Abnormal Uterine Bleeding Pathway

Author: Dr Priya Madhuvrata, Miss Mary Connor (STH), Dr Karen Joshi, Dr Emma Park, Dr Emma Reynolds (Primary Care)

Published Date: April 2020

Date to Review: February 2023

Abnormal uterine bleeding (AUB) is a syndrome defined as ‘bleeding from the uterine corpus that is abnormal in volume, regularity and/or timing that has been present for the majority of the last six months’ (irregular bleeding associated with hormonal contraception is often referred to as breakthrough bleeding). This definition of AUB includes heavy menstrual bleeding (HMB) and prolonged vaginal bleeding and overlaps with the term unscheduled vaginal bleeding, which is bleeding that occurs outside the normal menstrual period (or the regular withdrawal bleed associated with oral contraception) i.e. irregular bleeding, inter-menstrual bleeding (IMB), post-coital bleeding (PCB).

Menstrual problems often form part of a complex clinical picture with multiple symptoms. In a woman with abnormal vaginal bleeding a careful history and examination is required to diagnose AUB by excluding other causes such as vaginal pathology, cervical pathology and pregnancy. The NHS Sheffield guideline for AUB is intended to support assessment and management of these patients. A key step of the pathway is endometrial sampling which can only be undertaken by suitably accredited and trained GPs. The CASES gynaecology GPs can give clinical advice on a case-by-case basis if required.

UPDATE February 2020 - The pathway clarifies which patients are suitable for management in the community, i.e. those with heavy regular menstrual bleeding. It also advises as to which patients are suitable for pipelle biopsy in the community (only those with regular heavy menstrual bleeding with obesity or PCOS).

All patients with persistent (greater than 3 months) irregular bleeding, post coital bleeding or intermenstrual bleeding need secondary care referral along with those who have had treatment failure in primary care or palpable fibroids.

The two week wait criteria remain unchanged.