Abnormal uterine bleeding

1. ABNORMAL UTERINE BLEEDING
(AUB)

2. DEFINITION :
• Any uterine bleeding outside the normal
volume, duration, regularity or frequency.

3. NORMAL MENSTRUATION :
• Cycle interval 28 days (21-35 days)
• Menstrual flow 4 to 5 days
• Menstrual blood loss 35ml (25 to 80ml)

4. MENORRHAGIA :
• Cyclical bleeding at normal intervals the
bleeding is either excessive in amount (>80ml)
or duration (>7 days) or both.
• Menotaxis : prolonged bleeding

5. Polymenorrhoea (Epimenorrhoea)
• Cyclical bleeding where the cycle is reduced to
less than 21 days and remains constant at that
frequency.
Polymenorrhagia (Epimenorrhagia)
• When the frequent cycle is associated with
excessive and or prolonged bleeding.

6. • METRORRHAGIA : Irregular, a cyclical
bleeding from the uterus.
• MENOMETRORRHAGIA : Bleeding is so
irregular and excessive that the menses
cannot be identified at all.

7. • Oligomenorrhoea : Menstrual bleeding
occuring > than 35 days apart and which
remains constant at that frequency.
• Hypomenorrhoea : When the menstrual
bleeding is unduly scanty and lasts for less
than 2 days.

8. FIGO 2011 CLASSIFICATION OF AUB –
PALM COEIN
Structural causes (PALM)
• P - Polyp
• A - Adenomyosis
• L - Letomyoma
• M - Malignancy

9. Nonstructural systemic causes (COEIN)
• C - Coagulopathy
• O - Ovulatory dysfunction
• E - Endometrial
• I - Iatrogenic
• N - Not yet identified

10. Definition :
• Abnormal uterine bleeding in the absence of
organic pelvic pathology, systemic diseases,
endocrine disorders, blood dyscrasias,
iatrogenic causes and pregnancy.
DUB : Dysfunctional uterine bleeding

11. • Therefore the diagnosis of DUB is based on
exclusion of organic lesions.
• DUB is due to dysfunction of hypothalamo-
pituitary ovarian axis.

12. PATHOGENESIS OF DUB :
• Endometrium normally produces,
prostaglandin from arachidonic acid which is a
fatty acid.
• PGE2 and PGI4 are vasodilators and
antiplatellet aggregates.
• PGF2__ and thromboxane A 2 –
vasoconstriction and platelet aggregates.

13. • Progesterone is responsible for secretion of
PGF2__ .
• In onovulatory cycles, the absence of
progesterone and therefore PGF2__ causes
menorrhagia.
• In some cases tissue plasminogen activator
(TPA) which is a fibrinolytic enzyme is
increased leading to menorrhagia.

14. Classification of DUB
Anovulatory
(80%)
Ovulatory
(20%)
Threshold bleeding of
puberty menorrhagia
Irregular ripening
Metropathia haemorrhagia Irregular shedding
Premenopausal DUB IUCD insertion
Following sterilization operation

15. PUBERTY MENORRHAGIA :
• DUB in the 1st year of menarche
• Anovulatory cycles
• Due to immaturity of the hypothalamopituitary
ovarian axis.
• Takes 18 months to 2 years for cycles to be
regularised.
• No dysmenorrhoea
• Unopposed oestrogen causes endometrial
hyperplasia.

16. RULE OUT :
• Hypothyrodism
• Bleeding disorders
• Genital TB (early stages)
• Liver disorders
• Feminizing ovarian tumours granulosa cell and
theca cell tumours.

17. INVESTIGATION :
• Blood group Rh, HB%, PCV, peripheral smear.
• Platelet count
• BT, CT, PT APTT
• TFT
• LFT
• USG – PCOD to R/O organic pelvic patho
condition of uterus – rarely fibroid.
• Sarcoma Botyroides oestrogen producing ovarian
tumours.

18. TREATMENT :
• Assurance
• Correct anaemia
• NSAIDS – Mefenamic acid 500mg. TDS x 5 days
IBUPROFEN 400mg. BD x 3 days.
• Antifibrinohytic agents e.g. transexamic ACID
500mg. TDS x 5 days.
• Ethamsylate 500mg TDS x 5 days to decrease
the capillary fragility.

19. • Harmonal – in polymenorrhoea /
polymenorrhagia start MPA (medroxy
progesterone acetate) 10mg OD from D5 to D25
x 3 months.
• In Menorrhagia – start MPA 10mg OD from
D15 to D25 x 3 months.
• OC pills to regularise the cycle for 3 months

20. D & C not done – only as a last resort.
• 90% patients respond to this type of
treatment without compromise on
reproductive function.
• Desmopressin – indicated in Von Wille brand’s
disease and factor VIII deficiency. It is a
synthetic analogue of arginine – vasopressin
given IV or intranasal.

21. DUB in reproductive age group and perimenopause:
• Clinical features are similar.
• No dysmenorrhoea as cycles are anovulatory.
• R/O pregnancy in reproductive age group.
• R/O malignancy in perimenopausal women
with a fractional curettage.

22. Ovular DUB – 20%
IRREGULAR RIPENING IRREGULAR SHEDDING (Halban’s
Disease)
Due to corpus luteum
insufficiency
Due to persistence of corpus
luteum
Break through bleeding
occurs before the actual
menses in the form of
spotting or brownish
discharge.
Menses comes on time but is
prolonged not heavy.
Progesterone given during
the luteal phase (D15 to D25)
cures the spotting.
Progesterone can suppress
the bleeding but needs to be
taken on tapering dose for
20 days to complete the
cycle.

23. Metropathia Haemorrahagia (Schroeder’s disease)
• Seen in women between 40 to 50 years.
• Not related to parity.
• Typical history – 6 to 8 weeks amenorrhoea
followed by menorrhagia (painless).
• Uterus is just bulky (myohyperplasia).
• HPE – cystoglandular hyperplasia or Swiss cheese
appearance.
• May be associated with follicular cyst ovary (1 or
both)

24. Investigation :
• Blood group Rh, HB% , PCV
• Platelet count
• PT, APTT, BT, CT
• TFT
• LFT

25. • USG
– to R/O organic pelvic pathology
– size of uterus, ET
– Condition of ovaries
• Hysteroscopy, SIS (Saline infusion
sonography).
• Fractional curettage – endometrial study to
R/O malignancy - Endometrial CA

26. TREATMENT :
• General – correct anaemia
• NSAIDS – Mefenamic acid 500mg BDx 4 to 5
days
• Antifibrimolcytic drugs –
– Tranexamic acid 500mg TDS x 4 to 5 days
– Capillary Haemostatic –
Ethamsylate 250mg TDS x 4 to 5 days.
– Ethamsylate can also be started 5 days prior as it
decrease capillary fragility.

27. PROGESTERONE – to stop bleeding
• MPA 10mg TDS x 5 days full by
10mg BD x 5 days full by
10mg HS x 10 days.
• Withdrawal bleeding in 2 to 5 days blood loss WML.
• Further course MPA 10mg HS x 20 days start from 5th to
25th day
OR
• Depot medroxy progesterone acetate.
DMPA – 3 monthly infections decrease the no. of
menses in a year.

28. Medical curettage :
• To arrest bleeding in acute phase
Northisterone acetate (Primolut N)
5mg TDS x 5 days
5mg BD x 5 days
5mg HS x 5 days

29. • ORMELOXIPHENE (SERM also used as
nonsteroidal OC pills – Saheli) in DUB – 60mg
twice weekly for 12 weeks and thereafter
weekly.
• It does not cause breast and uterine CA
because of its anti oestrogenic effect.
• It also protects the bone and CVS.

30. • Mirena – IUCD. Avoids the side effects of oral
harmones.
• It directly suppresses endometrium with
minimal side effects. It has no action on the
ovaries, therefore E2 and progesterone level
remain normal.
• Decrease blood loss by 70 to 80% in 3 months.
• Acts as a contraceptive.

31. MIRENA IUCD
• 52mg levonorgestrel
• Last for 5 years

32. Disadvantages of Nirema :
• Slightly difficult to insert.
• Takes 3 months to become effectie.
• Amenorrhoea in 20 to 25 % which is not
desirable in younger women.
• Hysterectomy required in 25% by the end of 3
years because of recurrence of Menorrhagia.

33. MIS – Minimal Invasive Surgery :
Role of D & C :
• Diagnostic –
– To note the type of endometrium.
– To detect endometrial CA
– To detect genital TB
• Therapeutic –
– 30 to 40% relieved of menorrhagia at least for a
short period.

34. ABLATIVE THERAPY :
1st GENERATION
• Hysteroscopic endometrial ablation by
resectoscope, loop, rollerball coagulation and
laser (TCRE – Transcervical endometrial
resection)
2nd GENERATION
• Radiofrequency induced thermal ablation
cavaterm balloon therapy.
• Microwave endometrial ablation (MEA) laser
therapy.

37. HYSTERECTOMY FOR DUB :
LAVH : Laparoscopy assisted vaginal hysterectomy.
TLH : Total laparoscopic hysterectomy.
VH : Vaginal hysterectomy.
TAH : Total abdominal Hysterectomy.
INDICATIONS :
• If medical / MIS falls or DUB recurs
• In women > 40 years who opt for hysterectomy as
a primary treatment.

38. VAGINAL HYSTERECTOMY IS CONTRAINDICATED IF :
• Uterus is grossly enlarged.
• Previous surgery with possible adhesions,
fixity and limitation of uterine mobility.
• Presence of endometrioses or adnexal mass.
• Women <50years ovaries to be conserved
unless diseased.

39. ENDOMETRIAL HYPERPLASIA :
• Anovulatory cycles with unopposed Estrogen
activity on endometrium.
• Metropathia haemorrhagica
• Obese women
• Polycystic ovarian disease
• Woman on tamoxifen
• Menopausal women on HRT without
progesterone
• Feminizing ovarian tumour.

40. TYPES OF ENDOMETRIAL HYPERPLASIA :
• Simple endometrial hyperplasia
- without Atypia – 1% chance of malignancy
- with atypia – 8%
• Complex endometrial hyperplasia
- Without atypia – 3% chance of malignancy
- With atypia – 29%