Presentation on Abnormal uterine bleeding

1. Abnormal Uterine
Bleeding

2. 2
Many terms
Menorrhagia
Hypermenorrhea
2
Metrorrhagia
Menometorrhagia
Amenorrhea
Polymenorrhea Oligomenorrhea

3. 3
What’s normal?
Character Descriptive term Normal limits
Frequency of menses
Frequent
Normal
Infrequent
<21
21-38
>38
Duration of flow
Prolonged
Normal
Shortened
>8
3-8
<3
Volume of monthly blood loss,
mL
Heavy
Normal
Light
>80
5-80
<5

4. 4
Etiology of AUB

5. 5

6. 6
Classification: PALM-COEIN

7. 7
Structural causes (PALM)
A.Polyps – AUB-P
◦ endocervical or
endometrial
B.Detected by
ultrasound or
sonohysterography
C.Often irregular, light
bleeding

8. 8
Structural causes (PALM)
A.Adenomyosis –
AUB-A
B.Controversial as a
cause of bleeding
C.Diagnosed with
ultrasound, MRI,
pathology

9. 9
Structural causes (PALM)
A.Leiomyoma – AUB-L
◦ Submucous
◦ Intramural
◦ Subserosal
B.Diagnosed with exam,
ultrasound, MRI, CT
C.Heavy, regular
bleeding

10. 10
Structural causes (PALM)
A.Malignancy and
hyperplasia – AUB-
M
B.Diagnosed by
biopsy
C.Irregular bleeding

11. 11
Non-structural causes COEIN
Coagulopathies or bleeding disorders
Ovulatory dysfunction
Endometrial
Iatrogenic sources (medications, smoking)
Not yet classified

12. 12

13. 13
Hysteroscopy
13
Sonohysterogram
U/S
MRI

14. 14
Management

15. 15
Management
A.Medical management should be initial
treatment for most patients
B.Need for surgery is based on various factors
(stability of patient, severity of bleed,
contraindications to med management,
underlying cause)
◦ Type of surgery dependent on above +
desire
for future fertility
C.Long term maintenance therapy after acute
bleed is controlled

16. 16
Treatment - Acute
A.Unstable
Tranexemic acid
Blood transfusion
IV Fluids
B.Stable:Oral meds
◦ Medroxyprogesterone (Provera) – 10 mg BD
Norethisterone 10 mg TDS- BD
OCPs
Hematinics

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Chronic Treatment Considerations
A.Etiology and severity of bleeding (eg, anemia,
interference with daily activities)
B.Associated symptoms (eg, pelvic pain, infertility)
C.Contraceptive needs or plans for future pregnancy
D.Contraindications to hormonal or other medications
E.Medical comorbidities
F.Patient preferences regarding medical versus surgical
and short-term versus long-term therapy

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Non-surgical treatment Options
A.Expectant management
B.NSAIDs
C.Antifibrinolytic agents - Tranexemic acid (Lysteda)
D.Hormonal methods
1. Combination methods
2. Levonorgestrel IUD
3. Cyclic progestin
4. GnRH agonists (leuprolide)
E.Metformin and other insulin-sensitizing drugs for irregular
bleeding in women with polycystic ovary syndrome

19. 19
Surgical Management Options
A.D&C
B.Endometrial Ablation
C.Uterine Artery Embolization
D.Hysterectomy

20. 20

21. 21
Case 1
A 35 year old female is evaluated for a 5 month history of heavy
menstrual bleeding. She has been menstruating for the last 8
days and is still going through 10 pads or more daily with frequent
clots. She has fatigue but no dizziness. She and her husband
would like to conceive a 2nd child next year. She does not smoke.
PMHx: DM2
Vitals: Afebrile, BP 138/71, HR 80. BMI 40.2
Pelvic exam: moderate amount of blood in vaginal vault.
What do you want to do next?

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Case 1(continued)
urine hcg is negative.
Hct 30
Biopsy is negative.
Pelvic u/s shows a large submucosal fibroid. You consult ob/gyn
for a myomectomy, scheduled in 2 weeks.
Which of the following is the most appropriate next step in
management?
A. Levonorgestrel IUD (Mirena)
B. Estrogen
C. Estrogen-progesterin oral contraceptive
D. Re-evaluate in 2 weeks
22

23. 23
Case 1: Correct Answer = C
Estrogen-progestin OCP and IUD are effective
treatments for heavy menstrual bleeding.
Estrogen/progestin OCP is the better choice as pt
is planning to conceive in the near future. Pt also
does not have any contraindications to estrogen.
PE and DVT are complications of IV estrogen.
Monitoring (D) is not appropriate given her
significant, ongoing blood loss.

24. 24
49 year old women presents to your primary care clinic with a 3 day history of
heavy menstrual bleeding. She denies dysmenorrhea but reports that her
menstruation cycle have been increasingly irregular over the past couple years,
including bleeding between periods. She is not sexually active and had a
bilateral tubal ligation 10 years ago.
Her physical exam demonstrated normal vital signs, no signs of hypovolemia,
no bruises. Pelvic exam was unremarkable for tenderness, nodularities, or
abnormal size uterus. Cervix was normal with blood in the os.
What do you want to do next?
Case 2

25. 25
Case 2 (continued)
Pregnancy test is negative and pap smear was performed
and was wnl.
Which of the following is the most appropriate next step in
management of this patient?
A.Endometrial biopsy
B.Measure serum LH and FSH
C.Pelvic U/S
D.Oral contraceptives
25

26. 26
Case 2: Correct Answer = A
A. Endometrial biopsy—Need to rule out
endometrial cancer in patients older than 45
with AUB
B. Measuring LH and FSH can confirm
menopause, but does not rule out endometrial
cancer.
C. Pelvic ultrasound– good with uncertain
findings on pelvic exams
D. Oral contraceptives are appropriate for
patients with anovulatory bleedings. But
endometrial carcinoma needs to be ruled out

27. 27
26 year old female presents with 4 days of history of light vaginal bleeding after
intercourse. Prior to this incident, she reports regular menstruation cycle and no
vaginal discharge.
Her physical exam was unremarkable. Her pelvic exam was unremarkable
except small amount of blood in the cervical os.
What is the next best step in management?
A. Perform endometrial biopsy
B. Start oral contraceptive
C. Perform pelvic ultrasound
D. Urine HCG
Case 3

28. 28
Case 3: Correct Answer = D
A. Endometrial biopsy is important to rule of endometrial
cancer. In this younger patient, need to rule out more
common causes initially
B. Oral contraceptives are appropriate in anovulatory women.
However, need to rule out endocrine and pregnancy first
C. Pelvic ultrasound important for the identification of
anatomical abnormalities or staging of pregnancy. However,
pelvic exam was unremarkable and screening of pregnancy
with serum markers has not been performed yet
D. Urine HCG– Pregnancy is a common cause of abnormal
uterine bleeding and needs to be ruled out in all women who
have not gone through menopause

29. 29
Case 4
A 46 year old woman presents to your office with a complaint of intermenstrual bleeding. Her
last menstrual period ended 10 days ago, however for the past 3 days she noticed bleeding
requiring 3-4 pads/daily. She reports that prior to this her periods were regular, lasting 5 days
with occasional light intermenstrual bleeding over the last 6 months. She is sexually active and
uses barrier contraception.
On physical exam she was afebrile, BP 134/86, HR 74. Pelvic exam demonstrated slightly
enlarged, globular uterus, with blood noted in cervical os. Pregnancy test is negative.
Which of the following is the most appropriate next step in the evaluation of this patient?
A. Magnetic resonance imaging
B. Transvaginal ultrasound
C. Hysteroscopy
D. Reassurance and monitoring

30. 30
Case 4: Correct Answer = B
A. MRI is not the primary imaging modality to
evaluate AUB, however may be used as a
follow-up test after ultrasonography
B. Transvaginal ultrasound is important in this
patient with AUB and exam findings
suggestive of structural abnormality. Would
consider EMB as >45 yo.
C. Hysteroscopy/SIS should be done in patients
with concerning uterine cavity findings on
TVUS
D. Monitoring would not be appropriate in the
setting of abnormal bleeding and concerning

31. 31
Case 5
A 29 year old woman presents to your office with a complaint of heavy
menstrual bleeding. She has been menstruating for the last week with
persistent heavy bleeding and passage of clots. She denies being sexually
active. She is a current smoker (1-2 pack/day) and her only medications are
metformin .
On physical exam she was afebrile, BP 154/102, HR 62. BMI 31. Pelvic exam
demonstrated moderate amount of blood in vault.
What do you want to do?

32. 32
Case 5 (continued)
Pregnancy test negative. Endometrial biopsy was performed and results are
negative for malignant or hyperplastic disease.
Which of the following is the most appropriate next step in the management of
this patient?
A. Estrogen-progestin oral contraceptive
B. Endometrial ablation
C. Levonorgestrel (Mirena) IUD
D. Hysterectomy
32

33. 33
Case 5: Correct Answer = C
A. Estrogen-progestin OCPs are effective in the treatment
of heavy menstrual bleeding, however this patient has
several risk factors for thrombosis
B. Endometrial ablation is a minimally invasive option in
patients in which medical therapy has failed. Medical
therapy should be initiated, also it is unknown whether
the patient wants to maintain fertility
C. Levonorgestrel IUDs are effective in the treatment of
heavy menstrual bleeding and would be an appropriate
choice in this patient with contraindications to estrogen
use
D. Hysterectomy is curative in the treatment of uterine
bleeding, however medical therapy and less invasive
treatments are preferred initially