Approach to abnormal uterine bleeding Definitions Causes - multisystemic Management/Treatment

1. Abnormal Uterine Bleeding

2. Bleeding is considered to be abnormal in the
following situations:
• Bleeding between periods
• After sex
• Spotting any time in the menstrual cycle
• Bleeding that is heavier than normal or prolonged duration
• Bleeding after menopause

3. Definitions
Abnormal uterine bleeding includes the following:
• Menorrhagia – increase in the volume or duration or both. Menstrual cycle
is regular.
• Polymenorrhoea – normal volume and duration of menstruation but
shortened cycle – decreased interval <25 days
• Metrorrhagia – bleeding independent of menstrual pattern. Volume not
usually excessive.
• Menometrorrhagia – increased flow during menstruation and between
menstrual periods. No pattern. Flow may become continuous.
• Oligomenorrhoea – normal volume and duration of menstruation but
lengthened cycle >35 days

4. Aetiology
Classifications:
• Dysfunctional uterine bleeding
• Pregnancy related
• Blood disorders
• Genital tract pathologies
• Iatrogenic
• Endocrine
• Systemic disorders

5. Dysfunction Uterine Bleeding
Bleeding in the absence of organic disease.
Ovulatory:
Due to problems with corpus luteum
1. Poor formation or function of corpus luteum
• Leads to decreased secretion of oestrogen and progesterone during
the luteal phase (second half) of cycle.
• In addition there is irregular ripening of endometrium.
• Presents with premenstrual spotting, menorrhagia, or
polymenorrhoea.

6. Ovulatory DUB cont
2. Irregular shedding of endometrium
• Persistence of corpus luteum therefore persistent progesterone
secretion during menstruation.
• Prolonged luteal phase.
• Therefore postmenstrual spotting occurs – bleeding continues
intermittently for several days after normal menstrual flow has
stopped.
• Associated with menorrhagia or oligomenorrhoea.

7. DUB cont
Anovulatory
Bleeding is not preceded by ovulation therefore luteal secretory changes
absent.
1. Excessive oestrogen stimulation of endometrium
• Progesterone absent therefore it can’t counter effects of oestrogen.
• Results in endometrial hyperplasia and no bleeding during this time.
• Eventually oestrogen levels fluctuate and decrease leading to heavy
bleeding from the hyperplastic endometrium.
• Cyclical and regular OR acyclical and irregular OR prolonged amenorrhoea
follow by bouts of metropathia haemorrhagica (excessive bleeding).

8. Anovulatory DUB cont
2. Inadequate oestrogen stimulation
• Circulating oestrogen levels low
• Therefore endometrium proliferation is present to a lesser degree
• Waxing and waning of oestrogen production leading to drop in
oestrogen level. Endometrium cannot be maintained – bleeding
occurs.
• Acyclical and irregular

9. Pregnancy related bleeding
• Miscarriage: the ending of a pregnancy before viability of foetus is
reached. Presents with vaginal bleeding that ranges from light to
heavy and is accompanied by abdominal and back pain – according to
stage of miscarriage.
• Ectopic pregnancy: is implantation of blastocyst anywhere other than
the endometrial lining of uterine cavity. Presents with amenorrhoea
followed by vaginal bleeding and abdominal pain.
• Gestational trophoblastic disease: abnormal proliferation of the
trophoblast – range from benign to malignant. Complete mole will
present with vaginal bleeding between 11th and 25th week of
pregnancy as well as persistent and excessive nausea and vomiting.

10. Blood Disorders
• Thrombocytopaenia
• Von Willebrand’s disease
• Leukaemia
Present with menorrhagia

11. Genital Tract Pathology
• Congenital uterine abnormalities: Mullerian duct abnormalities (uterus and
upper 2/3 of vagina) may present with menorrhagia or spasmodic
dysmenorrhoea.
• Trauma
• Infection
• Endometriosis: functioning endometrial tissue is implanted outside the
uterine cavity. Presentation may include dysmenorrhea, dyspareunia,
infertility, dysuria, and pain during defecation but depends on where
implant occurs.
• Adenomyosis: presence of endometrial tissue in myometrium. Presents
with menorrhagia, dysmenorrhoea, metrorrhagia.

12. • Benign neoplasms: Fibroids can cause menorrhagia or
menometrorrhagia.
• Malignant neoplasms: Carcinomas and sarcomas, as well as hormone-
producing tumours

13. Iatrogenic
• Hormonal contraceptives: Progestogen injections initially cause
irregular bleeding.
• Hormonal replacement therapies
• Intrauterine contraceptive device
• Anticoagulant
• Haemodialysis

14. Endocrine
• Hypothyroidism: may present with menorrhagia
• Adrenal disorders
Systemic disorders
• Hepatic disease
• Renal disease
• Obesity

15. Aetiology according to age
• Prepubertal child: Consider precocious puberty, nonmenstrual
bleeding (due to foreign bodies, vaginitis, tumours), and bleeding
disorders
• Adolescent: Most common cause is anovulatory dysfunctional uterine
bleeding. The first 30 to 40 cycles are anovulatory (first 2-3 years).
Also consider pregnancy, infection, hormonal birth control, and
bleeding disorders.

16. • Reproductive age (20-40 years): causes to consider are uterine
fibroids, uterine adenomyosis, endometrial polyps, pregnancy, cancer,
infection, bleeding disorders, hormonal contraception, and medical
illnesses.
• Post-menopausal (>40 years): Causes to consider are anovulatory
DUB, malignant or benign neoplasms, infection of the uterus, use of
blood thinners or anticoagulants

17. Approach to Abnormal Uterine Bleeding
History:
• Menstrual history: LNMP, normal cycle, any changes in cycle, clots,
symptoms of ovulation, post-coital bleeding, intermenstrual bleeding,
menopause
• Sexual history: sexually active, coitarche, number of partners,
contraceptive use, STIs
• Gynae: any previous problems, medication, pap smears
• Obs: parity, infertility
• Medical: bleeding disorders, endocrine disorders, diabetes,
hypertension, HIV

18. • Drugs: anti-coagulation, contraception, HRT
• Surgical: previous operations
• Family: bleeding disorders, cancer of endometrium or breast
• Social: smoking

19. On Examination
• General: Shock, petechiea, purpura, endocrine stigmata, PCOS
• Breast
• Abdomen: pregnancy, liver and spleen (bleeding disorders), mass
• Pelvic: Local lesions in vulva, vagina, cervix, uterus and adnexa. PR
(bleeding). If virgo intacta – ultrasound, PR

20. Investigations
• Pap smear: rule out malignancy – especially
reproductive/postmenopausal patients
• Ultrasound: PCOS, mass, abnormal pregnancy states, endometrial
thickness
• FBC: Hb, WCC, platelets
• Pregnancy test: abnormal pregnancy states, miscarriage
• Urine: dipstix for haematuria
• Endocrine: Prolactin, TFTs, FSH, LH

21. Management
Acute Bleed
Resuscitate if necessary:
• ABC
• 2 wide bore IV lines
• FBC, U&E, type and screen
• Order 4 units of blood – 2 stat
• Catheterise

22. Hormonal Therapy
• Oral progestogen
For acute episode of anovulatory uterine bleeding. 10-30mg daily 7-10 days
Arrests bleeding within 24-36 hours
Converts uterus from a proliferative endometrium to secretory endometrium
• High dose oestrogen
Day 1: 1 tablet 5 times daily
Day 2: 1 tablet 4 times daily
Day 3: 1 tablet 3 times daily
Continue until 1 tablet taken daily and bleeding stops
Include anti-iemetic

23. • Surgical therapy
Uterine curettage temporarily arrests the haemorrhage. Bleeding
recurs within a few months.

24. Definitive Management
Medical management of menorrhagia
• Antifibrinolytic drugs
Tranexamic acid
Prevents breakdown of clots
Useful where oestrogen/progesterone therapy contraindicated
• NSAIDs decrease bleeding by 35-40%
Mefenamic acid 500mg TDS OR Brufen 400mg TDS
Where hormone therapy contraindicated

25. • COC
Reduce bleeding by 53%
Mechanism may be by inducing endometrial atrophy
Maintain cycle control
• Progestogens
Anovulatory DUB where oestrogen contraindicated
• Intrauterine system
• Danazol
Direct inhibition of sex hormone steroid synthesis
• Gonadotropin-releasing hormone analogues
Inhibit release of FSH and cause suppression of ovarian steroid hormone
production

26. Surgical Management
Patients in whom medical management is ineffective or unmanageable
side effects
• Endometrial ablation
Safe alternative to hysterectomy
Destroys stratum basalis layer of endometrium therefore preventing
regeneration
Methods include laser ablation, endometrial resection, and various
balloon techniques

27. • Hysterectomy
Definitive management for abnormal uterine bleeding in following
patients:
 Completed their families and over age 45
 Medical management failed
 Premalignant conditions of cervix/endometrium
 Failed endometrial ablation