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Practice Clinical updates

Investigating abnormal uterine bleeding in reproductive aged women

BMJ 2022; 378 doi: (Published 16 September 2022) Cite this as: BMJ 2022;378:e070906
  1. R MacGregor, academic clinical fellow in primary care1,
  2. V Jain, Wellbeing of Women clinical research training fellow2,
  3. S Hillman, NIHR academic clinical lecturer in primary care1,
  4. M A Lumsden, honorary professor of gynaecology and medical education and CEO of International Federation of Gynecology and Obstetrics3
  1. 1Unit of Academic Primary Care, University of Warwick, Coventry CV4 7AL, UK
  2. 2MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
  3. 3Reproductive and Maternal Medicine, University of Glasgow, Glasgow G4 0SF, UK
  1. Correspondence to: R MacGregor Becky.MacGregor{at}

What you need to know

  • Abnormal uterine bleeding (AUB) is common, and the cause must be understood in order to direct management

  • AUB in the perimenopause is a risk factor for endometrial hyperplasia or malignancy, and investigation is warranted

  • Iron deficiency and iron deficiency anaemia are extremely common in women with AUB and often easily remedied

A 35 year old woman presents to her GP with heavy periods, which are gradually getting worse. She is soaking through her clothes on her heaviest days and is concerned about leaving the house. She has also noticed an increased level of tiredness and inability to concentrate at work.

Abnormal uterine bleeding (AUB) is a common presentation in primary care. Estimates vary, but the prevalence among non-pregnant women of reproductive age globally is thought to be between 20% and 35%.123 This article refers to women, but the concepts apply to all people who menstruate. AUB affects women of all ages and backgrounds, with women from ethnic minority backgrounds and those living in deprivation the least likely to seek or receive treatment.3 In the past 10 years, systems for the nomenclature and classification of AUB have been established, with the International Federation of Obstetrics and Gynaecology (FIGO) publishing guidance in 2011 and updated in 2018 to guide patient care and management of those with AUB in the reproductive years.24 The UK’s National Institute for Health and Care Excellence (NICE) also published updated guidance for heavy menstrual bleeding in 2018.1


Abnormal uterine bleeding is the term used to encompass the symptoms of heavy menstrual bleeding and intermenstrual bleeding, and describes any bleeding from the uterus that is abnormal in flow volume, regularity, frequency, or duration.4 AUB is a symptom not a diagnosis. Avoid using terms such as menorrhagia, metrorrhagia, dysfunctional uterine bleeding, and …

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