Abnormal Uterine Bleeding: Diagnostic Evaluation, Medical and Surgical Management, and Patient Blood Management — A Narrative Review

Objective: Abnormal uterine bleeding (AUB) is a common gynecologic presentation and a major contributor to iron deficiency and anemia, making patient blood management (PBM) clinically relevant throughout diagnostic evaluation and treatment. This review aimed to provide an evidence-informed and clinically actionable overview of the diagnostic workup and stepwise medical and procedural management of AUB, while integrating PBM principles to reduce avoidable transfusion exposure. Mechanism: AUB arises from both structural and nonstructural etiologies as defined by the polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified (PALM-COEIN) classification. Persistent or excessive uterine bleeding can lead to iron depletion, iron deficiency, and overt anemia, which in turn may aggravate fatigue, dizziness, reduced functional status, and perioperative risk. PBM is therefore mechanistically relevant in AUB because it addresses not only bleeding control but also the prevention, identification, and correction of anemia, while minimizing unnecessary blood loss and inappropriate transfusion. Findings in Brief: Diagnostic evaluation should follow the PALM-COEIN framework to distinguish structural from nonstructural causes. Core investigations include pregnancy exclusion when applicable, complete blood count with iron assessment such as ferritin, targeted testing for coagulopathies in selected patients, especially adolescents with heavy menstrual bleeding, and first-line imaging with transvaginal ultrasound. Hysteroscopy or sonohysterography and endometrial sampling are indicated in patients with suspected focal lesions, persistent symptoms, or increased risk of endometrial malignancy. Medical treatment options include nonsteroidal anti-inflammatory drugs, tranexamic acid, combined hormonal therapy, progestins, and levonorgestrel-releasing intrauterine systems. Procedural management includes hysteroscopic lesion-directed surgery, endometrial ablation in selected candidates, uterine artery embolization, and hysterectomy when definitive treatment is required. PBM should emphasize early recognition and treatment of iron deficiency with oral or intravenous iron, minimization of iatrogenic blood loss, and restrictive transfusion strategies in hemodynamically stable patients, generally guided by symptoms, comorbidities, and hemoglobin thresholds around 7–8 g/dL, with reassessment after each unit transfused. Conclusions: A PALM-COEIN-based management pathway that integrates accurate diagnosis, stepwise therapy, and PBM principles can improve clinical outcomes in patients with AUB while reducing unnecessary transfusion exposure. Early correction of iron deficiency and individualized escalation from medical to procedural treatment are central to effective and blood-sparing care.