causes ,investigations and treatment

1. ABNORMAL UTERINE BLEEDING
BY Dr VIJETA

2. PALM-COEIN CLASSIFICATION
• PALM-Polyp
Adenomyosis
Leiomyoma
Malignancy
• COEIN- Coagulopathy (AUB-C)
Ovulatory disorder (AUB-O)
Endometrial (AUB-E)
Iatrogenic
Not yet classified

3. Coagulopathy (AUB-C)
• Von-Willebrand disease
• Disorder of platelet number and function

4. OVULATORY DYSFUNCTION (AUB-O)
• The state of chronic anovulation is the result
of unopposed estrogen stimulation of the
endometrium with consequent irregular
breakdown and bleeding.

5. • Hyper-thyroidism, hypothyroidism, hyper-
prolactinemia ,hormone producing ovarian
tumours ,cushing disese are all endocrine
syndromes that can induce ANOVULATION.
• BUT the primary etiology of AUB-O is chronic
anovulatory syndrome ,often commonly
described as POLYCYSTIC OVARY.

6. AUB- IATROGENIC
• Haemorrhagic diatheses can occur with
leukemia with chemotherapy treatment or
secondary to oral anti-coagulant .
• Hormonal interventions like oral
contraceptives can also result in Abnormal
bleeding patterns rather than improvement of
symptoms.

7. EVALUATION
• Rule out pregnancy –UPT
• Document ovulation (menstrual history)
• Medical disorders
• Endometrial biopsy if at risk of hyperplasia
• Rule out Anatomic abnormality
• USG

8. TREATMENT
• Because most patients with AUB have an
underlying etiology of chronic anovulation
with unopposed estrogen stimulation of the
endometrium , medical treatment with
progestins is the mainstay of therapy.
• MEDROXYPROGESTERONE ACETATE 10mg
• NORETHINDRONE ACETATE 5 mg /day

9. • After initial control of DUB, the 12 day course can
be repeated at monthly intervals to prevent
development of hyperplasia.
• It is convenient to start each new course on the
1st day of each month.
• A regular withdrawl can be expected to start
either during the last 2 days of progestin or
within several days of the last dose.
• Failure to withdraw could signify pregnancy or
development of hypoestrogenic state.

10. • PROGESTIN IMPREGNATED IUD
• INJ. DMPA 150mg im combined with 3 days of
oral medroxyprogesterone acetate 20mg
every 8hrs for 9 doses.

11. ORAL CONTRACEPTIVE PILLS
• ORAL CONTRACEPTIVES in a step down regimen
• 2-4 pills are given daily
one every 6-12 hrs
for 1 week.
THIS WILL CONTROL ACUTE BLEEDING allowing time to complete
diagnostic evaluation.
• Withdrawl of medication will result in heavy bleed. On the 5th day
of this bleed, a low dose cyclic oral contraceptive is started and
repeated for 3 cycles to allow orderly regression of the excessive
proliferative endometrium .
• Alternatively ,
the dosage of combination pills can be tapered (4 times a day then
3 times a day then 2 times a day over 3 to 6 days and then
continued at 1 pill /day.

12. HYSTEROSCOPY
• Who fail to respond to hormonal treatment.
• Polyp,submucous myoma

13. • If atypical hyperplasia is present, and
preservation of fertility is desired , a more
aggressive progestin therapy is required.
• MEDROXY PROGESTERONE ACETATE 30mg
/day for 3 months.
• Pt should be monitored by repeat endometrial
sampling to assess the efficiency of medical
treatment.

14. COAGULATION DISORDERS
• DESMOPRESSIN 0.3ug/kg in 50ml saline over
15-30min.

15. Ablation or destruction of
endometrium

16. NOVASURE ABLATION
• NovaSure® endometrial ablation is for premenopausal women with
heavy periods due to benign causes who are finished childbearing.
• Pregnancy following the NovaSure procedure can be dangerous.
• The NovaSure procedure is not for those who have or suspect
uterine cancer; have an active genital, urinary or pelvic infection; or
an IUD.
• NovaSure endometrial ablation is not a sterilization procedure.
• Rare but serious risks include, but are not limited to, thermal injury,
perforation and infection. Temporary side effects may include
cramping, nausea, vomiting, discharge and spotting.

20. THERMAL BALLOON ABLATION

22. ROLLER BALL ABLATION

24. MICROWAVE E ENDOMETRIAL
ABLATION

25. • THANKYOU