risk factors

- Adolescence and perimenopause (anovulatory cycles)
- Obesity and polycystic ovary syndrome
- Thyroid disease or hyperprolactinaemia
- Anticoagulants or bleeding disorders such as von Willebrand disease
- Hormonal contraception or intrauterine devices

## Pathophysiology

In normal cycles, progesterone withdrawal triggers an orderly shedding of a stable [endometrium](https://durgical.com/en/anatomy/endometrium/). Without ovulation, unopposed estrogen builds a thick, fragile endometrium that sheds irregularly. Structural lesions increase surface area or disturb contraction, and clotting disorders impair haemostasis.

## Classification

- PALM-COEIN (FIGO): PALM structural causes, COEIN non-structural causes
- Acute (heavy enough to need urgent intervention) or chronic (present for most of the past six months)
- Patterns: heavy menstrual bleeding, intermenstrual bleeding, irregular, frequent or infrequent bleeding

## Symptoms and signs

- Heavy or prolonged periods, sometimes with clots or flooding
- Bleeding between periods or after intercourse
- Irregular or unpredictable cycles
- Fatigue, breathlessness or dizziness from anaemia

## Red flags

- Haemodynamic instability or soaking pads very quickly
- Bleeding after menopause
- Positive pregnancy test with bleeding (possible miscarriage or ectopic pregnancy)
- Heavy bleeding since menarche, suggesting a bleeding disorder
- Postcoital bleeding or a visible cervical lesion

## Diagnosis

**Clinical**
Detailed bleeding history, pregnancy and contraceptive status, medications and bleeding symptoms; speculum examination to look for cervical or vaginal causes.

**Tests**
Pregnancy test (hCG); complete blood count and ferritin; TSH and prolactin when indicated; coagulation studies and von Willebrand testing if a bleeding disorder is suspected; cervical screening if due. Endometrial biopsy for women 45 and older or younger women with persistent bleeding or unopposed estrogen.

**Imaging**
Transvaginal ultrasound looks for fibroids, polyps and adenomyosis; saline infusion sonohysterography or hysteroscopy for the uterine cavity; MRI in selected cases.

## Differential diagnosis

- Pregnancy-related bleeding (miscarriage, ectopic pregnancy)
- Cervical lesions or cervicitis
- Vaginal trauma or atrophy
- Bleeding from the urinary tract or [rectum](https://durgical.com/en/anatomy/rectum/)

## Goal of treatment

Stop acute bleeding, find and treat the cause, correct anaemia and reduce future bleeding in line with the woman's fertility wishes.

## Treatment

**Acute**
In acute heavy bleeding: haemodynamic support, intravenous or high-dose hormonal therapy and antifibrinolytics; uterine tamponade or curettage when these fail.

**Medical**
Levonorgestrel intrauterine system, combined hormonal contraceptives or progestins for chronic heavy or anovulatory bleeding.

**Medical**
Antifibrinolytics (tranexamic acid) and non-steroidal anti-inflammatory drugs during menses; iron to correct deficiency.

**Surgical**
Polypectomy, myomectomy, endometrial ablation or hysterectomy according to the cause and fertility wishes.

## Drugs for this condition

- [Tranexamic acid](https://durgical.com/en/pharmacology/tranexamic-acid/)
- [Ethinylestradiol + levonorgestrel](https://durgical.com/en/pharmacology/ethinylestradiol-levonorgestrel/)
- [Goserelin](https://durgical.com/en/pharmacology/goserelin/)

## Complications

- Iron deficiency anaemia
- Hypovolaemic shock in acute heavy bleeding
- Missed endometrial hyperplasia or cancer
- Reduced quality of life and missed school or work

## Prognosis

Most causes can be controlled with medical or minimally invasive treatment. Anovulatory bleeding in adolescence often settles as cycles mature.

## Test yourself

Think of the answer, then tap the question to see it.

## What does the acronym PALM-COEIN stand for?

Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia; Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified.

## Which test is done first in every woman of reproductive age with abnormal bleeding?

A pregnancy test.

## Which bleeding disorder should be considered in an adolescent with heavy periods since menarche?

Von Willebrand disease.

## When is endometrial sampling usually recommended in abnormal uterine bleeding?

From about age 45, or earlier with persistent bleeding, unopposed estrogen exposure, obesity or failed treatment.

## Why does anovulation cause irregular heavy bleeding?

Without progesterone, unopposed estrogen builds a thick, unstable endometrium that sheds irregularly.

[Add to my cards (5)](https://durgical.app/estudiar/?add=/en/conditions/abnormal-uterine-bleeding/)

## Related conditions

- [Uterine fibroids (leiomyomas)](https://durgical.com/en/conditions/uterine-fibroids/)
- [Adenomyosis](https://durgical.com/en/conditions/adenomyosis/)
- [Endometrial cancer](https://durgical.com/en/conditions/endometrial-cancer/)
- [Polycystic ovary syndrome](https://durgical.com/en/conditions/polycystic-ovary-syndrome/)
- [Hypothyroidism](https://durgical.com/en/conditions/hypothyroidism/)
- [Iron deficiency anaemia](https://durgical.com/en/conditions/iron-deficiency-anaemia/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Abnormal Uterine Bleeding](https://www.ncbi.nlm.nih.gov/books/NBK532913/) (StatPearls (NCBI Bookshelf), 2025).

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Source: https://durgical.com/en/conditions/abnormal-uterine-bleeding/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/abnormal-uterine-bleeding/