abnormal uterine bleeding

1. DR. ARSLA MEMON

2. GOALS
 INTRODUCTION
 FIGO CLASSIFICATION
 COMMON TERMINOLOGY
 APPROACH TO PATIENT
 INVESTIGATION
 MANAGEMENT OPTIONS
 RECOMMENDATIONS

3. INTRODUCTION
 The normal menstrual cycle lasts 28 ± 7 days,
the flow lasts 4 ± 2 days, and the average
blood loss is 40 ± 20 ml, upper limit is 80 ml
 Abnormal uterine bleeding (AUB) is defined
as changes in frequency of menses, duration
of flow or amount of blood loss.

4. PREVALENCE
 30 percent of reproductive age women suffer
from menorrhagia
 Menorrhagia and uterine fibroids account for
up to 75 percent of all hysterectomies.
 25% surgeries are due to AUB.
 One national study found that menstrual
disorders were the reason for 19.1 percent of
20.1 million visits to physician offices for
gynaecologic conditions over a two-year
period.

5. TYPES OF AUB
 ACUTE, CHRONIC, AND INTERMENSTRUAL AUB
 Chronic AUB is defined as bleeding from the uterine corpus
that is abnormal in volume, regularity, and/or timing that
has been present for the majority of the last 6 months.
 Acute AUB is an episode of heavy bleeding that is sufficient
severity to require immediate intervention to prevent
further blood loss.
 Acute AUB may present in the context of existing chronic
AUB or might occur without such a background history

6. Intermenstrual aub
 IMB occurs between clearly defined cyclic
periods.
 PREDICTABLE (endometrial, hormonal)
 Midcycle
 Premenstrual
 UNPREDICTABLE “occur any time in cycle
and can arise from any where in lower genital
tract

7. AUB
 MIDCYCLE
 Usually last for 12-72
hrs
 Destabilization of
endometrium due to
sudden fluctuation of
estradiol level
 Physiological 1-2%
 Spotting around
ovulation
 PREMENSTRUAL
BLEEDING
 Occur upto 10 days
prior to menses
 Endometrium shed
early due to lack of
progesterone
 Often termed as luteal
phase deficiency

8. FIGO CLASSIFICATION OF
AUB
 FIGO) oncology staging systems are practical, universally
accepted, and aid clinicians and investigators in the
guidance of research,treatment, and prognosis of
gynecologic cancers .
 describes the new PALM-COEIN Classification for Causes
of Abnormal Bleeding
 The system was developed with contributions from an
international group of both clinical and nonclinical
investigators from 17 countries on six continents.
Recommended standardized nomenclatures.

9.  The classification system is stratified into nine basic categories that are
arranged according to the acronym PALM-COEIN . Polyp, Adenomyosis,
Leiomyoma, Malignancy and hyperplasia,Coagulopathy, Ovulatory
Disorders, Endometrium, Iatrogenic, andNot Classified
 In general, the components of the PALM group are discrete (structural)
entities that are measurable visually, by use of imaging techniques, and/or
by use of histopathology
While the COEIN group is related to entities that are not defined by
 imaging or histopathology (nonstructural).
 The categories were designed to facilitate the current or subsequent
development of sub classification systems.

11. Polyps (AUB-P)
Polyps are categorized as being either present or
absent as defined by one or a combination of
ultrasound (including saline infusion
sonography) and hysteroscopic imaging with or
without histopathology.
 Although there is no current distinction
regarding the size or number of polyps, it is
probably important to exclude polypoid-appearing
endometrium from this category, for
such an appearance may well be a variant of
normal.

12. Adenomyosis (AUB-A)
The relationship of adenomyosis to the genesis of AUB is unclear.
criteria for diagnosing adenomyosis have traditionally been
based on histopathologic evaluation of the depth of
‘‘endometrial’ tissue beneath the endometrial–myometrial
interface from hysterectomy specimens, the histopathologic
criteria vary substantially and the requirement to diagnose
adenomyosis limited value in a clinical classification system
In this system adenomyosis is diagnosed by uterine imaging the
limited access of women to MRI in the world community, it is
proposed that sonographic criteria for adenomyosis comprise the
minimum requirements for daignosis.

13. Leiomyomas (AUB-L)
Most leiomyomas (fibroids) are
asymptomatic, and frequently their presence
is not the cause of the complaint of AUB.

14. Malignancy and Premalignant
Conditions (AUB-M
 Although relatively uncommon in reproductive-aged
women, atypical hyperplasia and malignancy are
important potential cause of AUB.
This diagnosis must be considered in any woman in
the reproductive years and especially where there
may be predisposing factors such as obesity or a
history of chronic anovulation.
 Consequently, when an investigation of a women in
her Reproductive years with AUB identifies a
premalignant hyperplastic or malignant process, it
would be classified as AUB-M .

15. (AUB-C)
 The term coagulopathy is used to encompass the
spectrum of systemic disorders of hemostasis
that may cause AUB.
 13% of women with heavy menstrual bleeding
(HMB) have biochemically detectable systemic
disorders of hemostasis, most often von
Willebrand disease ..

16. (AUB-O)
Ovulatory dysfunction can contribute to the
genesis of AUB, generally manifesting in some
combination of unpredictable timing of bleeding
and a variable amount of flow, which in some
cases results in HMB.
 Some of these manifestations relate to the
absence of predictable, cyclic production of
progesterone, but in the later reproductive years
may be a consequence of luteal out of phase
events

17.  PCO ,hypothyroidism, hyperprolactinemia,
mental stress,obesity, anorexia, weight loss, or
extreme exercise such as that associated with
elite athletic training).
 In some instances, the disorder may be
iatrogenic, caused by gonadal steroids or drugs
that impact dopamine metabolism such as
phenothiazines and tricyclic antidepressants

18. Endometrial Causes (AUB-E)
 There may be primary endometrial se, but may
disorders that do not manifest HMB, IMB, such as
endometrial inflammation or infection,
abnormalities in the local inflammatory response, or
aberrations in endometrial vasculogenesis. At the
present time, there are no available specific tests for
these disorders, so the diagnosis of AUB-E should
be determined by exclusion of other identifiable
abnormalities in women of reproductive years who
appear to have normal ovulatory function

19. Iatrogenic (AUB-I)
 Unscheduled endometrial bleeding that occurs during the use of
exogenous gonadal steroid therapy is termed ‘‘breakthrough
bleeding’’ (BTB),the major component of the AUB-I .
 Included in this category are the women using the
levonorgestrel-releasing intrauterine system (LNG-IUS), who
frequently experience BTB in the first 6 months of therapy .
 When AUB is thought to be secondary to anticoagulants such as
warfarin or heparin, or systemic agents that contribute to
disorders of ovulation such as those that interfere with dopamine
metabolism, it is categorized as AUB-C or AUB-O, respectively .

20. Not Classified (AUB-N)
There exist a number of entities that may or
may not contribute to or cause AUB in a given
woman for they have been either poorly
defined, inadequately examined, and/or are
extremely rare. Examples arteriovenous
malformations and myometrial hypertrophy.

21. TERMINOLOGY
 Oligomenorrhea Bleeding occurs at intervals of > 35 days and usually is
caused by a prolonged follicular phase.
 Polymenorrhea Bleeding occurs at intervals of < 21 days and may be
caused by a luteal-phase defect.
 Menorrhagia Bleeding occurs at normal intervals (21 to 35 days) but
with heavy flow ( ≥ 80 mL) or duration ( ≥ 7 days).
 Menometrorrhagia Bleeding occurs at irregular, noncyclic intervals and
with heavy flow ( ≥ 80 mL) or duration ( ≥ 7 days).
 Amenorrhea Bleeding is absent for 6 months or more in a non
menopausal woman.

22.  intermenstrual cervical disease, intrauterine device, endometritis, polyps,
submucous myomas, endometrial hyperplasia, and cancer.
 Midcycle spotting Spotting occurs just before ovulation, usually because of a decline
in the estrogen level.
 Postmenopausal bleeding Bleeding recurs in a menopausal woman at least 1 year
after cessation of cycles.
 Dysfunctional uterine This ovulatory or anovulatory bleeding is diagnosed after the
exclusion of bleeding pregnancy or pregnancy-related disorders, medications,
iatrogenic causes, obvious genital tract pathology, and systemic conditions

23. CLINICAL CONSEQUENCES
 Impact on quality of life
 Anemia
 Infertility
 Endometrial cancer
 Financial

24. DIFFERENTIAL DAIGNOSIS
 Systemic conditions
 Adrenal hyperplasia and
 Cushing’s disease
 Blood dyscrasias, including
 leukemia and
 thrombocytopenia
 Coagulopathies
 Hepatic disease
 Hypothalamic suppression
 (from stress, weight loss,
 excessive exercise)
 Pituitary adenoma or
 hyperprolactinemia
 Polycystic ovary syndrome
 Renal disease
 Thyroid disease
 Genital tract pathology
 Infections: cervicitis, endometritis,
 myometritis, salpingitis
 Neoplastic entities
 Benign anatomic abnormalities:
 adenomyosis, leiomyomata,
 polyps of the cervix or endometrium
 Premalignant lesions: cervical
 dysplasia, endometrial
 hyperplasia
 Malignant lesions: cervical
 squamous cell carcinoma,
 endometrial adenocarcinoma,
 estrogen-producing ovarian
 tumors, testosterone-producing
 ovarian tumors, leiomyosarcoma
 Trauma: foreign body, abrasions,
 lacerations, sexual abuse or assault

25. DIFFERENTIAL DAIGNOSIS
 Pregnancy and
pregnancyrelated
 conditions
 Abruptio placentae
 Ectopic pregnancy
 Miscarriage
 Placenta previa
 Trophoblastic disease
 Medications and iatrogenic
causes
 Anticoagulants
 Antipsychotics
 Corticosteroids
 Herbal and other supplements:
 ginseng, ginkgo, soy
 Hormone replacement
 Intrauterine devices
 Oral contraceptive pills,
 including progestin-only pills
 Selective serotonin reuptake
 inhibitors7
 Tamoxifen (Nolvadex)7
 Thyroid hormone replacement

26. DAIGNOSTIC APPROACH TO AUB
 Pelvic pain Miscarriage, ectopic
pregnancy, PID, trauma,
 sexual abuse or assault
 Nausea, weight gain, urinary
frequency, fatigue Pregnancy
 Weight gain, cold intolerance,
constipation, fatigue
 Weight loss, sweating, palpitations
 Easy bruising, tendency to bleed
 Jaundice,
 Hirsutism, acne, acanthosis
nigricans, obesity
 Postcoital bleeding Cervical
dysplasia, endocervical polyps
 Galactorrhea, headache, visual-field
disturbance
 Weight loss, excessive exercise,
stress
 Hyperthyroidism
 Coagulopathy
 Jaundice, history of hepatitis Liver
disease obesity Polycystic ovary
syndrome
 Pituitary adenoma
 Hypothalamic suppression

27. PHYSICAL EXAMINTION
 Pallor , exopthalmos BMI ,Thyromegaly, weight
gain, edema
 Thyroid tenderness, tachycardia, weight loss,
velvety skin,stigmata of endocrine
disorder,secondary sexual charscterstics
 Bruising, jaundice, hepatomegaly
 Enlarged uterus leiomyoma, ascites,
 Firm, fixed uterus
 Adnexal mass,
 Uterine tenderness, cervical motion tenderness

28. INVESTIGATION
 Beta-subunit human chorionic
gonadotropin Pregnancy
 Complete blood count with
platelet count ,ferritin
 coagulation studies
 Liver function tests,
prothrombin time
 Thyroid-stimulating hormone
 Prolactin
 Blood glucose
 DHEA-S, free testosterone, 17-
hydroxyprogesterone (Ovarian
or adrenal tumor if
hyperandrogenic)
 Papanicolaou smear
 Cervical testing for infection
 Imaging and tissue
 Endometrial biopsy or dilatation
and curettage
 Transvaginal ultrasonography
 Saline-infusion
sonohysterography
 Hysteroscopy
 MRI

29. TRAETMENT OF AUB
 Age
 desire to preserve fertility
 coexisting medical conditions,
 patient preference
 the patient should be aware of the risks and
contraindications to allow informed choice.
 patient satisfaction may be influenced by
efficacy, expectations, cost, inconvenience, and
side effects.

30.  PREGNANCY
 MALGNANCY TO BE RULED OUT

31. AUB
 ORGANIC CAUSE
 PELVIC PATHOLOGY
 INFECTION (contact
tracing)
 ECTROPION
 MEDICAL DISEASE
 NO CAUSE
 DUB
 MILD
 MODERATE
 SEVERE

32. MEDICAL TREATMENT
 NON-STEROIDAL ANTI-INFLAMMATORY DRUGS
 Endometrial prostaglandins are elevated in women with heavy
menstrual bleeding.
 (NSAIDs) inhibit cyclo-oxygenase and reduce endometrial
prostaglandin levels,taken with menses decrease menstrual
blood loss by 20 to 50 percent.
Improve dysmenorrhea in up to 70 percent of patients.
Therapy should start at the first day of menses and be continued
for five days or until cessation of menstruation.

33. ANTIFIBRINOLYTIC AGENTS
Tranexamic acid a synthetic derivative of the
amino acid lysine, exerts an antifibrinolytic effect
through reversible blockade on plasminogen.
The drug has no effect on blood coagulation
parameters or dysmenorrhea.
One third of women experience side effects,
including nausea and Leg cramps.
Tranexamic acid one g every six hours for the first
four days of the cycle reduces menstrual blood
loss by up to 40%.

34. DANAZOL
a synthetic steroid with mild androgenic properties, inhibits
steroidogenesis in the ovary and has a profound effect on
endometrial tissue, reduce menstrual blood loss by up to 80
percent.
 Following danazol therapy (100-200 mg daily), 20 percent of
patients reported amenorrhea and 70 percent reported
oligomenorrhea.
 Approximately 50 percent of the patients reporte no side effects
 most common complaint was weigh gain of two to six pounds in
60 percent of patients.
 The recommended treatment is 100 to 200 mg daily for three
months.

35. PROGESTINS
 Randomized controlled trials have shown cyclic
progestins to be ineffective in controlling regular
heavy menstrual bleeding compared to NSAIDs and
tranexamic acid.
 Progestins may be useful for women with irregular
cycles and with anovulatory cycles when given for 12
to 14 days of each month.
 Medroxyprogesterone acetate given for
contraception induces amenorrhea within the first
year in 80 percent of women, although as many as
50 percent experience irregular bleeding.

36. COMBINED ORAL CONTRACEPTIVE
PILL
The reduction of menstrual blood loss is probably the
result of induced endometrial atrophy.
 A randomized controlled trial of women taking an
Ocp containing 30 μg ethinyl estradiol showed 43
percent reduction in menstrual blood loss compared
to baseline.
 Two longitudinal case control studies have found
that users were less likely to experience heavy
menstrual bleeding or anemia.
 Additional advantages of OCPs include
contraception and reduction of dysmenorrhea,Best
cycle control WITH

37. PROGESTIN INTRAUTERINE SYSTEM
 Progesterone impregnated intrauterine
devices (IUDs) reduce menstrual bleeding.
levonorgestrel intrauterine system (LNG-IUS)
is a T-shaped IUD which releases a steady
amount of levonorgestrel (20 μg/ 24 hrs) from
a steroid reservoir around the vertical stems
of the device.

38. GNRH AGONISTS
GnRH agonists induce a reversible
hypoestrogenic state, reducing total uterine
volume by 40 to 60 percent.
 Myomas and uterine volume expand to
pretreatment levels within months of cessation
of therapy.
 GnRH agonists are effective in reducing
menstrual blood loss in perimenopausal women,
but are limited by their side effects, including hot
flashes and reduction of bone density.

39. Surgical management
 DILATATION AND CURETTAGE
temporary reduction in menstrual blood loss
immediately after the procedure;
however, losses returned to previous levels or
higher by the second menstrual period .
 may have a diagnostic role when endometrial
biopsy is inconclusive and the symptoms
persist or when underlying pathology is
suspected.

40. ENDOMETRIAL DESTRUCTION

41. HYSTRECTOMY
The risks of major surgery must be weighed against
alternatives.
 Hysterectomy is a permanent solution for the treatment of
menorrhagia and abnormal uterine bleeding, and is
associated with high levels of patient satisfaction in
properly selected patients.
 For the woman who has completed her childbearing,
reviewed the alternatives, and has tried conservative
therapy without acceptable results, hysterectomy is often
the best choice.

42. RECOMMENDATIONS
1. Women with irregular menstrual bleeding
should be investigated for endometrial polyps
and/or submucous fibroids.
2. Women presenting with menorrhagia should
have a current cervical cytology and a complete
blood count. Further investigations are
individualized.
It is useful to delineate if thebleeding results from
ovulatory or anovulatory causes.

43.  Clinicians should perform endometrial sampling based
on the methods available to them. An office
endometrial biopsy should be obtained if possible in all
women presenting with abnormal uterine bleeding over
40 years of age or weighing more than or equal to 90
kg.
 4. Hysteroscopically-directed biopsy is indicated for
women wit persistent menstrual bleeding, failed
medical therapy or transvaginal saline sonography
suggestive of focal intrauterine pathology such as
polyps or myomas. Women with persistent symptoms
but negative tests should be reevaluated.

44. Progestogens given in the luteal phase of the ovulatory
menstruaL cycles are not effective in reducing regular
heavy menstrual bleeding .
While dilatation and curettage (D&C) may have a
diagnostic role, it is not effective therapy for women
with heavy menstrual bleeding.
The endometrium can be destroyed by several different
techniques but reoperation rate at five years may be up
to 40 percent This should be reserved for the woman
who has finished her childbearing and is aware of the
risk of recurrent bleeding.