Insight AUB Management Guidelines on AUB in Reproductive Period

Insight AUB
Management Guidelines on
AUB
in Reproductive Period
Evidence based on --- FOGSI AUB guidelines
10TH JUNE DEHRADOON ,
15TH SEPTEMBER , Delhi (D.G.F. CME)
DR. JYOTI BHASKAR
MD MRCOG PGDMLS
DGF CME

International guidelines on Management of AUB
Faculty of Family Planning and Reproductive Health Care (FFPRHC) Guidance
2004
National Institute for Health and Care Excellence (NICE) 2007
Clinical Practice Guideline: Management of Abnormal Uterine Bleeding
(France)
Finnish Society of Obstetrics and Gynecology, 2006
Cochrane Review:-Progesterone or Progestogen releasing Intra Uterine
systems for Heavy Menstrual Bleeding; 2005
Clinical Practice Guideline: Management of Menorrhagia (Ministry of Health –
Malaysia); 2004
ACOG Guidelines- Management of Acute Abnormal Uterine Bleeding in
Non-pregnant Reproductive-Aged Women, 2013 reaffirmed in 2015
SOGC Canadian Clinical Practice Guideline: Management of AUB in Pre-
Menopausal Women; 2013

Why India specific guidelines for
AUB??
Need
for AUB
GCPR
Inconsistency
in day to day
management
of AUB
Unavailability of
clear diagnostic
and therapeutic
criteria impact
overall standard
of health care
High
prevalence of
AUB among
women in India
Diverse clinical
practices
Lack of good
clinical practice
guidelines
specific to Indian
context
1. The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available
at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
2. Rahnn et al. J Clin Epidemiol. 2011;64(3):293-300

AUB-Spectrum of problem
11
Total women in
reproductive age group
Women
affected
with AUB
at any
given
point
17.9
Total women in
reproductive age group
Women
affected
with AUB
Women
not
affected
In World In India
Prevalence increases with age, reaching 24 percent in women aged 36 to 40. 1
1. Harlow SD, Campbell OM. BJOG. 2004;111:6– 16; 2. Omidvar S, Begum K. J Nat Sci Biol Med.
2011;2:174–9. 3. Chattopdhyay B, Nigam A, Goswami S. Eur Rev Medi Pharmacol Sci. 2011;15:764–768

Burden of HMB in India
Excessive bleeding has been reported in about 8-9%
women from India and neighboring countries.1
42-53% of women aged < 21 years and those > 21 years
complained of excessive bleeding.2
15% of all gynecology OPD visits and 25% of all
gynaecological surgeries3
1. Harlow SD, Campbell OM. BJOG. 2004;111:6– 16; 2. Omidvar S, Begum K. J Nat Sci Biol Med. 2011;2:174–9.
3. Chattopdhyay B, Nigam A, Goswami S. Eur Rev Medi Pharmacol Sci. 2011;15:764–768
8–9%
42–53%
15%
AUB impacts up to 30% of women at some time in their
lives

Indian Women
Behaviour & Attitude are Different
MYTHS
• Return to womanhood
• kachra blood
• Sign of feminity
• Related to Menopause
• Hormonal Imbalance
• GOD IS GREAT
FEARS
• Fear and Anxiety of
meeting a doctor
• Fear of prolonged, painful
treatment
• Fear of Operation
• Inconsistency
• Ignorance and Money
Issues

Impact of AUB on Quality of life (QoL)
Major impact on a woman’s
quality of life
Over 60% of women
diagnosed with HMB ended
up having a hysterectomy
within 5 years from the
diagnosis4
About 1/3rd of
hysterectomies for HMB
result in removal of
anatomically normal
uterus5
Impact of HMB
Anxiety
Decreases
work
productivity2
Iron
deficiency
anaemia 1
Discomfort
1
Negative
impact on
relationship
with
partners3
Decreased
QOL1
1. Ghazizadeh S. Int J Women’s Health. 2011;3: 207–21. 2. Magon N. J Midlife Health. 2013;4(1):8–15; 3. Bitzer J.Open Access J Contracep.
2013; 21–28; 4. NICE 2007; can be accessed at: https://www.nice.org.uk/guidance/cg44 5.Roy SN, Bhattacharya S. Drug safety 2004

Methodology
Review of literature: Best evidence
Evidence reviewed by experts group
Variability in Indian context identified: cultural,
racial, socioeconomic background
Need identified to formulate GCPR in Indian
context
Draft recommendations framed : April 2014
Expert Panel meeting, 26.9.2015: Draft discussed
Where evidence was limited, the panel relied on
experience/ clinical judgement
Final version framed → Graded

Level of evidences
Strength of recommendation (adapted from AACE Task Force)
A Strongly recommended
B Intermediate
C Weak
D Not-Evidence based, Panel recommended
Scale of scientific support
1 Meta-analysis of randomized controlled trials and randomized controlled trials
2
Meta-analysis of non-randomized prospective or case-controlled trials, non-randomized
controlled trials, prospective cohort study, and retrospective case-control studies
3
Cross-sectional studies, surveillance studies (registries, surveys, epidemiologic studies,
retrospective chart reviews, mathematical modelling of database), consecutive case series,
single case reports
4 Opinion/consensus by experts or preclinical study
1. Handelsman et al. Endocr Pract. 2013;19:675-93

What is Abnormal Uterine Bleeding
(AUB)??

Abnormal Uterine Bleeding
1. ACOG: Obstet Gynecol. 2013;121(4):891-6. 2. NICE Guidance 2007
ACOG1 NICE2
Bleeding from uterine
corpus that is abnormal in
a) regularity,
b) volume,
c) frequency, or
d) duration and
e) occurs in the absence of
pregnancy
When a woman experiences a
change in
a) her menstrual loss, or
b) the degree of loss or
c) vaginal bleeding pattern
differs from that
experienced by the age-
matched general female
population

Definition Of HMB
“Excessive menstrual blood loss which interferes
with the woman’s physical, emotional, social
and material quality of life, and which can occur
alone or in combination with other symptoms.”
Nice guidelines 2007

Acute and Chronic AUB
• Acute uterine bleeding unrelated to pregnancy was
defined in as “that which is sufficient in volume as to, in
the opinion of the treating clinician, require urgent or
emergent intervention.” (FIGO definition)
• Chronic: AUB present for most of the previous 6 months
1. ACOG: Obstet Gynecol. 2013;121(4):891-6.
2. Munro et al. Am J Obstet Gynecol. 2012 Oct;207(4):259-65.

FIGO Nomenclature
L.IN.MA.WH.02.2016.0746

• Allows for standardisation and uniformity
• Rectify the inconsistencies in AUB management

FIGO System of Nomenclature
for the etiologies of AUB
Polyps (P)
Adenomyosis (A)
Leiomyoma (L)
Malignancy & Hyperplasia
(M)
Coagulopathy (C)
Ovulatory dysfunction (O)
Endometrial (E)
Iatrogenic (I)
Not defined (N)
Submucosal
Other
Structural causes
a) discrete in nature,
b) can be measured visually
with imaging techniques
and/or histopathology
Non- Structural causes
entities that are not defined
by imaging or histopathology
Munro et al. Am J Obstet Gynecol. 2012 Oct;207(4):259-65.

Evidence-based Guidance for Clinical
Decision Making and Approach to
Diagnosis of abnormal uterine bleeding
“An Indian Perspective”
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Evaluation, Investigations & Diagnosis
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Recommendations:
History / Examination
Use PALM-COEIN , Abandon old terminology
(Grade A; Level 4)
Thorough history, physical examination to direct
need for investigations/ Treatment
(Grade A; Level 4)

Diagnosis and Evaluation
Thorough History
(Grade A; Level 4)
Preliminary
assessment (Grade A;
Level 4)
Investigations
(Grade A; Level 4)
Menstrual
Pattern
a) Duration,
b) amount,
c) cycle length,
d) regularity,
e) intermenstrual
bleed
Pain a) Dysmenorrhea,-
spasmodic or
congestive,
b) intermenstrual,
chronic pain,
c) dyspareunia
Concomitant
Medications
(Grade B;
Level 4)
a) Anticoagulants,
b) Tamoxifen
c) Hormonal
contraceptives
d) Anti depressants
and anti psycotics
e) Corticosteroids
History suggestive of bleeding
diathesis, PCOS or thyroid disorder
1) Laboratory
testing
2) Imaging
3) Specialized
tests
4) Endometrial
histopathology
Assess pallor, BMI , BP, features
suggestive of PCOS, thyroid
disorders
Abdominal
examination
Palpable uterus
Per speculum
examination
cervical lesions,
discharge
PAP SMEAR
Per vaginum
examination
uterine size,
contour,
consistency,
tenderness,
adnexal mass or
tenderness
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice
recommendations for AUB. Available at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-
aub.pdf Last accessed at 24 February, 2016 L.IN.MA.WH.02.2016.0746

• CBC with platelets is recommended for
all women with AUB
History of heavy
bleeding
• Rule out pregnancy as cause of AUB
• Beta- human Chorionic Gonadotropin
Pregnancy
• TSH
• Total and free T3, Total and free T4
Thyroid disorders
(when clinically indicated)
• Bleeding time, Platelets, prothrombin
time, partial thromboplastin time in
adolescents and in adults with a positive screen
for coagulopathies
• vWB–ristocetin cofactor activity, vWB factor antigen,
factor VIII
Coagulation disorders
(when clinically indicated)
Laboratory Testing
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB.
Available at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016

Positive Screen for Coagulopathies
Any of the following Criteria ( Grade B; level 4)
• History of heavy bleeding since Menarche
• One of the Following
• At least TWO of the following
PPH
Bleeding associated with dental work
Surgery-related bleeding
• At least one episode of Bruising per month
• At least one episode of Epistaxis per month
• Frequent gum bleeding
• Family History of bleeding symptoms

Imaging
Ultrasound
Imaging – Mandatory
2D TVS/ TAS
Magnetic Resonance
Imaging - Optional
Hysteroscopy
Doppler
sonography
Suspected AV malformation,
malignancy cases and to
differentiate between fibroid
and adenomyomas (Grade B;
Level 3)
3D USG For evaluating intra
myometrial lesion in selected
patients for fibroid mapping
(Grade B; Level 4)
SIS If intracavitary lesion is
suspected and hysteroscopy
is not available (Grade A;
Level 1)
USG should be done in AUB to evaluate uterus,
adnexa and endometrial thickness (Grade A; Level 1)
a) Map exact location of
fibroids before planning
conservative surgery and
prior to therapeutic
embolization for fibroids
b) To differentiate
between fibroids and
adenomyomas
a) Direct visualization
of intracavitary lesion
(Grade A; Level 1)
b) Facilitates directed
biopsy
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at
http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
Not indicated
for ALL AUB

Recommendations: HYSTEROSCOPY
Indications:
 Intermenstrual spotting
 Evaluation of intracavitary lesion
 Dys-synchronicity between symptoms & HPE (Grade
A; Level 2)
 Increased Endometrial thickening on TVS, but HPE
inadequate/atrophic
 No response to medical management
Not indicated for all AUB – NOT TO BE DONE ROUTINELY

GCPR- Endometrial Assessment and Biopsy
recommended in
women with AUB
Older than 40
years of age
(Grade A; Level 2)
Less than 40 years
who are at risk of
endometrial cancer
(Grade A; Level 2)
Risk factors of endometrial cancer
• Irregular bleeding
• Obesity associated with hypertension
• Endometrial thickness > 12 mm
• Polycystic Ovarian syndrome (PCOS)
• Diabetes Mellitus
• History of malignancy of ovary/breast/
endometrium/colon
• Use of Tamoxifen for HRT or breast cancer
• AUB-unresponsive to medical management
• HNPCC syndrome (hereditary nonpolyposis
colorectal cancer or Lynch Syndrome)
Endometrial assessment (EA)
Endometrial histopathology Dilatation and curettage Hysteroscopy
Performed if
endometrium is
thick on imaging
but HPE is
inadequate, to
rule out polyps
(Grade A; Level 2)Not be a procedure of choice
for EA (Grade A; Level 3)
Endometrial aspiration should be the
preferred procedure for obtaining
endometrial sample for histopathology.

Algorithm for the Diagnosis of AUB
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at
24 February, 2016

Evidence-based Approach for
Management of abnormal uterine
bleeding in Indian women of
reproductive period
“An Indian Perspective”

Treatment Options
Medical
Non-
hormonal
Non-
steroidal
Surgical
Certain
clinical
situations
Hormonal
Depends on
• Clinical condition,
• Overall acuity
• Suspected aetiology,
• Desire for future fertility and
• Underlying medical problem
Preferred
Depends on
• Clinical stability,
• Severity of bleeding,
• Contraindications/ lack of
response to medication,
• Desire for future fertility
1. ACOG: Obstet Gynecol. 2013;121(4):891-6.

Current Treatment Options
• Pharmacological
– Levonorgesterol -
Intrauterine System
(LNG-IUS)
– Antifibrinolytics
– NSAIDS
– GnRH analogues
– Oral contraceptives
– Cyclic progestins
 Surgical
 Endometrial ablation (EMA)
 Considered appropriate only for patients
who have completed their family.
 It is also not suitable for women with a
large uterus
 Hysterectomy
 Remains the definitive treatment for
HMB
 Should not be used as first-line
treatment in cases with primary HMB
unless all other treatments are
contraindicated or refused by the
patient.
 Uterine fibroid embolization
 New and still experimental

Management Algorithms for
Patients with AUB-PALM
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Treatment Algorithm: AUB-P
In women with AUB diagnosed with
POLYPS
Single endometrial polyp
Young woman desirous of
immediate pregnancy
Multiple endometrial polyps and women is
not desirous of continued fertility
Suggested to perform
Hysteroscopic polypectomy
(Grade A; Level 1)
LNG IUS insertion
(Grade A; Level 1)
Histopathology examination
If benign
lesion on
HPE
If HPE suggest
malignancy
Further management
should as AUB-M.
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available
No further RX

Recommendations for AUB-A
For managing AUB-A: Individualize
Age
Symptoms (AUB, pain and infertility)
Associated leiomyomas, polyps,
endometriosis
Fertility desire

Treatment Algorithm: AUB-A
LNG IUS is
recommend
ed as 1st line
therapy
(Grade A;
Level 1)
In women with AUB due to
Adenomyosis
Women desirous of fertility
Unwilling for
immediate
conception
Resistant or
unwilling to use
LNG IUS
Gonadotropin releasing
hormone (GnRH) agonists
with add back therapy is
recommended as 2ndline
therapy (Grade A; Level 1)
GnRH agonists cannot be
indicated for symptomatic relief
Combined oral contraceptives,
Danazol, NSAIDS and progestogens
are recommended (Grade B; Level 4)
Women not desirous of fertility
Vaginal or laparoscopic
hysterectomy / Trans-
cervical resection of
endometrium is
recommended (Grade A;
Level 3)
LNG IUS 1st LINE
long-term GnRH agonists and
add-back therapy can be
initiated
Medical management
Failure or refusal for medical
management
L.IN.MA.WH.02.2016.0746
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at
24 February, 2016
Adenomyomectomy  conservative surgery that may be offered in selected cases
presenting with infertility or with strong desire to retain uterus. (Grade B; Level 2).

Leiomyoma sub-classification
1. Munro et al. Am J Obstet Gynecol. 2012 Oct;207(4):259-65.

Recommendations: AUB-L
 Individualized : Age, parity, symptoms, fertility desire
 Type 0-1
 Hysteroscopic myomectomy (<4 cm)
 Abdominal myomectomy (>4 cm) (Grade B; Level 4)
 First generation ablation (TCRE / REA)- in selected cases
undergoing hysteroscopic myomectomy in pts not desiring
pregnancy

If treatment fails, or if
myoma is causing infertility
Tranexamic acid or COCs
or NSAIDS – 2nd line
(Grade A; Level 1)
Women >40 years and
not desirous of fertility
Hysterectomy is
definitive
treatment / LNG-
IUS before
resorting to Sx
(Grade B; Level 3)
Treatment Algorithm: AUB-L Type II – VI
Intramural/Sub-serous
(symptomatic)
(type II-VI)
LNG-IUS
(Grade A; Level 1)
Abdominal (open or laparoscopic)/ Hysteroscopic
myomectomy is recommended (Grade A; Level 3)
The Federation of Obstetricand Gynecological
Societies of India. Good clinicalpractice
recommendations for AUB. Availableat
http://www.fogsi.org/wp-
content/uploads/2016/02/gcpr-on-aub.pdf Last
accessed at 24 February, 2016
Immediate
conception desired
Conception not desired
for at least 1 year
FAILURE
FAILURE

Newer promising options :
PRMs: Ulipristal acetate (5 mg/D) (Grade A; Level 1)
Mifepristone (5-10 mg/D), low doses
N/A (Grade A; Level 1)
 Endometrial ablation:
- HMB with small uterine fibroids (< 3 cm), uterus <10
wks
- 2nd gen. ablation techniques should be used (TBEA,
MEA)
Recommendations: AUB-L

Revised classification of
Endometrial hyperplasia WHO 2014
New Term Coexistent Invasive
Endometrial Cancer
Progression To
Invasive
Cancer
Hyperplasia without
Atypia
<1% RR:1.01-1.03
Atypical
Hyperplasia
25-33% RR:14-45

Standard protocol for
management of malignancy to
be followed (Grade B; Level 4)
Endometrial hyperplasia
(AUB-M)
AUB-M
If LNG IUS is contraindicated or
patient unwilling to use LNG IUS
Hysterectomy-
definitive
treatment
(Grade B; Level 2)
Hyperplasia without
atypia
LNG IUS is
recommended as 1st
line therapy
(Grade A; Level 1)
Treatment Algorithm for AUB-M
Endometrial
malignancy
Oral Progesterones
can be used(Grade A;
Level 1)
Atypical endometrial
hyperplasia
Conservative treatment with high-dose
progestins and close histological
monitoring should only be considered in
exceptional cases
Preventive hysterectomy
should only be considered in
exceptional cases (e.g., extreme
obesity without any prospect of
weight loss).

Recommendations for AUB-M
Endometrial Hyperplasia with Atypia –
If uterus preserved
• EA to be repeated 6 monthly for close monitoring
• Endometrial ablation not recommended-
complete destruction not ensured, histological
follow up difficult

Management of AUB-PALM
Key recommendations for Treatment of AUB-PALM
AUB-P  Single Polyps: Hysteroscopic polypectomy
 Multiple Polyps: Hysteroscopic polypectomy followed by LNG IUS placement
if benign lesion on HPE.
AUB-A  Women desirous of fertility: and immediate conception not desired: LNG
IUS 1st line of treatment
 Women not desirous of fertility: Long term GnRH agonists with add back
therapy
AUB-L  Submucosal: Hysteroscopic/abdominal resection depending on size
 Intramural/subserosal: Immediate conception not desired LNG IUS 1st line
of treatment and immediate conception desired Tranexmic acid
 Women >40 years and fertility not desired: Hysterectomy
 Women >40 years and fertility desired
a) Long term management of AUB-L(III-VI) LNG IUS 1st line of treatment
b) Short term management GnRH agonists with add back therapy
AUB-M Atypical Hyperplasia fertility not desired: hysterectomy
Hyperplasia without atypia LNG IUS is 1st line of treatment. If contraindicated
then progesterone receptor modulators

Management Algorithms for
Patients with AUB-COEIN
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After consultation with haematologists
Tranexamic acid 1g
QID (Grade A; Level 2)
In women with AUB due to
coagulopathy (AUB-C)
Hormonal treatment-
secondary option
COCs/LNG IUS is
recommended (Grade A;
Level 2)
Treatment Algorithm: AUB-C
Following considerations have to be taken care of:
• In refractory cases von-willebrand disease with uncontrolled uterine bleeding with above
medical management, specific factor replacement where possible or desmopressin to be given
in consultation with haematologist.
• When surgical interventions are indicated, for appropriate pre-, intra- and post-operative
management of bleeding – Factor replacement /desmopressin
Non hormonal treatment-
primary options
L.IN.MA.WH.02.2016.0746
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at http://www.fogsi.org/wp-
content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016

Treatment Guidelines: AUB-O
• In women not desiring conception presently, COCs can be
used as first-line therapy for 6-12 months
(Grade A; Level 1).
• Cyclic luteal-phase progestins (for 10-14 days) can be used as a
specific treatment in women with AUB-O (Grade A; Level 1)
• Norethisterone cyclically (for 21 days) is given as initial
therapy in acute episodes of bleeding for short-term
management of 3 months (Grade B; Level 4).

Treatment Guidelines: AUB-O
• It is suggested to assess response after 1 year of medical
management and judge to continue/discontinue existing
therapy (Grade B; Level 4).
• Surgical intervention is not recommended unless, there is
evidence of persistent AUB or failure of medical
management to alleviate the condition (Grade A; Level 4).
• If COCs are contraindicated or patient is unwilling for COCs,
LNG-IUS is recommended if she wishes to use it for at least 1
year (Grade A; Level 1).
• In adolescents with AUB-O, both hormonal and non-
hormonal therapies can be prescribed. (Grade A; Level 4).

Endometrial (AUB-E)
1. Management of AUB-E can be similar to the management
of AUB-O (Grade A; Level 4).
AUB that occurs due to a primary disorder of the
endometrium and secondary to endometrial
inflammation or infection, abnormalities in the local
inflammatory response or endometrial vasculogenesis, in
the context of predictable and cyclic menstrual bleeding
with no other definable causes

Iatrogenic (AUB-I), Definition
and recommendations
• Patients with unscheduled endometrial bleeding due to:
– Using gonadal steroid (eg, estrogens, progestogens, androgens) or
– gonadal steroid-related therapy (eg, GnRH agonists, aromatase
inhibitors, selective estrogen receptor modulators, or progesterone
receptor modulators, heparins and anti-coagulants)
Treatment Algorithm: AUB-I
• Whenever feasible, medications causing AUB should be changed to other
alternatives, if no alternatives are available
• LNG-IUS is recommended for treatment (Grade A; Level 1).
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available

In women with AUB (not
yet defined-N)
Medical management
If fails or
contraindicated
If LNG IUS is
contraindicated
Women desires contraception
For AUB that is mainly cyclic or
has predictable
Treatment Algorithm: AUB-N
LNG IUS is
recommended as
1st line therapy
(Grade A; Level 1)
COCs are
recommended as 2nd
line therapy
(Grade A; Level 1)
GnRH agonists
along with add-
back hormone
therapy are
recommended
(Grade B; Level 4).
Surgical treatment
(such as ablation)
Non hormonal options such NSAIDS and
Tranexamic acid are recommended
(Grade A; Level 1)
1) Uterine Artery
embolization is
recommended.
2) Hysterectomy is the
last resort (Grade
B; Level 4).
In women with AUB
(not yet defined-N)-
AV Malformation

Management of AUB-COEIN
Key recommendations for Treatment of AUB-COEIN
AUB-C  Non-hormonal is primary treatment: Traxenemic acid
 Hormonal treatment: secondary treatment LNG IUS/COCs
AUB-O  Women not desirous of fertility: COCs for 1st 6 months. If COCs are
contraindicated then LNG IUS is preferred as 1st line treatment
 Surgical treatment not a choice of treatment unless failure of medical
management.
AUB-E  Similar to AUB-O
AUB-I  LNG IUS is preferred choice of treatment
AUB-N  Women not desirous of contraception: LNG IUS is 1st line of treatment
 If medical and surgical treatment fails: or is contraindicated :GnRH
agonists are preferred

LNG IUS
LNG IUS
FIRST LINE OF TREATMENT IN AUB
AUB –P- multiple polyps after hysteroscopic polypectomy if
benign lesion on HPE
AUB-A -women desirous of fertility but not immediate
conception/ Not desirous of fertility
AUB-L - Intramural/subserosal leiomyoma Type III-VI leiomyoma
in peri-menopausal women
AUB –M- - Hyperplasia without atypia
AUB- O & E In women with ovulatory dysfunction and COCs are
contraindicated or unwilling
AUB I due to iatrogenic causes
AUB-N when women are not desirous of fertility.

Endometrial Ablation in AUB
Benign lesions (All except AUB-M)
As primary Tt if intolerant/ no response to
medical Tt
Poor surgical candidates for hysterectomy
Pt preference
(Grade A, Level 1)
SOGC Clinical practice Guidelines 2015
Initial cost of ablation- significantly lower than hysterectomy
Since re-treatment is often necessary, the cost difference
narrows over time
Cochrane 2010

Role of Hysterectomy
Extremely Limited
Should be a Last resort unless indicated
INDICATIONS
1. AUB A & L – When medical treatment fails
though it is a definitive treatment
2. AUB M – Atypical Hyperplasia

Uterine artery embolization
Indications
 AV Malformations (Grade A, Level 1)
 Symptomatic fibroid with significant symptoms
 No desire for fertility but want to preserve uterus
 Poor surgical risks
 Severely anemic & require immediate intervention
RESULTS
 Symptomatic improvement : 84% at 6 mths
 83% at 24 mths
 Reduction in fibroid volume: 40–70%
 Reintervention:15-28%(Hysterectomy, Myomectomy, Rpt. UAE)
NICE GUIDELINES for UAE, 2010
(Grade A, Level 1)

Summary-Clinical recommendations
Key recommendations for Diagnosis of AUB
1) For proper Evaluation
a) Thorough history of bleeding patter, pain and concomitant
medication
b) Preliminary assessment- Abdomen, vaginal and cervical
examinations for any structural distortions
c) Investigations
 Laboratory testing: for coagulopathies, pregnancy and thyroid
disorder
 Imaging: TVUS for endometrial thickness, doppler USG for
AVM, 3D USG for myometrial lesions and SIS for intracavitary
lesions
 MRI: to map exact location of fibroids and differentiate
between fibroids and adenomyomas.
 Hysteroscopy: diagnosis of uterine abnormalities.
2) Endometrial Assessment and Biopsy
 Endometrial histopathology: performed in all women >40
years and <40 years at risk of endometrial carcinoma.
Endometrial aspiration is preferred method for EA.
 Hysteroscopy: performed if endometrium is thick but
inadequate to rule out polyps.
Key recommendations for
Management of AUB
1) LNG IUS is recommended as 1st
line of treatment for:
a) AUB due to multiple polyps after
hysteroscopic polypectomy if benign
lesion on HPE
b) AUB-A women desirous of fertility
but not immediate conception
c) Intramural/subserosal leiomyoma
d) Type III-VI leiomyoma in peri-
menopausal women
e) Hyperplasia without atypia
f) In women with ovulatory
dysfunction and COCs are
contraindicated
g) AUB due to iatrogenic causes
h) AUB-N, when women are not
desirous of fertility.
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at http://www.fogsi.org/wp-
content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016

Take home message
 AUB is a common problem from menarche to
menopause in India
 PALM-COIEN system- simplified the clinical
classification and provided an organized approach for
diagnosis and evaluation of AUB.
 Individualized / Cafeteria approach
 Medical management is the First Line of Rx
 Hysterectomy is the LAST RESORT
 Evidence based management can avoid number of
unnecessary hysterectomies

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Insight AUB Management Guidelines on AUB in Reproductive Period

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