2. Definition
Abnormal uterine bleeding (AUB) refers to menstrual bleeding of abnormal quantity,
duration, or schedule.
A common gynaecological complaint (1/3 of visits)
A United States population-based survey of women ages 18 to 50 years reported an
annual prevalence rate of 53 per 1000 women
Caused by a wide variety of local and systemic diseases or related to medications
3. Terminology
Structural causes
Hormonal causes-Dysfunctional uterine bleeding
Systemic diseases that cause abnormal uterine bleeding
4. PALM-COEIN Classification
Structural Imaging, Histology Or Both
Polyp
Adenomyosis
Leiomyoma
Malignancy and hyperplasia
Unrelated To Structural Abnormalities
Coagulopathy
Ovulatory disorders
Endometrium
Iatrogenic
Not Classified
5. Normal Menses
Frequency: every 21 to 35 days
Occurs at fairly regular intervals
Volume of blood ≤80 mL
Volume of blood is difficult to measure. In clinical practice, heavy menses are generally defined
as:
soaking a pad or tampon more than every two hours, or
a volume of bleeding that interferes with daily activities (eg, wakes patient from sleep,
stains clothing or sheets).
Duration is 2-5 days
Normal menstrual bleeding is a oestrogen- progesterone withdrawal bleeding
6. Patterns of Abnormal Bleeding
Hypermenorrhoea (menorrhagia): Heavy/prolonged bleeding
Hypomenorrhea: light menstrual flow
Obstruction: cervical or hymenal stenosis
Oral contraceptives, LNG-IUD
Uterine synechia (Asherman’s syndrome)
Polymenorrhagia: Periods that occur less than 21 days apart
Oligomenorrhea: Periods that occur more than 35 days apart
7. Metrorrhagia (intermenstrual bleeding): bleeding that occurs at any time between
menstrual periods
Menometrorrhagia: bleeding that occurs at irregular intervals. Amount and duration may
vary
Contact bleeding (Postcoital bleeding)
8. Initial Evaluation-History
Gynaecologic and obstetric history
Menstrual history, LMP
Sexual intercourse? Trauma? (Bleeding after trauma usually suggests vaginal or cervical
Etiology)
Contraceptive use (IUD, OCP, progestin-only pill use)
Other medical history
Systemic diseases (especially endocrine, liver, renal, and haematological diseases)
Family history (esp. bleeding disorders)
Medication use (hormonal, drugs that ↑PRL, anticoagulants)
Excessive exercise, eating disorders
9. Is the patient pregnant?
All patients with AUB should have pregnancy testing
It should also be performed in women who report no sexual activity and in those who
report use of contraception.
Is the patient premenarchal or postmenopausal?
The differential diagnosis of AUB for reproductive-age women differs from that of
premenarchal or postmenopausal patients
10. Initial Evaluation-Symptoms
Are there any associated symptoms?
Lower abdominal pain, fever, and/or vaginal discharge could indicate infection (pelvic
inflammatory disease [PID], endometritis)
Dysmenorrhea, dyspareunia or infertility suggest endometriosis and possible adenomyosis.
Changes in bladder or bowel function suggest extrauterine uterine bleeding or a mass effect
from a neoplasm.
Galactorrhoea, heat or cold intolerance, hirsutism, or hot flashes suggest an endocrinological
issue.
11. Initial Evaluation-Physical Exam
Vital signs should be assessed first
A general examination should be performed to look for
signs of systemic illness, such as
Anaemia
Fever
Ecchymoses
Enlarged thyroid gland
Evidence of hyperandrogenism (hirsutism, acne, clitoromegaly, or male pattern balding)
Acanthosis nigricans may be seen in women with polycystic ovarian syndrome (PCOS)
Galactorrhoea (bilateral milky nipple discharge) suggests the presence of hyperprolactinemia
12. A complete pelvic examination should be performed
Abnormal findings along the genital tract (mass, laceration, ulceration, friable area, vaginal or
cervical discharge, foreign body)
An enlarged uterus → pregnancy, leiomyoma, adenomyosis, malignancy
Limited uterine mobility → pelvic adhesions or a pelvic mass
Pelvic adhesions → prior infection, surgery, or endometriosis
A boggy, globular, tender uterus is typical of adenomyosis.
Uterine tenderness → pelvic inflammatory disease (PID)
Presence of an adnexal mass or tenderness
16. Labs: Acute AUB
Pregnancy test (b-hcg)
FBC, UEC
Group and cross match blood
Coagulation study - e.g. PTT/INR; when indicated - vW-factor assay, ristocetin cofactor assay, Factor
VIll etc.
TSH, LFT, Nutritional/iron studies, renal, adrenal function in most patients
17. Labs: Chronic AUB
Pap Smear / Cervical cytology
Hormonal Assay - FSH/LH, Prolactin levels,
Nutritional/iron studies
Gonorrhoea/Chlamydia in high risk patients
Retroviral screen
Endometrial biopsy / endometrial sampling in an older patient
18. Imaging
Pelvic Ultrasound
TVUS: (transvaginal US is the primary imaging of uterus for evaluation of AUB)
Sono-hysterography (aka saline infusion sonohysterography)
Hysteroscopy
MRI
22. Defination
It is irregular proliferation of the endometrial glands with an increase in the gland to stroma ratio
when compared with proliferative endometrium
Endometrial hyperplasia is the precursor of endometrial cancer which is the most common
gynecological malignancy in the Western world.
The incidence of endometrial hyperplasia is estimated to be at least three times higher than
endometrial cancer
23. Epidemiology
The most common presentation of endometrial hyperplasia is abnormal uterine bleeding; includes
heavy menstrual bleeding
inter-menstrual bleeding
irregular bleeding
unscheduled bleeding on HRT
Postmenopausal menopause
24. Risk Factors
Increased body mass index (BMI) ; with excessive peripheral conversion of androgens in
adipose tissue to estrogen;
Anovulation associated with the perimenopause or polycystic ovary syndrome (PCOS);
Estrogen-secreting ovarian tumors, e.g. granulosa cell tumors (with up to 40% prevalence
of endometrial hyperplasia)
Drug induced endometrial stimulation e.g. the use of systemic ERT or long-term
tamoxifen
25. Clinical presentation
The most common clinical presentation of patients with endometrial hyperplasia is abnormal
uterine bleeding, whether in the form of menorrhagia, metrorrhagia, or post menopausal
bleeding
vaginal discharge
26.
27. Diagnosis
Histological examination by outpatient endometrial sampling
Diagnostic hysteroscopy should be considered if biopsy fails or is nondiagnostic, or if
endometrial hyperplasia is diagnosed in a polyp or other isolated focal lesion.
Trans-vaginal ultrasound may have a role in the diagnosis of endometrial hyperplasia in pre- and
postmenopausal women.
Dilation and curettage D&C
