ABNORMAL UTERINE BLEEDING
FOUNDER PRINCIPAL & CONTROLLER;
JHALAWAR MEDICAL COLLEGE AND
EX. PRINCIPAL & CONTROLLER;
MAHATMA GANDHI MEDICAL COLLEGE
AND HOSPITAL , SITAPURA, JAIPUR
Normal Menstrual Cycle
Menstration is a cyclic physiological phenomena
starting at the age of Menarche (10-12years) till
establishment of Menopause (45-55 yrs).
It is regulated by hypothalmo-pituitary- ovarian
hormones secreted in pulsatile and cyclic
Also influenced by endometrial response top
these (E& P ) hormones and coagulation
Cycle lenghth-21-35 days , mean menstrual
blood loss -30-40 ml , duration of bleeding
Volume of blood flow is assessed by number of pads / tampons used
whether the pads are fully/ partially soaked , presence of clots. It can
be better assessed by pictorial charts--
Pad Area Soaked 1st day 2nd
3rd Day 4th Day 5th
X 1 // / /
X 5 /// //
Total Points 89(<1oo)- Nor
// // / /
x 5 ///
D X 15
Arrest of Menstrual bleeding
1 Haemostasis by plate let plug and clot formation – starts
soon the bleeding starts and open BV are plugged .once
Blood vessels are plugged , fibrin deposition occurs ---
Fibrinolysis also go hand in hand to balance and keep the
blood loss fluid.
2.Prostaglandin Mediation – Archadonic acid and Pg
synthetase enzyme produce PGs ---pge2 –vasodilator,
PGf2a--- vaso constrictor andThromboxane – vaso
constrictor. Estrogen produce PGE2 and PGF2a in ratio of
1:1 in proliferative phase ; while Progesterone produce
PGE2 and PGF2a + thromboxane (a2) in a: 2 ratio in
premenstrual phase so balance is shifted towards
vasoconstricton which help in contrl of bleeding.
Arrest of Menstrual bleeding
3.Tissue Repair --- starts from the mouths of
open endometrial glands in the denuded
areas , endothelium out grows and covers the
raw area under the influence of Epithelial
Growth Factor ( EGF) and blood vessels
regrow due toVascular endothelial Growth
Factor (VEGF).Thus the raw area of
remaining basal endometrium is completely
epithelized under Estrogen effect.
Abnormal uterine bleeding
Organic Causes Functional Uterine bleeding(DUB)
Deseases Of GenitalTract—
Pregnancy related irregularity
Abnormal Bleeding from GenitalTract without
any demonstrable organic cause.
IUCD Related Irregularity Diagnosis is made by excluding organic cause
Benign Conditions-- Altered Hypothalamus-pituitary-ovarian-
Fibroids, its polyps Function
Altered endometrial response to Sex
Endometrial Polyp altered proprtion of estrogen and progestrone
production and their effect on Endometrial
Malignant Lesions phasing may cause DUB.
Menstrual Patterns IN DUB
Regularity—1. regular ,2 irregular , absent.
Frequency---1. frequent < 21 days, 2. Normal
21-35 days,3. Infrequent >35 days.
Duration– Normal 2-8 days , Prolong > 8 days
.shortened <2 days .
Volume – normal 20 -80ml , Heavy > 80
ml, Light < 15 ml
Menorrhagia –Regular cycle with prolonged or
Polymenorrhoea – frequent cycles but normal
Poly menorrhagia – frequent cycles with heavy
Metrorrhagia ----Inter menstrual Bleeding .
Oligomenorrhoea—Infrequent cycle with normal
Hypomenorrhoea—Regular normal cycle with
In some adolescent girls and perimenopausal women,
Ovarian follicles develop(FSH Stimulation) and
produce estrogen in variable amount leading to
proliferation of endometrium .
Dominant follicle may not develop due to insufficient
LH surge – no ovulation—no development of carpus
Luteum ---no progesterone --- no secretary changes in
endometrium ; estrogen still secreted by follicles
(grannulosa cells) .
Unopposed estrogenic Stimulation and some time
hyper ( super threshold ) level of estrogen results in
over growth of endometrium(hyperplasia) ----resulting
in prolonged cycle and increased blood loss during
When endometrium over grow s its blood
supply , lack of progesterone causes
decrease PGE2 vasodilators initially and
Avascular necrosis of functional
endometrium occur , endometrium is shade
off Lack of vasoconstrictors--- PGf2a and
thromboxane results in excessive blood loss
which is pain less and prolonged for 20-
30days (As irregular shading of endometrium
continues for such a long time ).
Persistent Follicles under go the formation of
Anovlatory DUB Metropathia Hamorrhagica
Accounts for 80% of DUB; at Pubertal and perimenopausal age
,Patient has variable period of amenorrhoea followed by
prolong, heavy , painless bleeding .
Prroplonged Un opposed Estrogen
Complex Hyperplasia with Atypia
Endometrium in Metyrpathia
Usually reveals cystic hyperplasia( simple
hyperplasia with out atypia) called swiss
cheese appearance .
- Hyperplastic glands and strauma.
- Cystic or irregularly dilated glands.
- Thick walled , tortuous , dilated spiral
arterioles and veins.
- Infarction and thrombosis of blood vessels.
- Necrosis of functional endometrium .
Progress And Course of Metropathia
Incidence of malignancy ---
simple cystic Hyperplasia---1%
Complex hyperplasia with atypia---29%
It is further increased in perimenopausal
women who are obese, diabetic,on E2 therapy,
hypertensive and relatively infertile , H/O Ca
endometrium in family and had PCOD.
Young Girls who are obese with or with out PCOD
are prone to have metropathia Haemorrhagica
of early changes which are reversible with
progesterone / Ocs therapy.
The endometrial adenocarcinoma in the polyp at the left
is moderately differentiated, as a glandular structure
can still be discerned. Note the hyperchromatism and
pleomorphism of the cells, compared to the underlying
endometrium with cystic atrophy at the right.
This is often seen in peri menopausal women .
There is insufficient development of ovarian
follicles resulting in low estrogen level not able
to sustain endometrium or trigger LH surge ( no
Such women can have prolonged and excessive
bleeding due to absence of progesterone and
lack of PGF2a and thomboxane.
Bleeding PV in these women can be controlled
with cyclic E2 + P CombinationTherapy as both
are at low level .
More common in women of reproductive age
group (21-40 years ) .
Accounts for 20% cases of DUB.
Patient usually present Cyclic excessive
bleeding / premenstrual spotting.
Periods are associated with Pain .
Menorrhagia (DUB )
An alteration in ratio of PGE2 and PGF2a ( vaso
dilator : vaso constrictor )occurs in some women
despite of ovulation and normal progesterone
production from carpus luetium .
Increase in PGE receptors in endometrium ,
reduction in thrombxane production and
increased fibrinolytic activity has also been
demonstrated in these women .
PgF2a causes Dysmenorrhea.
HP report of endometrium reveals secrtory
DUB: Classification, Pathophysiology And Endometrial
Altered PG E : PG F
Reduced PG F2
Reduced PG F2
followed by bleeding
Reduced PG F2
Luteal Phase Defect
In adequate Functioning of carpus luteum can
-- in sufficient and erratic production of
Progesterone.As well as alteration in the
ratio of PGE : PGF
---resulting in irregular and patchy screttory
changes in the endometrium
Both pathophysiological deficit leads to
irregular ripening and or irregular shading
of endometrium .
History Taking In DUB
Age at menarche.
Menstrual History—regularity, frequency, duration of
bleeding ,Volume of blood loss.
Post coital bleeding ?
Dysmenorrhoea – spasmodic / congestive .
O.H.---fertility / infertility/ gravidity / parity etc.
AssociatedVaginal Discharge .
RescentAbortion / delivery / ectopic pregnancy .
IUCD insertion , ocs, hormone therapy/ drugs.
Symptoms of thyroid disease.
Symptoms of any bleeding disorder.
General Physical .
Signs of PCOD .
PV examination --- uterine, position, size. Shape
surface , consistency ,tenderness and mobility .
Furnaces for any anneal mass /tenderness/
LaboratoryTests HB ,T/DLC, BT. CT, PT , PPT, platelets
count , ESR, Fasting Blood Sugar,,T3-T4-TSH.– to know
degree of anemia, to exclude coagulation disorders and
leukemia's, Diabetes and thyroid disorders.
TVS /abdominal USG –to exclude Genital tract lesions like
fibroids, endometrial thickening , endometriosis, PCOD ,
polyps , IUCD pregnancy related conditions anneal mass
Soon Historiography– intra cavity lesions like polyp fibroid
Dilatation Curettage--- Endometrial sampling for HPR---
type of endometrial ; secretary , LPD, proliferative /
hyperplasia , inflammation like tuberculosis and
precancerous or cancer lesion .
Hysteroscopy---diagnostic as wells therapeutic use in
IUCD sub mucous fibroid , polyps .
Differential Diagnosis Symptoms and signs Investigations
Bleeding Disorder s previous history Present BT, CT , Platelet count , PT
PCOD (hormonal disorder
but ovarian enlargement
can be detected )
,Resident of Goiter endemic
area, clinical symptoms and
T3 ,T4 andTSH profile.
USG, FSH/LH ratio ,serum
prolactn and SerumE2 level
on day 2 of menses.
Differential diagnosis in Reproductive Age
Differential diagnosis Symptoms & Signs Investigations
Evacuation of vascicular
PostAbortal Bleeding , ch.
Ectopic ,Post delivery
bleeding , retained IUCD
H/o recent abortion , missed period ,
delivery/ insertion of IUCD / Medical
Fibroid Uterus Menorrhagia/ Poly menorrhagia ,
congestive dysmenorrhea , irregular
enlarged uterus but not tender.
Menorrhagia/ Poly menorrhea , cutting
pain during menses / coital pain
,Infertility. Enlarged (Localized in
adenomyoma) RV RF Fixed and tender
uterus and adenexa/ mass.
Chronic PID Poly menorrhagia, congestve
dysmenorrhoea,leucorrhea chronic pain
in lowe abdomen and sacral region.
Tender uterus , fixed / restricted mobility
Differential Diagnosis In
Perimenopausal Age Group
Differential Diagnosis Symptoms And Signs Investigations
Multipara, menorrhagia ,
Uterus bossed and
irregularly Enlarged firm to
hard and not tender.
Menorrhagia, multipara ,
congestive dysmenorrhoea .
Uterus regularly enlarged
soft and tender
Endometrial Carcinoma Nullipara, obese ,
hypertensive , delyed
menopause , diabetic ,
family history +/_ , PCOD ,
Irregular /freuent cycles
Fractional Curretage and
endometrial HP Examination
General Measures –> Rx of anaemia , life style
modification ---weight reduction by diet control and
1.Non Hormonal like Antifibrinolytics, PG synthesis
inhibitors , Capillary fragility inhibitors.
2. Hormonal ---Progesterone—oral , IM,
Progesterone bearing IUCD.
Estrogen +progesterone combination.
3. Others ---Danazoloe , GnRH analoges /
Surgical-- &c , EndometrialAblation , Hysterectomy
Management Of AUB According to Endometrial TVS
DUB management in Reproductive Age Group
Medical Rx USG
Response No Response Rx Accordingly
Cont. For USG
3-6 months/ Polyp Normal
Response No Response
Endo . Ablation
LNG -IUS= Levonorgstrel intra
Management of DUB in Adolescent Girls
? Bleeding disorder /Thyroid dysfunction/ PCOD
NO YES Investigate & Rx
Profuse bleeding Moderate Bleeding
High Dose Progesterone Cyclical combined Ocs for
Followed By E+P combination 3-6 months
for 3-6 Months
DUB Management in Perimenopausal age
Abnormal Uterine Bleeding
Risk Factors for Hyperplasia , carcinoma , irregular acyclic Bleeding
USG, Fractional Curretage, endometrial HP
Atypical Hyperplasia Simple Hyperplasia
Low Dose Ocs / cyclical
Drugs used in RX of DUB
NonHormonal Drugs Dose
500mg tid/qid for 3-5 days
PG synthetase Inhibitors
Mefenamic Acid 500mg tid for 3-5days.
Capillary Fragility inhibitors
Ethamsylate 500mg qid for 4-5 days
Hormone therapy in DUB
Norethisterone / Medroxipogesterone/
Duphaston—to arrest bleeding-----------
10mg 6hrly for24-48 hrs
follwed by 10 mg /day for 15-
10mg daily from 10th -25th day
for 3-6 cycles.
Estrogen + Progesterone combintion
Ethinyl estradiol + norethysterone / norgestrel/
20-30 ug + o.5-0.75mg
cyclically daily starting on 4th
day to 25th day of cycle –for 3-
Estrogen only---Ethinylestradiol 50ug /day for 5 days
danzole 100-200mg /day for 3-6
3.6mg IM once in 4 weeks
60mg twice weekly for 12
Progesterone Intra Uterine System
The commonly used progesterone is
Levonorgestrel bearing IUCD (LNG-IUS).
It can reduce the blood loss up to 90%.
It is effective contraceptive too( 5years).
It is as effective as endometrial ablation avoiding
surgical management like hysterectomy.
LNG-IUS delivers 20 ug levonorgestrel daily to
It causes glandular atrophy and stromal
It has minimal action on Hypothalmo-pituitary –
Nosystemic side effect.
Surgical Treatment of DUB
-Dilatation & Curretage—routine / Fractional
Total with unilateral salping overiotomy/
Ablation means == elimination
failed medical therapy .
Young women desires to preserve uterus.
Poor surgical risk for hysterectomy (non
carcinoma lesion of endometrium)
2. Contra Indications
Desire for fertility
Large uterine cavity -- <12cm.
Endometrial hyperplasisia with Atypia.
Suspected malignancy of genital tract.
Multiple or large fibroids/ nonfunctional ovarian
Disadvantages of !st generation Ablation
Require skilled person.
Require long training.
Require general anasthesia.
More chances of uterine perforation and fluid
Long term results of Ablation---
30% women remain amenorrhi0ec .
40-50 % women have reduced bleeding during
their menstrual periods.
10-20 % women reqquire hysterectomy due to
failure e.g. no relief from bleeding.
Endometrial hyperplasia with atypia.
Failed Medical therapy in women over the
age of 40-45.
Failed endometrial Ablation.
Other pelvic pathology that needs surgery
Summary of DUB management
Age Group USG Endometrial
Adolescent Abdominal to
rule out any
Seldom done Usually sffice Seldom
done abd /
Always 1st line Secod line of
Abd /TVS Should be
Mostly 1st line
Some time !st
Line Of Rx
AUB can be due to organic disease or functional
It can occur in any age group –adolescent/ reproductive
or perimenopausal .
Dub is diagnose by exclusion of organic lesions by
clinical and investigatory methods.
Drug Rx (non hormonal –then hormonal should be given
first as majority of cases will get desired response.
LNG –IUS has revolutionized the medical management
and has reduced the need of surgical Rx.
If medical management fails – endometrial ablation can
If there are contra indication for Ablation and or it fails
hysterectomy can be done in Perimenopausal women .
Rx of DUB Is to Be Individualized Approach