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gyn.abnormal-uterine-bleeding.core.v1PRODUCTION
gyn.abnormal-uterine-bleeding.core.v1

Abnormal uterine bleeding (reproductive age — FIGO PALM-COEIN)

obstetricssubacutechronicadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

AUB is a SYMPTOM in a NONGRAVID reproductive-age woman — exclude pregnancy first; PALM-COEIN is additive (causes coexist). FIGO System 1 (pattern) is the gateway to System 2 (cause) (Munro PMID 21345435; 30198563)

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scope confirmed: nongravid reproductive-age woman with abnormal bleeding pattern

Patient inputs (18)

Age sets the endometrial-malignancy pre-test prior and biopsy threshold (≥ 45 y sample all); also shifts bleeding-disorder prior (39 % adolescents vs 16 % adults, Comishen PMID 39617186)

HMB since menarche, family bleeding history, or surgical/dental/postpartum bleeding triggers a von Willebrand / coagulopathy screen (AUB-C; ACOG; Borzutzky PMID 31886837)

Regular cyclic vs irregular/anovulatory bleeding distinguishes AUB-O; anovulation links to PCOS and unopposed-oestrogen endometrial risk (Comishen PMID 39617186)

Obesity, PCOS, anovulation, tamoxifen, Lynch syndrome lower the endometrial-biopsy age threshold below 45 y (ACOG endometrial-assessment doctrine; Mayo PMID 30711128)

Iatrogenic AUB (AUB-I); anticoagulant-associated bleeding changes the therapeutic ladder and requires haematology coordination (Munro PMID 21345435)

Migraine-with-aura, VTE history, thrombophilia, breast cancer, cirrhosis, SLE-aPL gate combined hormonal therapy via US-MEC 2024 (Nguyen PMID 39106314)

Fertility desire excludes ablation/hysterectomy and favours TXA/LNG-IUS/myomectomy (SOGC leiomyoma PMID 25767949)

Frequency / duration / regularity / volume — FIGO System 1 is the gateway to System 2 cause classification (Munro 2018 PMID 30198563)

PALM-COEIN is defined only for NONGRAVID reproductive-age women — pregnancy-related bleeding must be excluded before the AUB pathway applies (Munro PMID 21345435)

Quantifies anaemia severity and iron stores; HMB is the chief IDA driver and anaemia must be corrected before elective surgery (Jain PMID 37538019; SOGC PMID 25767949)

First-line imaging — distinguishes PALM (structural: polyp/adenomyosis/leiomyoma) from COEIN; endometrial thickness interpreted conditionally on menopausal status + hormone exposure (Weaver PMID 15845930; SOGC PMID 37244746)

Hypotension / orthostasis in acute heavy AUB → ED haemorrhage path + IV haemostatic therapy (ACOG CO 557 PMID 23635706)

Tachycardia is an early haemodynamic-instability marker in acute heavy AUB (ACOG CO 557 PMID 23635706)

PT/aPTT + vWF:Ag / vWF:RCo / factor VIII + platelet studies when AUB-C screen positive — vWD ~8 % overall, ~39 % bleeding-disorder prior in adolescents (Comishen PMID 39617186; Borzutzky PMID 31886837)

SIS / hysteroscopy localises focal intracavitary lesions (polyp, submucosal leiomyoma) when TVUS suggests focal pathology (SOGC leiomyoma PMID 25767949)

Histology for hyperplasia/malignancy — all ≥ 45 y, and < 45 y with unopposed-oestrogen/obesity/PCOS/Lynch/tamoxifen/persistent or failed-Rx; biopsy yield is conditionally dependent on the age/risk prior (ACOG; Mayo PMID 30711128)

Hormonal contraception/IUD breakthrough bleeding is a common iatrogenic cause (AUB-I) and modifies treatment selection (Munro 2018 PMID 30198563)

Thyroid dysfunction (~3 % prior) is a reversible non-structural contributor / AUB-O modifier (Comishen PMID 39617186)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningacute_heavy_aub_haemodynamic_instability
    Acute heavy uterine bleeding with orthostasis / SBP < 90 / HR > 110 / falling Hb (ACOG CO 557 PMID 23635706)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_related_bleeding_excluded_pathway
    Positive β-hCG with uterine bleeding — AUB/PALM-COEIN does NOT apply; route to pregnancy-bleeding pathway (Munro PMID 21345435)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereperimenopausal_or_age_malignancy_threshold
    AUB at age ≥ 45 y, OR < 45 y with unopposed-oestrogen / obesity / PCOS / Lynch / tamoxifen / persistent or failed medical Rx — biopsy yield conditionally dependent on the age/unopposed-oestrogen prior (ACOG endometrial-assessment; Mayo PMID 30711128; Long PMID 32008795)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepostmenopausal_bleeding_cannot_miss
    Any postmenopausal-pattern uterine bleeding — endometrial-cancer prior 7.7 %; mean endometrial thickness 16.4 mm (cancer) vs 4.1 mm (no cancer); 5-mm-cut-off LR+ is conditional on HRT (12 off-HRT vs 4.2 on-HRT) (Long PMID 32008795; Smith-Bindman PMID 9809732)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereadolescent_or_menarcheal_coagulopathy
    HMB since menarche, family bleeding history, or surgical/dental/postpartum bleeding — structured-screen sens 82 % (→ 95 % with PBAC>100); bleeding-disorder prior 39 % in adolescents vs 16 % adults; vWF-assay post-test conditional on this screen + age prior (Philipp PMID 18226613; Borzutzky PMID 31886837; Comishen PMID 39617186)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereimb_postcoital_with_infection_signs_pid_mimic
    Intermenstrual/post-coital bleeding WITH pelvic pain, discharge, or cervical-motion tenderness — PID/cervicitis look-alike that is time-critical (FIGO System 1 post-coital descriptor; Munro PMID 21345435)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateanticoagulated_iatrogenic_aub
    AUB on anticoagulant/antiplatelet therapy (iatrogenic AUB-I) — bleeding LR/utility of hormonal options is conditioned on the US-MEC anticoagulation state (Munro PMID 21345435; Nguyen PMID 39106314)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateus_mec_restricted_hormonal_eligibility
    Migraine-with-aura, VTE history without anticoagulation, known thrombophilia, active breast cancer, cirrhosis, or SLE-aPL — the SAME hormonal option flips US-MEC Category 1→4 by comorbidity vector (conditional dependency; Nguyen MMWR PMID 39106314)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesevere_iron_deficiency_anaemia
    Symptomatic anaemia from chronic HMB (fatigue/dyspnoea/tachycardia) or Hb requiring transfusion / pre-operative correction (Jain PMID 37538019; SOGC PMID 25767949)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateanovulatory_aub_o_endocrine_route
    Irregular/infrequent bleeding after long amenorrhoea with hyperandrogenism/metabolic features OR abnormal TSH — AUB-O; PCOS prior 8 %, thyroid prior 3 % (Comishen PMID 39617186)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Acute heavy AUB — haemostatic control (ACOG CO 557 PMID 23635706)
axis: aub_acute_haemostasis
Selected axis "Acute heavy AUB — haemostatic control (ACOG CO 557 PMID 23635706)" by default fallback (first axis)
  • conjugated equine estrogen (IV)
    first line
    estrogen
    25 mg IV q4–6h up to 24 h • IV • q4–6h
    triggers: acute_heavy_aub, haemodynamically_borderline, no_us_mec_category4_estrogen_contraindication
    ACOG CO 557 first-line medical haemostasis for acute heavy AUB when estrogen not contraindicated; transition to oral maintenance after control (PMID 23635706). rxcui omitted — no clean in-repo precedent (contested code 6373 not reused)
    rxcui 4099
  • high-dose monophasic combined oral contraceptive
    first line
    combined_oral_contraceptive
    monophasic 30–35 mcg ethinyl estradiol pill TID ×7 d then taper • PO • TID then taper
    triggers: acute_heavy_aub_stable, us_mec_category_1_or_2_for_chc
    ACOG CO 557 multi-dose COC regimen for stable acute AUB; US-MEC must permit combined hormonal contraception (PMID 23635706; Nguyen PMID 39106314). rxcui omitted (no in-repo precedent)
  • medroxyprogesterone acetate (high-dose oral)
    first line
    progestin
    20 mg PO TID ×7 d then taper • PO • TID then taper
    triggers: acute_heavy_aub_stable, estrogen_contraindicated_us_mec
    ACOG CO 557 oral progestin haemostasis when estrogen contraindicated (PMID 23635706). rxcui omitted (no in-repo precedent)
    rxcui 6691
  • tranexamic acid
    first line
    antifibrinolytic
    1 g IV (or 1.3 g PO TID) • IV/PO • q8h
    triggers: acute_heavy_aub, hormones_contraindicated_or_adjunct, no_active_thromboembolism
    ACOG CO 557 acute-AUB antifibrinolytic; reduces MBL 34–59 % (PMID 23635706; 21767224). In-repo validated rxcui 37798 (same ingredient PO/IV)
    rxcui 10691
  • dilation & curettage / hysteroscopy / intrauterine tamponade
    rescue
    surgical_haemostasis
    procedural
    triggers: haemodynamic_instability, failed_medical_haemostasis, unfit_for_medical_therapy
    ACOG CO 557 — surgical management for unstable patients or medical failure; choice by underlying pathology and fertility desire (PMID 23635706)

outpatient playbook — drug actions (5)

  1. 1. LNG-IUS 52 mg
    52 mg intrauterine • intrauterine • every 5–8 years
    trigger: Chronic HMB, no untreated focal structural lesion, US-MEC permits
    First-line — ECLIPSE MMAS MD 13.4 over 2 y; superior to COC and TXA (PMID 26507206/30742315/29656433)
  2. 2. combined oral contraceptive
    30–35 mcg EE monophasic daily • PO • daily
    trigger: LNG-IUS declined; US-MEC Category 1–2; contraception also desired
    Response 12→77 % vs 3 % placebo (PMID 30742315); US-MEC-gated (PMID 39106314)
  3. 3. tranexamic acid
    1.3 g PO TID • PO • TID ×≤5 d/cycle during menses
    trigger: Fertility desired or hormones contraindicated; no thromboembolism
    MBL −53 mL/cycle, 34–59 % (PMID 29656433/21767224); non-hormonal
  4. 4. long-cycle oral progestin
    MPA 10 mg daily ×21 d/cycle OR norethindrone 5 mg BID days 5–26 • PO • cyclic long-course
    trigger: Anovulatory AUB-O / estrogen contraindicated
    Endometrial protection + bleeding control (PMID 23595582)
  5. 5. ferrous sulfate
    325 mg every other day • PO • alternate days
    trigger: Iron-deficiency anaemia (parallel to all steps)
    Alternate-day improves absorption; HMB chief IDA driver (Jain PMID 37538019)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Heavy menstrual bleeding (HMB) — flooding/clots/double protection, interferes with QoL (FIGO System 1; Jain PMID 37538019); Intermenstrual / irregular / infrequent bleeding (FIGO System 1 pattern descriptors; Munro 2018 PMID 30198563); Acute heavy uterine bleeding episode (ACOG CO 557 PMID 23635706).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Abnormal uterine bleeding (reproductive age — FIGO PALM-COEIN)** (gyn.abnormal-uterine-bleeding.core.v1).
Phenotype framing: Assign PALM-COEIN class(es): structural PALM (Polyp / Adenomyosis / Leiomyoma FIGO 0–8 / Malignancy-hyperplasia) vs non-structural COEIN (Coagulopathy / Ovulatory dysfunction / Endometrial / Iatrogenic / Not classified). MECE pivot = TVUS/SIS (structural?) → biopsy (malignant?) → coagulation (bleeding disorder?) → cycle history (ovulatory?). Causes coexist — classify additively (Munro PMID 21345435)
Scope: AUB is a SYMPTOM in a NONGRAVID reproductive-age woman — exclude pregnancy first; PALM-COEIN is additive (causes coexist). FIGO System 1 (pattern) is the gateway to System 2 (cause) (Munro PMID 21345435; 30198563)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute heavy AUB — haemostatic control (ACOG CO 557 PMID 23635706)**.
1. conjugated equine estrogen (IV) 25 mg IV q4–6h up to 24 h IV q4–6h (estrogen, first line) — ACOG CO 557 first-line medical haemostasis for acute heavy AUB when estrogen not contraindicated; transition to oral maintenance after control (PMID 23635706). rxcui omitted — no clean in-repo precedent (contested code 6373 not reused)
2. high-dose monophasic combined oral contraceptive monophasic 30–35 mcg ethinyl estradiol pill TID ×7 d then taper PO TID then taper (combined_oral_contraceptive, first line) — ACOG CO 557 multi-dose COC regimen for stable acute AUB; US-MEC must permit combined hormonal contraception (PMID 23635706; Nguyen PMID 39106314). rxcui omitted (no in-repo precedent)
3. medroxyprogesterone acetate (high-dose oral) 20 mg PO TID ×7 d then taper PO TID then taper (progestin, first line) — ACOG CO 557 oral progestin haemostasis when estrogen contraindicated (PMID 23635706). rxcui omitted (no in-repo precedent)
4. tranexamic acid 1 g IV (or 1.3 g PO TID) IV/PO q8h (antifibrinolytic, first line) — ACOG CO 557 acute-AUB antifibrinolytic; reduces MBL 34–59 % (PMID 23635706; 21767224). In-repo validated rxcui 37798 (same ingredient PO/IV)
5. dilation & curettage / hysteroscopy / intrauterine tamponade procedural (surgical_haemostasis, rescue) — ACOG CO 557 — surgical management for unstable patients or medical failure; choice by underlying pathology and fertility desire (PMID 23635706)

Setting playbook (outpatient) — Exclude pregnancy, classify by FIGO PALM-COEIN, assess endometrial-malignancy risk by age, treat-to-target (acceptable bleeding + corrected anaemia) with LNG-IUS-first medical therapy or structural-directed procedures (Munro PMID 21345435; ECLIPSE PMID 26507206)
6. LNG-IUS 52 mg 52 mg intrauterine intrauterine every 5–8 years — Chronic HMB, no untreated focal structural lesion, US-MEC permits (First-line — ECLIPSE MMAS MD 13.4 over 2 y; superior to COC and TXA (PMID 26507206/30742315/29656433))
7. combined oral contraceptive 30–35 mcg EE monophasic daily PO daily — LNG-IUS declined; US-MEC Category 1–2; contraception also desired (Response 12→77 % vs 3 % placebo (PMID 30742315); US-MEC-gated (PMID 39106314))
8. tranexamic acid 1.3 g PO TID PO TID ×≤5 d/cycle during menses — Fertility desired or hormones contraindicated; no thromboembolism (MBL −53 mL/cycle, 34–59 % (PMID 29656433/21767224); non-hormonal)
9. long-cycle oral progestin MPA 10 mg daily ×21 d/cycle OR norethindrone 5 mg BID days 5–26 PO cyclic long-course — Anovulatory AUB-O / estrogen contraindicated (Endometrial protection + bleeding control (PMID 23595582))
10. ferrous sulfate 325 mg every other day PO alternate days — Iron-deficiency anaemia (parallel to all steps) (Alternate-day improves absorption; HMB chief IDA driver (Jain PMID 37538019))

Non-pharmacologic actions:
- Transvaginal ultrasound as first-line imaging (Weaver PMID 15845930)
- Saline-infusion sonography / hysteroscopy for focal lesion (SOGC PMID 25767949)
- Endometrial biopsy if ≥ 45 y or < 45 y with risk factors / failed Rx (Mayo PMID 30711128)
- Hysteroscopic polypectomy/myomectomy for focal intracavitary lesion (SOGC PMID 25767949)
- Refer gynaecologic oncology if endometrial hyperplasia with atypia / malignancy
- Haematology referral for confirmed bleeding disorder (Borzutzky PMID 31886837)
- Shared decision-making — values/fertility-sensitive (Dutton PMID 36997220)

AVOID / contraindication checks:
- Estrogen block if us mec category 4 (VTE history/thrombophilia/migraine with aura/active breast cancer) (Nguyen PMID 39106314)
- Tranexamic acid avoid active thromboembolism or concurrent prothrombotic state (ACOG CO 557 PMID 23635706)
- Exclude pregnancy with beta hcg before any aub therapy (Munro PMID 21345435)

Monitoring

Regimen monitoring:
- haemodynamics and Hb serial during acute episode (ACOG CO 557 PMID 23635706)
- transition to long term maintenance after bleeding controlled (ACOG CO 557 PMID 23635706)

Setting (outpatient) monitoring:
- Bleeding diary / PBAC + Hb/ferritin to treat-to-target (ECLIPSE PMID 26507206)
- LNG-IUS position + unscheduled bleeding at 3–6 months (PMID 26507206)
- Endometrial surveillance on progestin for hyperplasia (Mayo PMID 30711128)
- Interval imaging for structural leiomyoma/adenomyosis (SOGC PMID 25767949)

Follow-up plan: Treat-to-target sustained — revisit reproductive plan, contraception, and definitive options as fertility intent changes. Continued endometrial-malignancy surveillance for persistent AUB despite therapy (re-biopsy / hysteroscopy). Cross-refer: gyn.dysmenorrhea.core.v1 (overlap adenomyosis/endometriosis pain), endo.pcos.core.v1 (AUB-O cause), gynaecologic oncology if AUB-M. Counsel on long-term anaemia prevention (Jain PMID 37538019; Dutton PMID 36997220)
- Close-out criterion: long-term plan + surveillance + cross-referrals documented

Monitoring phase: Bleeding diary / PBAC + Hb/ferritin trajectory to treat-to-target. Re-image structural lesions (interval TVUS for leiomyoma/adenomyosis). Endometrial surveillance on progestin therapy for hyperplasia (re-biopsy per histology). Reassess US-MEC eligibility if new comorbidity. LNG-IUS expulsion / unscheduled bleeding check at 3–6 months (ECLIPSE PMID 26507206; SOGC PMID 25767949)

Disposition

Current setting: outpatient — Exclude pregnancy, classify by FIGO PALM-COEIN, assess endometrial-malignancy risk by age, treat-to-target (acceptable bleeding + corrected anaemia) with LNG-IUS-first medical therapy or structural-directed procedures (Munro PMID 21345435; ECLIPSE PMID 26507206)

Disposition criteria:
- Continue outpatient management if stable and responding (ECLIPSE PMID 26507206)
- Refer for surgery if structural cause not amenable to medical therapy or childbearing complete (SOGC PMID 25767949)

Escalation triggers (move to higher acuity):
- Acute heavy bleeding with haemodynamic instability → ED (ACOG CO 557 PMID 23635706)
- Severe symptomatic anaemia requiring transfusion → ED/admission
- Endometrial hyperplasia with atypia / suspected malignancy → gynaecologic oncology
- Refractory bleeding despite optimised medical therapy → operative gynaecology

Patient Action Plan

**Abnormal uterine bleeding self-management + treat-to-target plan**
Personalised values: palm_coein_cause, chosen_therapy_lng_ius_or_coc_or_txa, baseline_hb_ferritin, reproductive_intent, us_mec_category.

**Controlled — acceptable bleeding, anaemia corrected** (green):
Triggers:
- Bleeding within acceptable/normal pattern on therapy (FIGO System 1; ECLIPSE PMID 26507206)
- Haemoglobin/ferritin normalised
- Taking LNG-IUS / COC / TXA / progestin as prescribed
Actions:
- Continue prescribed therapy — do not stop because bleeding improved (ECLIPSE PMID 26507206)
- Keep taking iron until your provider says stores are replete (Jain PMID 37538019)
- Track your bleeding with a diary or app
- Attend follow-up labs and any endometrial surveillance as scheduled (Mayo PMID 30711128)
- Tell your provider before stopping/starting other medicines (some affect bleeding) (Munro PMID 21345435)

**Inadequate control or new symptoms** (yellow):
Triggers:
- Bleeding still heavy or irregular after starting therapy
- Fatigue, breathlessness, or palpitations (anaemia symptoms)
- New irregular spotting on hormonal therapy
Actions:
- Continue your therapy and contact your provider for review (ECLIPSE PMID 26507206)
- Restart/optimise iron if anaemia symptoms recur (Jain PMID 37538019)
- Do NOT stop an anticoagulant on your own if you take one — call your prescriber (Munro PMID 21345435)
- Bring your bleeding diary to the visit
Contact provider when:
- No improvement after a full treatment interval
- Persistent bleeding despite therapy (may need imaging / biopsy / procedure) (Mayo PMID 30711128)
- Bleeding between periods or after intercourse that is new

**Acute heavy bleeding / haemodynamic alarm** (red):
Triggers:
- Soaking through a pad/tampon every hour for several hours (ACOG CO 557 PMID 23635706)
- Dizziness, fainting, fast heartbeat, or feeling like you might pass out
- Passing very large clots with flooding
- Possible pregnancy with bleeding
Actions:
- Go to the emergency department now (ACOG CO 557 PMID 23635706)
- Bring your medication list including any blood thinner and hormonal therapy
- Tell ED staff this could be heavy uterine bleeding and whether pregnancy is possible
Contact provider when:
- Always seek emergency care for soaking-fast bleeding with light-headedness/fainting (ACOG CO 557 PMID 23635706)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Acute heavy uterine bleeding with orthostasis / SBP < 90 / HR > 110 / falling Hb (ACOG CO 557 PMID 23635706)
- [SEVERE] Positive β-hCG with uterine bleeding — AUB/PALM-COEIN does NOT apply; route to pregnancy-bleeding pathway (Munro PMID 21345435)
- [SEVERE] AUB at age ≥ 45 y, OR < 45 y with unopposed-oestrogen / obesity / PCOS / Lynch / tamoxifen / persistent or failed medical Rx — biopsy yield conditionally dependent on the age/unopposed-oestrogen prior (ACOG endometrial-assessment; Mayo PMID 30711128; Long PMID 32008795)

Citations

- FIGO PALM-COEIN System (Munro 2011/2018) + ACOG Committee Opinion 557 acute AUB + ACOG Practice Bulletin 128 (AUB-O) / 557 (acute AUB) / endometrial-assessment doctrine (CO 651/785) + US-MEC 2024 (CDC MMWR) + NICE NG88 HMB 2018/2021 + SOGC adenomyosis 2023 / leiomyoma management [PMID:21345435](https://pubmed.ncbi.nlm.nih.gov/21345435/)
- Cited evidence (PMID 30198563) [PMID:30198563](https://pubmed.ncbi.nlm.nih.gov/30198563/)
- Cited evidence (PMID 37538019) [PMID:37538019](https://pubmed.ncbi.nlm.nih.gov/37538019/)
- Cited evidence (PMID 30711128) [PMID:30711128](https://pubmed.ncbi.nlm.nih.gov/30711128/)
- Cited evidence (PMID 23635706) [PMID:23635706](https://pubmed.ncbi.nlm.nih.gov/23635706/)

Last reconciled with current guidelines: 2026-05-17.
References
  • FIGO PALM-COEIN System (Munro 2011/2018) + ACOG Committee Opinion 557 acute AUB + ACOG Practice Bulletin 128 (AUB-O) / 557 (acute AUB) / endometrial-assessment doctrine (CO 651/785) + US-MEC 2024 (CDC MMWR) + NICE NG88 HMB 2018/2021 + SOGC adenomyosis 2023 / leiomyoma management — PMID:21345435
  • Cited evidence (PMID 30198563) — PMID:30198563
  • Cited evidence (PMID 37538019) — PMID:37538019
  • Cited evidence (PMID 30711128) — PMID:30711128
  • Cited evidence (PMID 23635706) — PMID:23635706