ACOG Guidelines at a Glance: Bulletin on AUB-O: Much-Needed Updates
Commentary by Jon I. Einarsson, MD, PhD, MPH
The accepted nomenclature for abnormal uterine bleeding (AUB) changed in 2011 when ACOG adopted the PALM-COEIN system.1,2 Briefly, the PALM-COEIN system divides the etiology of AUB into structural and nonstructural causes with an additional qualifier indicating etiology or etiologies. Although many clinicians still use the term dysfunctional uterine bleeding (DUB) synonymously with AUB, the use of DUB is no longer recommended.
Abnormal uterine bleeding associated with ovulatory dysfunction (AUB-O) is one of the nonstructural causes of AUB and is most common at extremes of reproductive age. The Practice Bulletin on the management AUB-O published in July of 2013 brings much-needed updates in terminology and treatment options when compared to the prior Practice Bulletin from 2000. The evaluation and management is divided into age categories because etiology and treatment are age-dependent. The document also recommends ruling out structural causes of AUB.3
The limitations of endometrial sampling done as an office endometrial biopsy (EMB) or dilatation and curettage (D&C) in the operating room (OR) are well known, especially for detection of polyps or fibroids.4 Performance of a “blind” D&C in the operating room is not addressed in the Practice Bulletin, but in my opinion, it should no longer be considered the standard of care. I believe that patients who are being evaluated in the OR for AUB also should undergo hysteroscopy. Done in the office and coupled with endometrial biopsy, hysteroscopy offers a minimally invasive and cost-effective method of ruling out structural causes of AUB.5
Saline infusion sonohysterography coupled with EMB is another viable option. The ACOG Practice Bulletin recommends EMB in all women older than age 45 years with AUB and also patients aged 19 to 39 years who are not responding to medical therapy or who have prolonged periods of unopposed estrogen stimulation. It is important to highlight this, because clinicians may tend to overlook the possibility of endometrial malignancy in this younger age group.6