The Need for Investigations to Elucidate Causes and Effects of Abnormal Uterine Bleeding

Malcolm G. Munro, M.D.; Oskari Heikinheimo, M.D.; Rohana Haththotuwa, M.B.B.S.(SL); Jaydeep D. Tank, M.D.; Ian S. Fraser, M.D.


Semin Reprod Med. 2011;29(5):410-422. 

In This Article

Abstract and Introduction


This article describes a modern perspective on the basic investigations for abnormal uterine bleeding (AUB) in low-resource settings compared with a much more detailed approach for high-resource settings, bearing in mind issues of effectiveness and cost effectiveness. AUB includes any one or more of several symptoms, and it should be evaluated for the characteristics of the woman's specific bleeding pattern, her "complaint" and the presence of other symptoms (especially pain), the impact on several aspects of body functioning and lifestyle, and the underlying cause(s), especially cancer. Ideally, the evaluation is comprehensive, considering each of the potential etiological domains defined by the International Federation of Gynecology and Obstetrics PALM-COEIN system for the classification of causes. However, the detail of the questions and the extent of investigations will be significantly influenced by the technologies available and the time allotted for a consultation. In general, investigations should be performed only if they will make a material difference to the management approaches that can be offered. This should be an important consideration when a range of costly high-technology tests is accessible or when certain tests only have limited availability.


Abnormal uterine bleeding (AUB) is a term that covers a range of disturbed menstrual and nonmenstrual bleeding symptoms.[1] Some of these, such as heavy menstrual bleeding (HMB), intermenstrual bleeding (IMB), and irregular menstrual bleeding are very common. Individual women usually do not have an objective yardstick against which to measure their menstrual experience. Therefore, perception and tolerance play a major role in the likelihood that a woman will present to a health professional for assessment and management of a particular symptom. These factors vary considerably from one culture to another, and they are also influenced by the likelihood that effective treatment will or will not be available.

This article addresses the investigations that should be available, even in low-resource settings, and contrasts these with the ideal recommended investigations in most industrialized countries, as well as considering higher resource settings where the latest technologies are available. Even in these high-resource settings, cost effectiveness should be considered, an issue that is gaining worldwide importance as many health systems struggle to meet fiscal targets for health management. This is a critical issue for conditions that manifest with symptoms as common as AUB. Table 1 lists the key issues that should be considered in addressing the aims of investigations.


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