Evidence‑Based Assessment and Management of Abnormal Uterine Bleeding

Assessment of Acute Presentation

• A pregnancy test is mandatory in the initial evaluation of any woman with abnormal uterine bleeding to exclude gestational causes. Evidence level: insufficient (no high‑quality studies). 1

Diagnostic Imaging

• Transvaginal ultrasound is recommended as the first‑line imaging modality for identifying structural uterine pathology (e.g., polyps, fibroids, adenomyosis) in women presenting with abnormal uterine bleeding. Evidence level: expert consensus / moderate quality imaging guideline. 2, 3, 4

Endometrial Evaluation

• Endometrial sampling should be performed in women older than 45 years, in those with risk factors for endometrial cancer (e.g., obesity, diabetes, chronic anovulation), or when bleeding persists despite initial medical therapy. Evidence level: moderate (based on guideline recommendations). 2, 1

Classification of Causes (PALM‑COEIN)

• The PALM‑COEIN system categorizes abnormal uterine bleeding into structural (Polyp, Adenomyosis, Leiomyoma, Malignancy) and non‑structural (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not classified) etiologies. Evidence level: consensus classification endorsed by international gynecologic societies. 1

Evidence Gap for Specific Estradiol Regimen

• No guideline or high‑quality study supports the use of estradiol 2 mg daily for 7 days as a treatment for abnormal uterine bleeding; this regimen lacks evidence‑based endorsement. Evidence level: absent / not recommended. 1