[FR] Unmet needs in abnormal uterine bleeding due to ovulatory dysfunction (AUB-O)

Half of women who suffer from abnormal uterine bleeding never talk to a doctor about it. You heard right, one in two doesn't seek help, even when it affects their daily life. It is often thought that if a problem is so common, it must necessarily be well understood and treated — but the opposite is true. Abnormal uterine bleeding due to ovulatory dysfunction, known as AUB-O, remains largely underdiagnosed and undertreated, with consequences that go far beyond simple discomfort. The common mistake is to believe that it is enough to "normalize" or tolerate this bleeding, or that only the volume matters. In reality, what is missing is a personalized approach that starts from the first consultation — an accurate diagnosis, consideration of the patient's life context, and an adapted treatment that takes the long term into account, not just the short term. For example, for years, Professor Hisam Arab has been seeing women who have been experiencing heavy periods since adolescence but have never sought medical advice because, in their circles, it was the norm. He has seen patients wait five years before taking the plunge, and even after that, nearly a quarter of them have never received a clear explanation of treatment options. Arab has developed what he calls the "all-in-one" approach: at the first visit, he combines ultrasound diagnosis, screening for anemia, assessment of the need for referral to another specialist, and sometimes endometrial biopsy or hysteroscopy. As a result, we avoid endless journeys where each step takes months, and we don't miss hidden complications like anemia, which can cause fatigue, anxiety, hair loss, and absenteeism—all symptoms that, in isolation, never suggest a gynecological problem. Professor Natalia Pedenko, in Ukraine, recounts the case of a teenage girl with irregular bleeding and a diagnosis of polycystic ovary syndrome. Her only biological problem, apart from the irregular cycle, was a very low level of vitamin D. Rather than prescribing combined contraceptives, which can promote deep endometriosis in the long term, Pedenko opted for treatment with cyclic progesterone, which respects bone development, does not alter future fertility, and directly improves cycle regulation. What is striking is that by adapting the choice of progestin – dydrogesterone, micronized progesterone, or alternatives depending on the country – we can act at the root without triggering unnecessary side effects. Another example: a 33-year-old woman who, despite having had heavy periods for years, did not realize the seriousness of the situation because all the women in her family were experiencing the same thing. Her anemia was severe, but it was only by asking four simple questions about the impact of her periods that the diagnosis was made. It is these details that change the course of treatment: asking the right questions, suspecting anemia, considering the ovulatory cause even if the ultrasound is normal, and not hesitating to treat stress or vitamin D deficiency in parallel. What recent international recommendations highlight is the need to individualize each treatment according to age, desired fertility, contraindications to estrogen, and social context. In adolescent girls, anything that blocks the hormonal axis or harms bone density should be avoided. In women of childbearing age, a distinction is made between those who want contraception and those who want to preserve their fertility. And in perimenopausal women, we adapt to both the need for contraception and the symptoms of estrogen deficiency. A little-discussed point: in some countries, dydrogesterone is not available, so it is necessary to juggle micronized progesterone or other molecules, keeping in mind that the dose and type influence tolerance, efficacy, and side effects. Another angle rarely addressed: the importance of the choice of progestin in women who have migraines, diabetes, or who live in very sunny regions and fear melasma. For these women, dydrogesterone offers a clear advantage: no androgenic effect, no interaction with the intestinal microflora, and no increased risk of thrombosis. We also discussed supportive treatments in MAP — even there, dydrogesterone is now preferred for its proven safety. On a practical level, tranexamic acid is a valuable option for women with very heavy bleeding, but it should be used for short periods, in addition to the rest. In summary, the real revolution is not a new molecule, but this shift from a one-size-fits-all approach to truly personalized care, centered on each woman's experience, and which includes anemia as a major component, not a secondary one. Changing the question we ask means changing the patient's fate. Abnormal uterine bleeding is not just a matter of flow; it's a warning sign about overall health — and the key is to listen, diagnose quickly, and treat at the root. If you don't integrate all of this, you're completely missing the problem. What seems harmless or "normal" in a woman can hide a profound imbalance, and sometimes the only thing missing is a doctor who asks the right question. If you take away one sentence, let it be this one: half of women with abnormal bleeding don't even know they need help — and this silence is the first thing to address. 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