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Abnormal bleeding in the pre menopausal woman

Key learning points:

- Definitions of abnormal uterine bleeding (AUB)

- Overview of evaluation and causes

- Health education opportunities

Changes in menstrual patterns are a common reason for women to visit their general practitioner. Abnormal uterine bleeding (AUB) may impact massively on a woman's quality of life,1 leading to time off work, affecting finances and family life.

This article will look at the standard terminology for AUB and the primary care nurse's role in diagnosis. It will also explore the unique position the primary care nurse is in to educate women to recognise the need to report changes in their menstrual history.


AUB is characterised as any change from a woman's normal menstrual cycle, heavy menstrual bleeding being the most common affecting up to 30% of women in their reproductive years.2 It has been defined as “excessive menstrual blood loss which interferes with the woman's physical, social, emotional, and/or material quality of life... [that] can occur alone or in combination with other symptoms.”3 AUB is further categorised by volume, frequency, duration, and regularity of flow, as well as timing, from inter- menstrual or premenstrual to breakthrough bleeding. Table 1 illustrates the descriptions and terminology identified by an expert international consensus statement.4,5

Chronic AUB

Bleeding that is abnormal in duration, volume, and/or frequency and has been present for most of the last six months.

Evaluation of AUB

Accurate history taking alongside physical examination supports a timely diagnosis and correct treatment.

Nurses may be taking a formal history as part of a “well woman” check, but may also find that during other planned consultations such as a diabetic or hypertension clinic a woman may open up about her changes in menstrual history. It is important to elicit the frequency, timing-for example post coital, often seen with cervical pathology-volume and regularity of the bleeding. This can help differentiate anovulatory bleeding from ovulatory bleeding

For example, ovulatory AUB is commonly associated with dysmenorrhea and premenstrual symptoms occurring with regular menstruation. Anovulatory bleeding is generally heavy, irregular and prolonged, can occur at the perimenopause where it could be an indication of endometrial hyperplasia, a potential pre-cursor to cancer.

Elements of history taking should include:

- Vaginal discharge (e.g. colour, odour)

- Impact on quality of life (e.g. sexual and social function)

- Symptoms of anaemia (e.g. fatigue, shortness of breath)

- Cervical screening adherence

 - Any pre-existing systemic cause for bleeding (coagulation disorder)

 - Medication history to elicit whether pharmacologically induced (e.g. anticoagulants, tamoxifen)

- Family history (endometrial/colon cancer may represent a genetic link in the family known as Lynch Syndrome).

Clinical examination in the primary care setting should include vital signs, weight/BMI, thyroid/skin/abdominal examination. Specific gynaecological examinations could include inspection of the vulva, vagina, cervix, anus and urethra, bi-manual examination of uterus and adnexal structures. A rectal examination may be included if clarity is required on exact site if bleeding (e.g. spotting from haemorrhoids). Bloods should be taken for a full blood count (FBC) if there is a history of heavy bleeding.6 If a cervical smear is overdue this may be a good opportunity to bring it up to date.

In summary a thorough history and clinical examination will guide accurate diagnosis and correct, timely referral to secondary care if needed for further investigation and/or treatment.

Causes of AUB

Generally speaking AUB can be classified as either structural or non- structural.


Polyps: masses of varying size from a few millimetres to several centimetres in the endometrial (inner) lining of the uterus. There are two types. Sessile with a large flat base or more commonly pedunculated, attached to the uterus by a long stalk or pedicle. Pedunculated polyps can protrude through the cervix into the vagina. Larger polyps may be quite vascular.

Adenomyosis: endometrial glandular tissue is found within the myometrium (muscle) of the uterus.

Leiomyomas: benign tumours arising from an overgrowth
of smooth muscle and connective tissue, commonly known
as fibroids.

 Hyperplasia: excessive proliferation of endometrial cells. This often occurs where there is an excessive level of oestrogen, e.g. polycystic ovary syndrome (PCOS) and obesity. It is a risk factor for uterine cancer and should be monitored carefully.

Malignancy: rarely, abnormal bleeding in younger women may be caused by vaginal, vulval or uterine cancer. Almost two thirds of diagnoses of uterine cancer are in women aged over 55.7 Risk factors in younger, pre-menopausal women include obesity, diabetes, history of PCOS, family history of Lynch Syndrome and nuliparity.7

Non Structural

Ovulatory disorders, coagulopathy or hormonal imbalance.

Health Education Opportunities

As a specialist gynaecological cancer nurse, I care for the minority of women in whom abnormal bleeding is a symptom of cancer.

 A common theme among the younger women I see is the length of time reporting their symptoms and how long it then took to get a referral to a gynaecologist.

The reasons for this are complex. Women are very used to bleeding throughout their lives; it's not always regular and is interrupted by pregnancy, for example, or the contraceptive pill. They do not always recognise abnormal bleeding for what it is, mistaking abnormal bleeding for, say, onset of menopause. Women are often reluctant to talk about bleeding; a 2014 survey of women aged 16 to 25 found that many lack even the language to talk about gynaecological health,8 resorting to euphemism such as “lady bits”. Women report that health professionals do not take abnormal bleeding seriously. An audit conducted in 2009 looking at delays in diagnosing endometrial cancer recommended a public health campaign should be initiated.

Primary care nurses see many women at regular intervals and can take these opportunities to encourage them to open up bout their menstrual history. The practice nurse is well placed to reinforce health education messages on the importance of reporting AUB and in helping women to find the language to talk about it.


Click here to read a patient's point of view



1. Barnard K, Frayne SM, Skinner KM, Sullivan LM. Health status among women with menstrual symptoms. J Womens Health (Larchmt) 2003;12:911-9.

2. Market Opinion and Research International (MORI). Women's health in 1990. [Research study conducted on behalf of Parke-Davis Laboratories]. London: MORI; 1990.

3. National Collaborating Centre for Women's and Children's Health; National Institute for Health and Care Excellence. NICE guideline CG44: heavy menstrual bleeding. London: Royal College of Obstetricians and Gynaecologists, 2007. Available at:

4. Fraser IS, Critchley HO, Munro MG. Abnormal uterine bleeding: getting our terminology straight. Curr Opin Obstet Gynecol 2007;19:591-

5. Munro MG. Abnormal uterine bleeding. Cambridge: Cambridge University Press; 2010.

6. National Collaborating Centre for Women's and Children's Health; National Institute for Health and Clinical Excellence. Clinical guideline CG44: heavy menstrual bleeding. London: Royal College of Obstetricians and Gynaecologists; 2007. Available at:

7. National Cancer Intelligence Team. Outline of Uterine Cancer in the UK: incidence, mortality and survival. October 2013

8. Why 'vagina' should be part of every young woman's vocabulary. Call for young women to face up to embarrassment about gynaecological health as new charity survey reveals dangerous knowledge gap amongst UK women

9. Johnson N, Miles T, Ruth K, Bailey D. Delay in Diagnosing Endometrial Cancer Audit on Behalf of the South West Public Health Observatory Gynaecology Tumour Panel. Published by the South West Public Health Observatory Gynaecology Tumour Panel, Bristol, 2011.