The evaluation and management of abnormal uterine bleeding (AUB) has recently been focused on the specific etiology of the condition. The use of a pneumonic delineating the most common causes (PALM-COEIN see Box 3.1) has been established by the International Federation of Obstetrics and Gynecology (FIGO) and adapted by the American College of Obstetrics and Gynecology (ACOG) as the approach for these condition (1). As listed in Box 3.1, the “C” stands for coagulation disorders. Management of patients with coagulation disruption is a common encounter in the practice of obstetrics and gynecology. Multiple conditions and medications can cause defects in the coagulation pathway, leading to unpredictable and sometimes heavy uterine bleeding. The chapter reviews common causes including hereditary, genetic, acquired, and medication-related causes that are associated with a disruption of the coagulation pathway and thus lead to heavy bleeding in gynecology (Figure 3.1). Familiarity with the different pathways and elements involved in the process of coagulation as well as those that counteract it are important basic concepts to understand the etiology and management of all these conditions.
Box 3.1 Classification System for Abnormal Uterine Bleeding
Other leiomyoma (AUB-Lo)
Malignancy and hyperplasia (AUB-M)
Ovulatory dysfunction (AUB-O)
Not yet classified (AUB-N)
Scope of the Problem
FIGO Classification: Coagulopathies (AUB-C)
This category includes (1) those patients who have defects in the coagulation pathway as well as (2) those who have platelet disorders (either functional or in quantity) along with (3) those with chronic anticoagulation therapy. These patients present generally with abundant bleeding around menarche or close to their initiation of anticoagulation medication. Most of the patients who present early after menarche have not been diagnosed with a bleeding disorder as most have not had any surgical intervention that tested their coagulation capacity. Key items on history taking for these patients include the clues present during their interview. Family history of bleeding disorders is not uncommon. Epistaxis, gum bleeding, and taking a long time for bleeding to stop after minor cuts could be clues that increase the suspicion for these conditions.