2. MENSTRUAL CYCLE
• GnRH Portal circulation Pitutary Adenyl
Cyclase Release of Gn Follicular
maturation and Ovulation
• Normal menstruation results from progeston
withdrawal from Estrogen primed endometrium
• Lasts for 1-8 days, 10-80ml blood loss, the cycle
ranges 21-35 days, dark red not clotting.
3. ABNORMAL UTERINE BLEEDING(AUB)
Defn
• Any bleeding from the uterus that differ from
the usual menstrual cycle in frequency, amount,
or duration of flow.
Incidence
• It can occur in women of all age
• Common especially in both extreme of age
4. INCIDENCE
• AUB affects 10-30 % of reproductive-aged women
and up to 50 % of perimenopausal women .
• Factors that impact the incidence most greatly
are age and reproductive status.
• For example, uterine bleeding is uncommon in
prepubertal girls and menopausal women,
whereas rates of abnormal bleeding increase
significantly in adolescent, perimenopausal, &
reproductive-age groups
5. Causes of this bleeding may include
• neoplastic growth,
• hormonal dysfunction,
• reproductive-tract trauma,
• infection,
• coagulopathies, and
• complications of pregnancy.
* As a result, abnormal uterine bleeding is a common
gynecologic complaint that may affect females of
all ages
6. Classification of AUB
1. Functional uterine bleeding (organic origin)
A. Associated with pregnancy
B. Not Associated with pregnancy
2. Dysfunctional uterine bleeding (non-organic origin)
A. Anovulatory (90% DUB)
B. Ovulatory (10% DUB)
7. Pattern of AUB
1. Menorrhagia - prolonged/heavy cyclic menstruation
>8days, >80 ml of blood loss
causes
• complication of pregnancy
• submucous myoma
• Adenomyosis
• IUDs
• endometrial hyperplasia & malignancy
• dysfunctional uterine bleeding
8. Cont…
2. metrorrhagia - inter menstrual bleeding
causes
- endometrial polyps
- endometrial & cervical ca
- IUDs
• breakthrough bleeding (BTB) Unscheduled endometrial
bleeding that occurs during the use of contraception
• Withdrawal bleeding – refers to the predictable bleeding
that often results from abrupt progestin cessation
(hormonal contraceptives)
9. Contd…
• 4. menometrorrhagia - Menses with heavy,
irregular bleeding
causes
- malignant tumor
- complication of pregnancy
• 5. Metrotaxis
continious uninterrupted bleeding.
• Polymenorrhea –
Menses at intervals less than 21 days
10. Contd…
• 6. Oligomenorrhea
Menses at intervals >35 days apart
causes
- endocrine cause
- systemic cause
• 7. contact/post-coital bleeding
causes
- cervical eversion, polyps, ca
- cervical/vaginal infection
- atrophic vaginitis
11. hypomenorrhea
• Periods with unusually light flow (<10ml)
• hypogonadotropic hypogonadism (athletes,
anorexia)
• Asherman’s syndrome
12. Causes of AUB
The cause or DDx of AUB can be classified as
• Pregnancy related
• Infection
• Neoplasm
• Uterine condition
• Systemic illness
• Iatrogenic causes
• DUB
16. Causes of AUB by specific category
A. Pre pubertal ( CHILDHOOD)
• Vulvo-vaginal & external lesion Eg...trauma
• Foreign body in vagina
• Precocious puberty
• Trauma ..... sexual abuse
17. Childhood
• In this age group, the vagina, rather than the uterus, is
the most common source of bleeding.
• Vulvovaginitis is the most frequent cause, but dermatologic
conditions, neoplastic growths, or trauma by accident,
abuse, or foreign body may also be reasons.
• True uterine bleeding usually is caused by increased
estrogen levels.
* Precocious puberty,
* accidental exogenous ingestion, or
* ovarian neoplasms should be considered in these
children
18. ADOLECENCE
B. Adolescence
• Anovulation
• Pregnancy related causes
• Exogenous hormone use
• Coagulopathy
• other,...cervicitis, PID
AUB in adolescents results from anovulation and
coagulation defects at disproportionately higher rates
compared with older reproductive-aged women
In contrast, neoplastic growths such as polyps,
leiomyomas, & ovarian neoplasms are less frequent
19. Cont...
C. Reproductive age
• pregnancy related causes
• Anovulation
• Exogenous hormones
• Myoma
• Cervical and endometrial polyp
20. REPRODUCTIVE AGE
• Following adolescence, the H-P-O axis matures &
anovulatory uterine bleeding is encountered less
frequently.
• With increased sexual activity, bleeding related to
pregnancy and STD increases.
• The incidence of leiomyomas and endometrial polyps
increases with age, & thus bleeding from these lesions
becomes common in older reproductive aged women
21. D. Perimenopause
• Anovulation
• Myoma
• Cervical & endometrial polyp
• Thyroid dysfunction
• AUB is a frequent clinical problem, accounting for 70 % of all
gynecologic visits by peri- and postmenopausal women.
• As with perimenarchal girls, anovulatory uterine bleeding
from dysfunction of the hypothalamic-pituitary-ovarian axis
becomes a more common finding in this group.
• Alternatively, the incidence of bleeding related to pregnancy
and sexually transmitted disease decreases.
• With increasing age, there are greater risks of benign and
malignant neoplastic growth.
22. POST MENOPAUSAL BLEEDING
• Def :- any vaginal bleeding 6 or more month after
menopause
Etiology
• Atrophic endometritis or vaginitis..... common cause
• Exogenous estrogen (HRT)
• Endometrial or cervical polyp
• Endometrial hyperplasia
• Endometrial cancer
• Cervical ca, uterine sarcoma
23. CONT..
• Bleeding after menopause typically originate from
benign disease.
• majority of cases resulted from atrophy of the
endometrium.
• Benign endometrial polyps may also cause bleeding
in this pop/n.
• malignant neoplasms, especially endometrial
carcinoma, are found more frequently in this age
group than in others.
24. • Less commonly, estrogen-producing ovarian carcinoma
may cause endometrial hyperplasia with uterine bleeding.
• Similarly, ulcerative vulvar, vaginal, or cervical neoplasms
may also be sources.
• As with prepubertal females, because bleeding from the
rectum, vagina, or urethra may be confused by an elderly
woman. Thus, clear determination of the site of bleeding
is critical
25. DUB
• Diagnosis of DUB is made by exclusion of organic
structural causes of AUB
• Most common cause of AUB extreme age of women
reproductive year
• It is a disorder chxed by dysfunction of uterus, ovary,
pituitary, hypothalamus
• 90% of DUB result from anovulation
• 10% of DUB occur in ovulatory cycle
26. Dysfunctional Uterine Bleeding
• Up to ½ of women with abnormal bleeding will have DUB .
• In 80 to 90 % of these, bleeding results from dysfunction of
the H-P-O axis, which leads to anovulation .
• B/s anovulatory cycles produce no progesterone to stabilize
cyclic withdrawal of the estrogen-prepared endometrium,
bleeding episodes become irregular and amenorrhea,
metrorrhagia, and menorrhagia are common.
• For example, many women with anovulation may have
amenorrhea for weeks to months followed by irregular,
prolonged, and heavy bleeding.
• In the other 10-20 % of women with DUB, ovulation occurs
cyclically, and menorrhagia is thought to originate from
defects in the control mechanisms of menstruation
27. Pathophysiology Anovulatory DUB
• No progesterone is produced when ovulation does not
occur, and thus proliferative endometrium persists.
• At the tissue level, persistent proliferative endometrium
is often associated with stromal breakdown, decreased
spiral arteriole density, and increased dilated and
unstable venous capillaries .
• At the cellular level, the availability of arachidonic acid is
reduced, and prostaglandin production is impaired.
• For these reasons, bleeding associated with anovulation
is thought to result from changes in endometrial
vascular structure and in prostaglandin concentration,
and from an increased endometrial responsiveness to
vasodilating prostaglandins
28. Ovulatory DUB
• Whereas anovulatory DUB results from alterations in
vascular architecture and tone, ovulatory DUB is thought
to stem predominantly from vascular dilatation alone.
• For example, women with ovulatory bleeding lose blood
at rates 3 times faster than women with normal menses,
but the number of spiral arterioles is not increased .
• Thus in women with ovulatory DUB, it is thought that the
vessels supplying the endometrium have decreased
vascular tone and therefore increased rates of blood loss
resulting from vasodilatation .
• A number of causes that provoke this change in vascular
tone have been suggested, and prostaglandins have been
strongly implicated
29. EVALUATION OF AUB
• Diagnostic rules
1. consider pregnancy - AUB in reproductive age should be
consider complication of pregnancy unless prove other wise
2. consider coagulopathy - all adolescent with menorrhagia
with sever anemia should have evaluation for coagulopathy
3. consider pelvic lesion in women with evidence of ovulation
4. consider malignancy
5. consider hypothyroidism
6. consider DUB
30. Evaluation of AUB
History
• age
• Address
• menstrual history
- age of menarche
- frequency, duration of flow
- no of pads used per day
- passage of blood clots
- dysmenorrhea
- LMP
31. contd….
• Lower abdominal pain
• Excessive weight gain, fatigue, constipation
• Galactorrhea, loss of lateral field vision
• Easy skin bruisability, petechae
• History of STD
• Contraceptive history, drug use
32. Physical examination
• Vital signs, body habitus
• Check the skin for bruising, acne, hirsuitism,
acantosis nigrans
• Examine the thyroid
• Examine breast
• Examine abdomen
• Examine genital tract
34. Diagnosis
• The diagnostic goal with abnormal uterine bleeding
is to exclude cancer and to identify the underlying
pathology to allow optimal treatment.
• Technologic advances have changed the evaluation
of women with abnormal uterine bleeding, and
sonography, endometrial biopsy, and hysteroscopy
are used primarily.
• Many diagnostic algorithms of uterine bleeding focus
on identification of endometrial cancer.
• 80-90% of women with this cancer present with AUB.
35. Cont..
• The incidence & risk of endometrial carcinoma
increases with age and ¾ of women with this
malignancy are postmenopausal.
• Thus, in postmenopausal patients, the need to
exclude cancer intensifies & endometrial biopsy is
warranted.
• In the remaining 25 % of premenopausal women
with endometrial cancer, only 5 % are less than 40
years of age .
36. • Most of these premenopausal women are obese
or have chronic anovulation, or both .
• Thus, obese or anovulatory women with AUB
should also have endometrial cancer excluded.
• endometrial assessment is recommended in any
woman older than 35 years with abnormal
bleeding and in those younger than 35 years who
are suspected of having anovulatory uterine
bleeding refractory to medical management
37. Transvaginal Sonography
• this technology is chosen by many instead of endometrial
biopsy as a first-line tool to assess abnormal bleeding.
• If abnormal bleeding stems from myometrial pathology
such as leiomyomas or adenomyosis, sonography offers
anatomic information regarding the myometrium that is
not afforded by hysteroscopy or endometrial biopsy.
• In addition, transvaginal sonography (TVS) compared with
these other two offers greater patient comfort and
comparable detection of endometrial hyperplasia and
cancer
38. cont
• Endometrial thickness, which changes with the
menstrual cycle, has been correlated with
endometrial cancer risk in postmenopausal women
• Women with endometrial thicknesses >5 mm
warrant additional evaluation with saline-infusion
sonography (SIS), hysteroscopy, or endometrial
biopsy
• Endometrial thickness guidelines, however, have
not been established for premenopausal women.
39. • the normal endometrial thickness in premenopausal
women did not > 4 mm on day 4 of the menstrual
cycle, nor did it measure over 8 mm by day 8.
• a persistent finding of endometrial thickness,
independent of cycle day, measuring 12 mm should
prompt further evaluation in these women, especially
in those with risk factors for endometrial CA.
• Risks include extended AUB, chronic anovulation,
nulliparity, diabetes, obesity, hypertension, and
tamoxifen use
40. cont
• Qualities other than endometrial thickness are
also considered, and textural changes may
indicate pathology.
• For example, punctate cystic areas within the
endometrium may indicate a polyp.
• Conversely, hypoechoic masses that distort
the endometrium and originate from the inner
layer of myometrium most commonly are
submucosal fibroids.
• Although there are no specific sonographic
findings that are characteristic of endometrial
cancer, some findings have been linked with
greater frequency.
41. • For example, intermingled hypo- and hyperechoic
areas within the endometrium may indicate
malignancy.
• Endometrial cavity fluid collections and an
irregular endometrial-myometrial junction have
also been implicated.
• Thus, even with a normal endometrial stripe
width, endometrial biopsy or hysteroscopy with
biopsy should be performed to exclude
malignancy when there is heterogeneous
endometrial echogenicity or fluid collection
42. Saline-Infusion Sonography
• This simple, minimally invasive, and effective sonographic
procedure can be used to accurately evaluate the myometrium,
endometrium, and endometrial cavity.
• To perform SIS, a small catheter is threaded through the
cervical os into the endometrial cavity.
• Through this catheter, sterile saline is infused, and the uterus is
distended.
• Sonography is then performed using a traditional transvaginal
technique.
• This method allows visualization of common masses associated
with abnormal uterine bleeding such as endometrial polyps,
submucosal myomas, and intracavitary blood clots.
• Whereas these frequently create nondescript distortion or
thickening of the endometrial lining when imaged with TVS, SIS
typically permits detection of intracavitary masses as well as
differentiation of lesions as being endometrial, submucosal, or
intramural
43. cont• Importantly, neither hysteroscopy nor SIS can reliably discriminate between
benign and malignant focal lesions.
• Thus, because of the malignant potential of many focal lesions, excision of
most structural lesions, when identified, is recommended for those with risk
factors.
• For this, operative hysteroscopy is typically used.
• Another disadvantage to SIS is that it is best performed in the proliferative
phase of the cycle to minimize false-negative and false-positive results.
• For example, focal lesions may be concealed in a thick, secretory
endometrium. Also, the amount of endometrial tissue that can develop
during the normal secretory phase can be mistaken for small polyps or focal
hyperplasia.
• For many, SIS has more patient discomfort than TVS, and about 5 percent of
examinations cannot be completed because of cervical stenosis or patient
discomfort. As expected, stenosis is more prevalent in postmenopausal
women .
• This rate of incompletion mirrors that of diagnostic hysteroscopy.
• Although accurate for identifying focal lesions, SIS may not add to the value of
TVS alone to evaluate diffuse lesions such as hyperplasia and cancer.
• Therefore, in postmenopausal women with abnormal bleeding, and in whom
the exclusion of cancer is more relevant than evaluating focal intracavitary
lesions, use of SIS as an initial diagnostic tool may not have advantages over
TVS alone.
44. Transvaginal Color Doppler
Sonography
• This technique has been evaluated in identifying and differentiating
endometrial pathology in the context of uterine bleeding .
• transvaginal color Doppler sonography (TV-CDS) used to
differentiate between submucous leiomyomas and endometrial
polyps.
• endometrial polyps had only one arterial supply, whereas
submucosal leiomyomas generally received blood flow from several
vessels arising from the inner myometrium .
• Others have tried unsuccessfully to measure flow impedance to
determine malignant transformation within polyps.
• Thus, hysteroscopic excision and histopathologic evaluation of
endometrial polyps are still necessary for those at risk
45. Hysteroscopy
• This procedure involves inserting an optic endoscope, usually 3 to 5
mm in diameter, into the endometrial cavity.
• The uterine cavity is then distended with saline or another medium
for visualization.
• In addition to inspection, biopsy of the endometrium allows histologic
diagnosis of visually abnormal areas and has been shown to be a safe
and accurate means to identify pathology.
• In fact, for many studies done to investigate the accuracy of TVS or
SIS for evaluation of intracavitary uterine pathology, hysteroscopy is
used as the gold standard for comparison.
• The main advantage of hysteroscopy is to detect intracavitary lesions
such as leiomyomas and polyps that might be missed using
transvaginal sonography or endometrial sampling .
• In fact, some have advocated hysteroscopy as the primary tool for the
diagnosis of abnormal uterine bleeding.
• Although it is highly accurate for identifying endometrial cancer, it is
less accurate for endometrial hyperplasia.
• Thus, some recommend endometrial biopsy or endometrial curettage
in conjunction with hysteroscopy
46. cont• There are other limitations to hysteroscopy.
• Cervical stenosis sometimes will block successful introduction of the endoscope, and heavy
bleeding may limit an adequate examination.
• The use of misoprostol, 100 mg orally the evening before and the morning of hysteroscopy, is
useful for cervical softening in patients with suspected cervical stenosis.
• Hysteroscopy is more expensive and technically challenging than TVS or SIS.
• Many perform hysteroscopy in their office, whereas others prefer a day-surgery setting to provide
increased patient analgesia.
• Obviously, greater cost and anesthetic risks can attend completion in this latter setting.
• Although it can be painful, use of a 3.5-mm minihysteroscope instead of the conventional 5-mm
endoscope significantly decreases patient discomfort during office hysteroscopy
• Associated infection and uterine perforation have been reported with hysteroscopy, but
fortunately their incidence is low .
• There is concern that peritoneal seeding with malignant cells may take place during hysteroscopy
in some women subsequently diagnosed with endometrial cancer .
• Caution is advised with hysteroscopy in women at high risk for endometrial cancer, and some
suggest a negative endometrial biopsy result is necessary before hysteroscopy is done .
• Although there may be a risk of peritoneal contamination by cancer cells with hysteroscopy, there
is no evidence that the prognosis for patients is worsened
47. Summary of Diagnostic Procedures
• There is no one clear sequence to use of endometrial biopsy,
TVS, SIS, and hysteroscopy when evaluating AUB
• None of these will distinguish all anatomic lesions with high
sensitivity and specificity.
• That said, TVS for several reasons is a logical first step. It is
well-tolerated, cost-effective, and requires relatively minimal
technical skill. Additionally, it has the advantage of reliably
determining whether a lesion is diffuse or focal.
• Once anatomic lesions have been identified, subsequent
evaluation requires individualization.
• If endometrial hyperplasia or cancer is suspected, then
endometrial biopsy may offer advantages.
• Alternatively, possible focal lesions may be best investigated
with either hysteroscopy or SIS. Ultimately, the selection of
appropriate tests depends on their accuracy to characterize
the most likely anatomic lesions.
48. MANAGEMENT
• Goal of treatement of DUB
To control bleeding
Prevent recurrence
Preserve fertility
• Management depend on;-
Severity of bleeding
Age of patient and desire for future fertility
Presence of associated patology
49. Cont...
• Medical treatment of AUB
1. Controll of heavy bleeding
A. High dose estrogens
B. High dose coc pills
• Hemodynamic instability
Establish ABC
Open iv line
Prepare cross mach blood
51. The steps for placing of these are:
• Place a speculum in the vagina and visualize
the cervical os.
• Sterilize the cervix by swabbing.
• Stabilize the cervix by placing a single tooth
tenaculum or ring forcep
• Grasp the balloon or gauze with a long Kelly or
ring forceps and insert
52. • balloon, it is inflated after it is inserted into the uterus.
• Most commonly a 30 mL Foley catheter is used.
• if brisk bleeding continues and the uterus is enlarged a
larger balloon may be required
53. • Gauze, a continuous piece of gauze is preferred
to avoid retained pieces of gauze upon
removal.
• Gauze is placed until no further gauze can be
admitted.
• Firm, but not excessive, pressure is used
to avoid uterine perforation
54. Therapeutic measures
Uterine curettage-
• treatment of choice for profuse uterine
bleeding
• it can be performed rapidly,
• with cessation or significant decrease in
bleeding in less than one hour
55. High dose intravenous estrogen
– beneficial in combination with other measures
MOA-
• promotes rapid regrowth of endometrium
• stabilizes lysosomal membranes, and
• stimulates proliferation of endometrial ground
substance
If bleeding does not subside after 8hrs,
IV E should be stopped and other treatments
employed
If bleeding subsides,
IV E dc and an oral maintenance regimen is
prescribed;
56. Option –
Oral CEE — We use Premarin 2.5 mg four
times per day until the bleeding subsides or is
minimal
Oral contraceptive pill with 35 mcg estrogen
We use two pills per day for 5 days
followed by once a day for 20 days.
57. Uterine artery embolization —
• As a first line therapy
arteriovenous malformation
• limited use b/c-cannot be performed
as rapidly
• effective alternative to hysterectomy
Preserve their uterus
Hysterectomy -
In rare cases in which the above
measures fail
hysterectomy is a last resort.
58. • HEMODYNAMICALLY STABLE WOMEN
Hormonal treatments-
are the mainstay of therapy
with prolonged bleeding that is not
profuse ,lower doses of ocps are the best
option
59. High dose oral estrogen
First line therapy .
Premarin 2.5 mg qid until the bleeding
subsides or is minimal
moderate bleeding, twice daily.
discontinue after 21 to 25 days and
a progestin should be given
Depo 10mg/day for 10 days
60. • High dose causes nasea and vomiting
• antiemetic may be used
promethazine 12.5 to 25 mg per rectum)
High dose progestins
• Profuse or prolonged uterine hemorrhage
related to anovulation
61. • progestins-
inhibit further endometrial growth
organize and support the estrogen-primed
endometrium,
allowing effective sloughing upon hormone
withdrawal
in a denuded endometrium, progestins are
unlikely to be effective
62. • Progestins are continued for at least
5 to 10 days
• In anemic patients
a one- to two-month treatment
period in conjunction with iron
63. • Androgens (Danazol and Gestrinone)
creates a hypoestrogenic and
hyperandrogenic environment, induces
endometrial atrophy
• GnRH Agonists
• Create hypoestrogenic state,
induces endometrial atrophy and
amenorrhea in most women
may be helpful for
• short-term use in inducing amenorrhea
and allowing women to rebuild their RBC
mass prior to surgery.
64. • Tranexamic acid —
1 to 1.5 g po tid or qid
acts within two to three hours of
administration
• The drug exerts an antifibrinolytic effect
block lysine binding sites on plasminogen,
preventing fibrin degradation
65. • We use tranexamic acid
only when other options have been
unsuccessful and
only in women who are not at a high risk
of thrombosis
• Endometrial ablation
an effective Rx for acute or prolonged uterine
bleeding and
is used in medical therapy is contraindicated or
unsuccessful
66. • Hysteroscopy prior to ablation
• to identify and treat endometrial polyps or
intracavitary leiomyomas.
67. Management of DUB
1. Hormonal Rx
- Is the main stay of treatment.
Numerous regimens are available, including estrogens
followed by progesterone, progesterone alone, or
combination oral contraceptives.
Oral contraceptives, 3–4 times the usual dose, are
effective and may be simpler to use. Then the dose is
lowered after a few days and the lower dose is continued
for the next few cycles, particularly to raise the
hemoglobin levels in an anemic patient.
In adolescents in whom the bleeding is not severe, oral
contraceptives can be used as normally prescribed(one
pill per day).
68. • Medical treatment of dysfunctional uterine
bleeding includes tranexamic acid
(antifibrinolytic agent), NSAIDs, COCs,
progestins, androgens, and agonists of
gonadotropin-releasing hormone (GnRH
agonists)
69. Management of DUB…
2. Surgical Measures
For patients whose bleeding cannot be controlled with
hormones, who are symptomatically anemic, and
whose lifestyle is compromised by persistence of
irregular bleeding, D&C may temporarily stop bleeding.
If bleeding persists, levonorgestrel-releasing IUDs or a
minimal invasive procedure such as endometrial
ablation may be done.
However, if these minimally invasive procedures fail or
if the patient prefers a definitive solution,
hysterectomy may be necessary.
