Introduction, terminology, etiology, classification, investigation management of AUB

1. Abnormal UterineBleeding
AUB
DR K MANJU
PROFESSOR
(OBSTETRICS AND GYNAECOLOGY)
PMCH, PATNA

2. Abnormal Uterine Bleeding:
Introduction
• Common problem in FEMALES
• It has a substantial effect on health related quality of life
• Any bleeding from the uterus which is outside the
• normal volume
• regularity
• duration
• or frequency
is considered ABNORMAL UTERINE BLEEDING (AUB)

3. Normal Uterine Bleeding
• Normal uterine bleeding- Menstruation: cyclical
phenomenon regulated by HORMONES
• Reproductive aged women- From Menarche to Menopause
• Frequency – 21days to 35 days
• Duration – 2 to 8 days
• Flow –35 ml (20ml -80 ml)
• Pad used –3 to 6 pad /day

4. Blood loss-
Frequency
• Frequent: <21 days(>4/90
days)
• Normal:21-35 days
• Infrequent: >35 days (1-2/90
days)
Duration
• Prolonged:>8 days
• Normal:2-8 days
• Shortened:<2 days
Volume
• Heavy: >80 ml
• Normal: 20-80 ml
• Light: <20 ml
Key menstrual parameters

5. Menstrual Cycle
• FOLLICULAR PHASE: Begins
with menses ends with LH
hormone surge
• OVULATION PHASE: 30 to 36
hrs. Begins with LH surge and
end with OVULATION
• LUTEAL PHASE:14 days.
Begins with the end of the LH
surge and ends with onset of
menses
• MENSTRUAL PHASE

7. Arrest of bleeding…
• Hemostasis
• Platelet plug & clot formation:
Coagulation cascade
• Prostaglandin mediated
vasoconstriction:
Arachidonic acid cascade
• Tissue repair:
Re-epithelialization

8. Bleeding is abnormal if...
• It occur at interval of 21 days or less, or
35 days or more
• Last longer than 8 days
• Menstrual Blood Loss (MBL) of 80 or
more

9. Abnormal Uterine Bleeding: Incidence
• One of the common disorder in gynae and accounts for 30 to 40%
cases in OPD
• Can occur in women of all age
• Reproductive age 25-30 %
• Perimenopausal age 50 %
• Factors that impact the incidence most greatly are age &
reproductive status
• Uncommon in prepubertal girls and post menopause, where as rate
of abnormal bleeding increases significantly in adolescent,
perimenopausal and reproductive age groups

10. Terminology- Types Of Bleeding
• Heavy menstrual bleeding (HMB): Regular cycles, prolonged or
heavy bleeding
• Irregular bleeding: Cycles <21 or >35 days
• Intermenstrual bleeding (IMB): Small amounts of bleeding in
between regular cycles
• Amenorrhea: Absence of menstruation

11. Older Classification /Terminology
• DYSFUNCTIONAL UTERINE BLEEDING (DUB) – Abnormal Uterine
bleeding in absence of pelvic organic disease or syst disorder
• MENORRHAGIA –EXCESSIVE /Prolong bleeding, cycle- regular.
• METRORRHAGIA – Irregular, acyclical bleeding .
• POLYMENORRHEA – Frequent <21 days cyclical bleeding
• OLIGOMENORRHEA –Infrequent >35days
• AMENORRHEA- Absence of menstruation
• HYPOMENORRHEA – Scanty menstruation

12. New Terminology
AUB: Abnormal uterine bleeding, defined as-
excessive menstrual blood loss which interferes with women’s
physical, emotional, and quality of life
Heavy Menstrual Bleeding (HMB)
 Acute- An episode of heavy bleeding that is of sufficient quantity
to require immediate intervention to prevent further blood loss
 Chronic- bleeding that is abnormal in duration regularity, volume
or frequency
Intermenstrual Bleeding (IMB)
Small amount of bleeding in between regular cycle

13. AUB Patterns described as..
AUB- HMB
- Menorrhagia replaced by Heavy menstrual bleeding
HMB
AUB- IMB
- Metrorrhagia replaced by –Intermenstrual bleeding
- IMB –Cyclical or acyclical

14. AUB: Classification
• By FIGO (International Federation of Gynecology and Obstetrics), 2011
• Approved by ACOG (American College of Obstetrics and Gynecology),
2013
• For non pregnant reproductive age women
• PALM-COEIN etiological classification system (ACRONYM)
• PALM- consists of structural abnormalities
• COEIN- includes conditions that are unrelated to structural abnormalities

15. PALM-COEIN Etiological Classification
System:
PALM
• P- Polyp
• A- Adenomyosis
• L- Leiomyoma
 Submucosal Myoma
(LSM)
 Other (LO)
M- Malignancy and
Hyperplasia
COEIN
• C- Coagulopathy
• O- Ovulatory
dysfunction
• E- Endometrial
• I- Iatrogenic
• N- Not Yet Classified

16. AUB documentation as per PALM-COEIN
Etiological Classification
• AUB documented as
• PATHOLOGY being PRESENT – 1, or
• PATHOLOGY being ABSENT – O
• Multiple pathologies are documented simultaneously e.g.-
adenomyosis, hyperplasia and coagulopathy in a single
patient may be cited as –
• P0A1L0M1–C1O0E0I0N0, or
• Simplified- AUB-A,-M,-C

17. AUB Etiology- Structural causes
“PALM”
1. AUB–P: POLYP (P1A0L0M0–
C0O0E0I0N0)
Endometrial Polyp- localized outgrowth of the
endometrium stroma & glands
• Most common cause of AUB in reproductive and
postmenopausal women
• usually BENIGN but occasionally MALIGNANT
• Symptoms- HMB ,IMB, post menopausal bleeding
Cervical Polyp- From cervical gland
• BENIGN
• Symptoms- post coital bleeding or IMB
Cervical polyp

18. AUB–P (Polyp) PALM
• Polyp- suspected by history of IMB & thick
endometrium on USG
• MANAGEMENT:
• Medical management - ineffective
• Younger women – polypectomy. HPE to exclude
malignancy
• Women with multiple or recurrent endometrial polyp
with no fertility desire – hysteroscopic
polypectomy may be followed by LNG-IUS (if
benign polyp)
• Hysterectomy
Endometrial polyp

19. 2. AUB-A: ADENOMYOSIS
• Presence of Ectopic Endometrial gland and
Stroma in the Uterine Myometrium.
• Usually occur in MULTIPAROUS women of
PERIMENOPAUSAL AGE
• Symptoms- HMB, Secondary
dysmenorrhoea, chronic pelvic pain
• Sign- Uterus uniformly enlarged <14 wk
• USG-
• Asymmetrical thickening of uterine wall
• Loss of clear endo-myometrial border
• Myometrial cyst
AUB STRUCTURAL Etiology- PALM
AUB-A: Adenomyosis

20. AUB-A (ADENOMYOSIS) PALM
• Confirmed by evidence of Endometrial tissue
beneath the endometrial myometrial junction on HPE
AUB-A- usually refractory to medical treatment
Definitive cure:
• Surgery
• Conservative surgery- Resection of
Adenomyoma, myometrial reduction, Hysteroscopic
resection
• HYSTERECTOMY
Endometrial tissue consisting of
endometrial glands and stromal cells
within the myometrium

21. AUB-A (ADENOMYOSIS) PALM
Newer therapy -
• Endometrial ablation,
• UAE (Uterine Artery Embolization),
• MRg-FUS (Magnetic Resonance-Guided Focused Ultrasound)
• Medical- NSAIDs, COC (combined oral contraceptive), Danazol,
LNG-IUS, GnRH analogues, Aromatase inhibitor, Danazol loaded
IUS

22. AU b–L- leiomyoma -most common
benign tumour of uterus
• Leiomyoma can be –
• Submucous ,
Intramural & Subserous
• Bleeding pattern depends on –
SIZE, LOCATION and NUMBER of tumour
Diagnosed –history, clinical exam &USG
Aub–l- structural etiology palm
leiomyoma

23. 3. AUB-L: LEIOMYOMA
• Subclassified as
- those with at least ONE Submucous
leiomyoma, AUB-L-SM and
- those having NO Submucous
leiomyoma AUB-L-O [OTHER]
• Commonest cause of AUB in
Reproductive age
• Symptoms- HMB, IMB, irregular
bleeding
AUB STRUCTURAL Etiology- PALM
AUB-L: Leiomyoma

24. AUB-L (LEIOMYOMA) PALM
Management- Individualized
Medical-
- For small asymptomatic myoma at any age
- to control bleeding while waiting for surgery
- control bleeding (to correct anaemia)
- preoperative to reduce vascularity
- approaching menopause
Drugs- NSAID, COC, progestins- oral, LNG-IUS, Mifepristone, Danazol,
Gestrinone, SERM- Raloxifene & Ormeloxifene, SPERM- Ulipristal, GnRH
analogue- cabergoline , Aromatase inhibitor- anastrozole
SURGERY- MYOMECTOMY , HYSTERECTOMY
Myomectomy

25. NEWER THERAPY- in selected cases
• Uterine artery embolization
• Hysteroscopic resection- Submucosal myoma <4cm
• Laproscopic uterine artery ligation/ myomectomy
• Laproscopic myolysis
- Thermal myolysis
- Cryomyolysis
- Laser myolysis
- Radio-frequency myolysis
• MRg-FUS (Magnetic Resonance-Guided Focused Ultrasound) or HIFU
high intensity focused USG
AUB-L (LEIOMYOMA) PALM
Uterine artery embolization

26. AUB-L (LEIOMYOMA) PALM-myolysis
MRg-fus
Laproscopic myolysis Radio frequency myolysis
Magnetic Resonance-Guided Focused Ultrasound

27. AUB STRUCTURAL Etiology- PALM
AUB-M: Malignancy and hyperplasia
4. AUB-M: Malignancy and hyperplasia
• Endometrial Hyperplasia –
with ATYPIA or without ATYPIA
• Endometrial Carcinoma
-Usually presents with HMB OR Irregular
bleeding -in
- Peri menopausal age group
- Post menopausal women
Endometrial hyperplasia
Endometrial Carcinoma

28. .Other cancer of genital tract – may present
with AUB
• Cervical cancer –Occur in younger age [mid
40s], associated with IMB, PCB
• Vulval, Vaginal cancer- RARE, but can present
with bleeding
AUB-M (Malignancy and hyperplasia)
PALM
Cervical Cancer

29. AUB-M (Malignancy and hyperplasia)
PALM
STANDARD PROTOCOL
• AUB-M with endometrial hyperplasia with ATYPIYA
- Hysterectomy- standard treatment
- Conservative treatment with high dose Progestin- exceptional case,
risk of carcinoma always
• AUB-M with endometrial hyperplasia without ATYPIA: Hormones
LNG IUS -first line
Progestin- oral MPA
• Preventive Hysterectomy- considered in high risk group:
older age, early age of menarche, diabetes, obesity,history of breast cancer,
family h/o of endometrial cancer

30. AUB Etiology: Not Associated with structural
Abnormalities “COEIN”
1. AUB-C: COAGULOPATHY
• Disorders of blood coagulation
• Common disorders are
• Von Willebrand disease
• Thrombocytopenia ,
• Hemophilia, Leukaemia
• HEAVY Bleeding occurs at Menarche
• Family history present
• History of easy bruising
• Chronic liver disease- decrease in coagulation factor synthesis–HMB
• Anticoagulant use (warfarin) , APA ,VT can cause AUB

31. AUB-C (COAGULOPATHY) COEIN
• Medical management - effective
• Tranexamic acid
• LNG-IUS
• NSAID -Contraindicated –can alter PLT function & liver
function
• IM Injectable preparation –contraindicated
• Consult Haematologist

32. AUB Etiology NON STRUCTURAL- COEIN
AUB-O: Ovulatory Dysfunction
2. AUB-O: Ovulatory Dysfunction
• Common cause of AUB
• Previously classified as “ANOVULATORY DUB”
• Ovulatory Dysfunction-result from abnormal functioning of the
HYPOTHALAMIC-PITUITORY-OVARIAN AXIS
• Seen in
- Adolescent girls < 20 yrs: due to immaturity of HPO
axis & failure of positive feedback of estradiol to cause LH
surge
- Perimenopausal women > 41yrs: Due to lack of
synchronization between the component of HPO axis as
women approaches menopause

33. AUB-O (Ovulatory Dysfunction) COEIN
• Disorder of ovulation like-
Oligo ovulation, Anovulation, PCOD & Corpus luteum dysfunction
may result in AUB.
May be Associated with Obesity, Mental Stress,
Anorexia, Weight Loss, Hypo & Hyperthyroidism,
Hypo prolactinemia
• Spectrum of menstrual problems-
Prolonged HMB or Scanty, irregular bleeding
Short cycle with normal or heavy bleeding,
period of amenorrhea followed by painless, profuse, prolonged or
scanty bleeding
Polycystic ovaries

34. Contd..
Pathogenesis: ANOVULATION
• Low level of oestrogen→ No LH surge → NO OVULATION → NO corpus
luteum formation → NO PROGESTERON production → Decrease level of
PGF2α, other PGs & Thrombxanes → Increase Fibrinolysis → Painless
bleeding [no vasoconstrict]
• Presence of developing follicle → prolonged supply of Estrogen →
Endometrial proliferation & Hyperplasia → Fragile Endometrial with no
stromal support → continuous prolonged bleeding followed by → amenorrhea
AUB-O (Ovulatory Dysfunction) COEIN
No LH Surge
No ovulation
No corpus luteum
No progesterone
→

35. May be associated with –
- Follicular cyst of the ovary
- Endometrial hyperplasia
Prolonged amenorrhea- Endometrium shows CYSTIC
HYPERPLASIA, [SWISS CHEESE appearance]
“Metropathia hemorrhagica”, “Schroeder’s disease”
• Characteristic
- Hyperplastic gland &stroma
- Cystic or irregularly dilated gland
- Increase in Vascularization
- Necrosis of Superficial Endometrium
- Tortuous & Dilated SPIRAL ARTERIOLES and veins
AUB-O (Ovulatory Dysfunction) COEIN

36. Endometrial hyperplasia, simple. Proliferation of
endometrial glands and stroma without cytologic atypia.
AUB-O (Ovulatory Dysfunction) COEIN

37. • Combined Oral Contraceptive [COC]–first line treatment if
pregnancy not desired
• Cyclical Progesterone therapy-
• Cyclical Norethisterone for 21 days [day5 -25 ]x 3 cycle
• Cyclical Progestin luteal phase- for 10-14 days [ 15-25 ]-3
cycle
• LNG-IUS
Adolescent –both & Hormonal & non Hormonal treatment
AUB-O (Ovulatory Dysfunction) COEIN

38. 3. AUB-E: ENDOMETRIAL DYSFUNCTION
Primary Disorder of ENDOMETRIUM- cause of AUB
• Formerly known as OVULATORY DUB
• AGE 21 –40 YRS
• Clinical features
- HMB, Dysmenorrhea
- Normal Uterus
• Pathogenesis- Increase production of vasodilators PGE2
- Alteration in ratio PGF2α :PGE2
- Increase in Fibrinolytic activity
AUB Etiology NON STRUCTURAL COEIN
AUB-E: ENDOMETRIUM

39. • Diagnosis of EXCLUSION- after ruling out other identifiable abnormalities
in women with normal ovulatory cycle
• HPE: Endometrium reveals SECRETORY changes as OVULATION &
PROGESTERON normal
• Management: same as AUB –O, but only 21 days therapy is effective
• Chronic inflammation of the ENDOMETRIUM with or without associated
PID- Uncommon cause of AUB
AUB-E (ENDOMETRIAL Dysfunction)
COEIN
DUB may or may not be associated with OVULATION
• Anovular bleeding- 80%: AUB-O [Anovulatory DUB]
• Ovular bleeding - 20%: AUB-E [Ovulatory DUB]

40. 4. AUB-I: Iatrogenic
Exogenous therapy leading to unscheduled endometrial bleeding
-Exogenous steroids, estrogen & progestin therapy, GnRH,
Aromatase inhibitors, SERM, SPRM
-Intra Uterine Devices/ systems– IUCD, LNG-IUS
Symptoms: IUCD- HMB, LNG IUS- IMB & irregular bleeding
-Pharmacologic Agents- Anti convulsant- Valproic acid,
Antibiotics- Rifampicin
AUB Etiology NON STRUCTURAL COEIN
AUB-I: Iatrogenic

41. AUB –I (MANAGEMENT) COEIN
• Whenever possible: change Medication causing AUB
• Give Alternative therapy
• If Alternative not available – LNG-IUS can be used

42. 5. AUB-N: Not yet classified/ ill defined cause
- Congenital or acquired A-V Malformation
- Caesarean scar Defect
- Endometrial pseudo aneurysm
- Chronic Endometritis
• Treatment-
• Hormonal: LNG-IUS, COC
• A-V Malformation- Uterine Artery Embolization
• Non Hormonal- NSAID, Tranexamic acid
• GnRH Agonist with ADD-BACK therapy
• Conservative surgery[Ablation] & Hysterectomy- last resort
AUB Etiology NON STRUCTURAL -COEIN
AUB-N: Not yet classified
All these can cause AUB

43. AUB: Clinical Evaluation
HISTORY & PHYSICAL EXAM- help in diagnosis
HISTORY - THOROUGH
- Age, Menarche, Parity
- Menstrual pattern- regularity, frequency, duration & volume
- Menstrual calendar for bleeding pattern
- Dysmenorrhea , vaginal Discharge
- Post coital bleeding – polyp, carcinoma cervix
- Dyspareunia – Adenomyosis
- Infertility, Abortion, IUCD ,OC Pill,

44. AUB- History
• Information about –use of any medication , likely
to be the cause for AUB
• Screen for coagulopathy –Positive screen test if-
History of heavy bleeding at MENARCHE
History of PPH or Bleeding associated with Dental or any other
surgery
• Two of the following symptoms
• ≥ one episode of bruising/month
• ≥ one episode of epistaxis/ month
• frequent Gum bleeding or family history of bleeding symptom

45. GENERAL PHYSICAL EXAM –
• Pallor, Thyroid enlargement,
• Sign of PCOS- Hirsutism, Acanthosis Nigricans,
acne, BMI, Obesity
• ABDOMINAL EXAM– any mass
• SPECULUM EXAMINATION- exclude local
lesion: Polyp, erosion, growth
• BIMANUAL EXAMINATION-
• Uterine size, contour, tenderness, fixity
• Adnexal Mass/ Tenderness/ Induration
AUB: Clinical Evaluation
examination
Acanthosis nigricans
Hirsutism

46. AUB: Investigation –LAB testing
• Complete blood count [CBC] –for all
• Coagulation profile- platelet count, Bleeding time
• Prothrombin time ,partial thromboplastin time
• - Indicated in all young girl & women with
Positive screen test for coagulopathies
• Testing for –Von Willebrand disease [Hematologist]
• Thyroid function test–young girl, if needed
• Hormonal assay- LH, FSH, TESTOSTERONE,17HP,
Androstenedione, Prolactin level
• Pregnancy test –exclude

47. AUB : Investigation -IMAGING
• ULTRASOUND – Evaluate: UTERUS, ADENEXA, ENDOMETRIUM
-to help in diagnosis of myoma, polyp, adenomyosis & endometrial
thickness.
• DOPPLER ULTRASONOGRAPHY- In Suspected A-V malformation
- Malignancy & to differentiate between FIBROID &ADENOMYOSIS
• 3D-USG-To evaluate Intra-cavitary & Myometrial lesion
• SALINE INFUSION SONOGRAPHY [SIS]- Suspected intra-cavitary
lesion e.g. polyp
- USG performed after introduction of saline in to the uterine cavity
[Sonohysterography]

48. Aub- investigation--HPE
• Endometrial sampling for Histopathology [HPE]-
Women > 40 yrs
Women < 40yrs –having high risk factor for MALIGNANCY
• Like –Irregular bleeding, obesity, Hypertension, PCOS,
• Endometrial thickness >12mm, Diabetes,
• Family History of Malignancy–ovary, breast ,endometrium, colon
• Use of Tamoxifen
• Late Menopause
• exposure to unopposed estrogen
• AUB –unresponsive to medical therapy

49. AUB: Investigation- HPE
Endometrial aspiration –preferred method OF
• Endometrial sampling for HPE
Devices like VABRA Aspirator PIPELLE or Karman’s canula no 4- used
Easy to use with adequate sampling, Minimally invasive tech esp in
perimenopausal women
Can detect > 90% of endometrial Cancer
Premenstrual phase –preferred for procedure
• Endometrial curettage & Biopsy –for sampling & HPE –not choice
• Hysteroscopic directed endometrial sampling
• HYSTEROSCOPY –Better evaluation of endometrial lesion

50. AUB –INVESTIGATION
• HYSTEROSCOPY- not in all cases
- Helpful for diagnosing intra-cavitary lesion, type of Myoma
 MRI- not superior to others in overall diagnostic potential
 CERVICAL CYTOLOGY- Performed in all women to exclude
CIN

51. AUB: MANAGEMENT
Depends On Several Factors
 Age
 Severity of bleeding
 Etiology
 Desire of fertility
 Contraceptive needs
 Medical Comorbidities
Treatment Options
• General Measures
• Medical
• Conservative Surgery: Ablation
• Major Surgery: Hysterectomy

52. AUB Management:
General Measures
• Rest
• Treatment of ANAEMIA
• Oral iron
• Blood, PCV
• Lifestyle modification
- Weight reduction
- Diet
- Exercises

53. AUB Management: Definitive treatment
as per etiology: PALM – SURGICAL, COEIN –MEDICAL
• Should be initiated only after the
etiology is established
Endometrial Polyp &
Submucosal Myomas
HYSTEROSCOPIC RESECTION
/HYSTERECTOMY
Medical t/t ineffective
Adenomyosis HORMONES- Oral/ LNG-IUS;
HYSTERECTOMY
Intramural Myoma MEDICAL / SURGICAL
Endometrial Cancer with
Atypical Hyperplasia
HYSTERECTOMY
Hyperplasia without Atypia MEDICAL

54. AUB-COEIN- Management medical
MEDICAL TREATMENT: Hormonal & Non-Hormonal
First line management for
- AUB-C, AUB-O, AUB-E with HMB, IMB, Irregular
bleeding,
- bleeding without STRUCTURAL abnormalities,
to reduce blood loss

55. AUB –coein MANAGEMENT
MEDICAL
management
Non Hormonal:
• Antifibrinolytics: Tranexamic acid
- Well tolerated
- Dose- 1 gm /daily for 3 to 4 days
• PG Synthetase inhibitors: NSAIDS
- Ibuprofen, Naproxen & Mefenamic acid
- 500mg X 3 daily
- can be used in combination with
- Tranexamic acid as FIRST line

56. Progestin only- Oral, Injectable, IUS
- ORAL: Medroxyprogesterone, Norethisterone, Norethindrone
- Injectable: Medroxy Progesterone depot,
- IUS: Progesterone
Estrogen- Progestin combination
- Cycle control excellent.
- Low dose preparation cyclically –safe in nearly all age group for 3-6
cycle
AUB- coein MEDICAl management
HORMONAL

57. Estrogen only- seldom used, in AUB-O,
- young girl with atrophic endometrium
- conjugated equine oestrogen 25mg iv 6 hourly to prime endometrium
(usually not available)
- Ethinyl oestradiol 50 ug for 5days followed by combination O+P therapy
cyclically.
AUB MEDICAL -HORMONAL

58. Others:
• Danazol: antigonadotropin
- AUB- E100-200 mg daily x 3 month continuous
- if recurrent symptoms and those waiting for hysterectomy
• GnRH analogues
- Subtherapeutic dose- reduces blood loss, Therapeutic dose- amenorrhea
- Subcutaneously, intra nasally or im injection 3.6mg monthly
-only when waiting for surgery or to prepare endometrium for Ablative
Procedure
• Ormeloxifene-SERM- 60 mg x2 wkly- 3month –reduces blood loss
• Desmopressin – used in Von-willebrand’s disease & factor 8 deficiency
-
AUB MANAGEMENT: MEDICAL
HORMONAL

59. AUB-COEIN: GENERAL
MANAGEMNET GUIDELINE
• Tranexamic acid- first line therapy. Other non hormonal option- NSAIDs
• LNG-IUS – Desiring Contraception
• COC 2ND LINE therapy
• Cyclical oral Progestin [day 5-26] for 21days T/T of AUB-E
• Cyclical Luteal phase Progestin- orally10-14 days,[ day 15 to 25 ] for
AUB -O
• Ormeloxifene- Saheli: SERM- Where steroids contraindicated
• GnRH agonist with Add-back hormone- last resort
• Endometrial Ablation- if failure to medical or high risk for hysterectomy.-
Endo-Ablation replaced by LNG-IUS
• All AUB pts- HAEMATINICS to prevent ANAEMIA

60. AUB : SURGICAL-management
ABLATION /RESECTION
Conservative surgery: Endometrial Ablation
Indications: AUB-E or AUB-O with
- Failed medical therapy
- Young women with desire to preserve the uterus
- Poor surgical risk for hysterectomy
Contraindications–
- Desire for fertility
- Large uterus >12 wk
- Endometrial Hyperplasia
- Multiple/ large myoma
- Suspected malignancy
- Postmenopausal women
Endometrial ablation surgically destroys the
endometrial lining of uterus with goal to reduce
menstrual flow.

61. AUB Management:
Surgical- Ablation
TECHNIQUES: TWO
• Resectoscopic Endometrial Ablation- 1st
-Hysteroscopy & Anesthesia
• Transcervical Endometrial resection
• Endometrial Laser ablation
• Roller ball Electro coagulation
• Non Resectoscopic Endometrial Ablation -2nd
• Thermal Balloon ablation- most popular technique.
• Microwave Endometrial ablation
• Radio-frequency induced ablation
• Hydro-thermal ablation
• Cryotherapy
• LASER Interstitial therapy
Resectoscope

62. Radiofrequency ablation Plasma energy (ionized argon)
Cryotherapy
Types of Ablation
Resectoscopic techniques
Non Resectoscopic techniques
Transcervical resection
Laser ablation
Roller blade ablation

63. AUB Management : Ablation
Complications
• More with RESECTOSCOPE technique
• Efficacy of endometrial ablation is similar to LNG-IUS
(LNG-IUS has replaced Ablation)
• Complications –
- Uterine Perforation
- Haemorrhage
- Intrauterine scarring& hematometra
- Fluid overload & Pelvic infection
Also known as GLOBAL ABLATION technique, since entire endometrial
cavity is usually destroyed

64. DISADVANTAGES OF
RESECTOSCOPIC TECHNIQUES
 Long learning curve
 Requires general anaesthesia & skilled operator
 Has higher risk of complications
Demerits of Resectoscopic technology led to development
of Non Resectoscopic technique.

65. AUB Management:
Surgery- Hysterectomy
HYSTERECTOMY INDICATIONS:
 Failed Medical Therapy in perimenopausal
women
 Failed Endometrial Ablation
 Complex atypical hyperplasia in older women
 Other pelvic pathology needing concomitant
surgery

66. AUB MANAGEMENT: ACUTE
BLEEDING
• Treatment relies on- Etiology of bleeding, medical problem, fertility
desire & clinical stability. Pregnancy-EXCLUDE
• Medical therapy- Tranexamic acid, oral/ iv- 500- 1000mg [4gm/d]
• Progestin- oral norethisterone, Medroxyprogesterone- high dose
• COC (Combined Oral Contraceptive) cascade
• Conjugated equine estrogen iv 25 mg 4hrly
• Hospitalization – if unstable & serious
• Treat Anaemia

67. AUB : MANAGEMENT IN ADOLESCENT GIRLS

68. AUB : MANAGEMENT IN REPRODUCTIVE WOMEN

69. AUB : MANAGEMENT IN PERIMENOPAUSAL WOMEN