Abnormal uterine bleeding

1. AMENDED GUIDELINES OF
AUB
DR PUNEETA MAHAJAN
CONSULTANT
DR. BABA SAHEB AMBEDKAR MEDICAL
COLLEGE AND HOSPITAL
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2. • The International Federation of Gynecology and Obstetrics (FIGO) in 2011,
published recommendations having two systems:
 Terminology and Definitions for menstrual parameters.(FIGO- AUB System 1)
 PALM-COEIN system of classification of causes. (FIGO-AUB System 2).
• AIM : Standardize the terminology, investigation, diagnosis and
management of AUB
• These guidelines were updated in 2018
AUB is defined as bleeding from the uterine corpus that is
abnormal in duration, volume, frequency, and/or regularity not
related to pregnancy.
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3. Apart from the PALM-COEIN system, FIGO defines AUB also as:
• Acute AUB is defined as an episode of heavy bleeding that is of sufficient quantity to
require immediate intervention to prevent further blood loss.
• Chronic AUB is defined as bleeding from the uterine corpus that is abnormal in
duration, regularity, volume or frequency in absence of pregnancy and has been
present for most of the previous six months.
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4. • Review and promptly resuscitate
• Blood transfusion (Hb<7 gm%).
• Control the present episode of HMB
• Reduce menstrual blood loss in subsequent cycles.
TREATMENT OF ACUTE AUB
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5.  Medical treatment regimens for acute AUB:
 Premarin/ Conjugated equine estrogen(CEE) 25 mg I/V Every 4-6
hours for 24 hours
 Combined oral contraceptive(COC) : 1 TDS for 7 days
 Medroxyprogesterone acetate 20 mg orally TDS for 7 days
 Tranexamic acid 1 – 2 Tab TDS or 10mg/kg I/V (500 - 1000 mg/dose)
TDS for 5 days
 Intrauterine Foley’s catheter tamponade
After control of acute episode, further treatment of AUB depends on the
aetiology based on the PALM-COEIN classification.
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6. Updated (2018)
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7. Summary of changes to FIGO System1
PARAMETER CHANGE
1. Frequency Amenorrhea is now part of the frequency category
2. Regularity • Regularity: shortest to longest variation is 7–9 days
• Slight variance depends on age
• 8–25 y of age it is ≤9 d
• 26–41 y it is ≤7 d
• 42–45 y it is ≤9 d
3. Duration Now only two categories for duration
• Normal: ≤8 d
• Prolonged: >8 d
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8. PARAMETER CHANGE
4. Volume volume definition of symptom of HMB as proposed by NICE has
been adopted that is excessive menstrual loss which interferes with
woman’s physical, social, emotional and material quality of life.
Terms such as menorrhagia, metrorrhagia, oligomenorrhea, and
DUB have been abandoned.
5. Intermenstrual bleed • Definition of the symptom of inter-menstrual bleeding (bleeding
between regular cycles)
• Spontaneous bleeding occurring between menstrual periods
• Can be either cyclical, or random
Summary of changes to FIGO System1 cont.
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9. In the revised 2018, basic core classification of nine
categories PALM COEIN (based on etiopathogenesis of AUB)
remains the same.
STRUCTURAL CAUSES
(Based on imaging &HPE)
NON- STRUCTURAL CAUSES
(History, exam & lab invx)
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10. Documentation of AUB as per PALM-COEIN etiological classification:
• The status of each potential contributor of AUB is documented as being
present (1) or absent (0) in the acronym.
• Multiple pathologies are also documented simultaneously using the
acronym PALM COEIN:
• Eg. adenomyosis, hyperplasia and coagulopathy in a single patient may be
cited as P0 A1 L0 M1 – C1 O0 E0 I0 N0.
• Mentioning abbreviation for each identified cause after letters ‘AUB’ is
another alterative and simplified way of documentation in clinical settings
and above example may be cited as ‘AUB-A, -M, -C’.
• A leiomyoma may be documented as P0 A0 L1(SM) M0 – C0 O0 E0 I0 N0 or
AUB-L (SM – type0/1/2) if submucosal or as P0 A0 L1(O) M0 – C0 O0 E0 I0
N0 or AUB-L(O-type 3/4/5/6/7/8) if other than submucosal.
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11. Brief description of PALM-COEIN classification:
1. Polyps (P1 A0 Lo M0 – C0 O0 E0 I0 N0 or AUB-P)
• Epithelial proliferations arising from the endometrial stroma
and glands.
• Majority – asymptomatic(3.7% to 65%)
• Present(1) or Absent(0).
Treatment:
Hysteroscopic polypectomy - HPE (definative treatment option).
• HPE report - benign lesion and the patient is not desirous of fertility,
Levonorgestrel- Intrauterine system (LNG-IUS) may be considered.
• HPE report - suggestive of malignancy, managed as a case of AUB-M.
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12. 2.Adenomyosis (P0 A1 Lo M0 – C0 O0 E0 I0 N0 or AUB-A)
The morphological uterus sonographic assessment (MUSA) group suggested:
• Eight TVUS criteria for diagnosis of adenomyosis.
• Presence of two or more is highly associated with its diagnosis.
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13. MUSA EIGHT TVUS CRITERIA OF ADENOMYOSIS
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14. Depends on: Age, symptoms (AUB, pain and infertility) & association with
other conditions (leiomyomas, polyps and endometriosis)
1. HYSTERECTOMY : definitive treatment >40 years
2. CONSERVATIVE TREATMENT : younger patients
a. Medical : LNG-IUS, GnRH agonist, COC’s , danazol, NSAIDs, and
progestogens
b. Conservative Procedures:
• Hysteroscopic endometrial ablation and resection
• HIFU (High Intensity Focused Ultrasound)
• UAE (Uterine artery embolization)
TREATMENT
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15. 3. Leiomyomas (P0 A0 L1 M0 – C0 O0 E0 I0 N0 or AUB-L)
• Primary classification: presence(1) or absence(0’)
• Secondary classification: subdivision into submucous or ‘SM’ or others ‘O’.
• Tertiary classification:
 Submucous leiomyomas ‘SM’- Type 0, 1 ,2 ,3
 Others ‘o’
• intramural myomas that have myometrium between boundaries and
endometrium & serosa (Type 4)
• subserous tumors that are categorized according to the relative
proportions of the tumors within the myometrium (Types 5, 6, & 7).
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16. CHANGES : Inclusion of Type 3 as a submucous leiomyoma
Type definitions and distinctions
Distinction between Types 0 and 1; 6 and 7
Distinction between Types 2 and 3; 4 and 5 16

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TREATMENT
Asymptomatic fibroid: no treatment and regular follow-up except:
• submucosal leiomyoma causing infertility (after ruling out other causes)
• ureteral compression causing hydronephrosis.
• enlarging fibroid after menopause
Symptomatic fibroid: management options include
1. Medical
2. Surgical

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2. Medical Management:
• In perimenopausal women (can tide over to menopause)
• unfit for surgery
• preoperatively to reduce the size of the fibroid
• reduce menstrual bleeding to improve Hb before surgery.
Options:
NSAIDs and antifibrinolytics(tranexamic acid)
COC’s, Progesterone implants,
SPRM (Ulipristal acetate and Mifepristone),
LNG-IUS (if want to defer pregnancy for 1 year)

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Short term management: upto 6 weeks
GnRH agonists-
• Younger pt. to delay /avoid surgery
• surgically unfit
• Decreasing menstrual blood loss and improvement of anemia
• Reducing size of leiomyoma to facilitate minimally invasive surgery
• Perimenopausal women can tide over to menopause

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2. Surgical management
• MRI-guided focused ultrasonography (MRgFUS)
• Uterine artery embolization (retain their uterus but not fertility for uterus
up to 12 weeks size )
• Myomectomy: If medical management fails or if myoma is causing infertility,
• Abdominal route (open or laparoscopic if size >4cm)
• Hysteroscopic route (only if SM O,1 and size < 4cm)
• Hysterectomy
• Age >40 yrs
• symptomatic fibroids not responding to medical therapy
• have concurrent problems like CIN, endometriosis, adenomyosis that
require surgical management.
• Asymptomatic enlarged fibroid 12 – 14 weeks?

22. 4. Malignancy (P0 A0 L0 M1 – C 0 O0 E0 I0 N0 or AUB-M)
AUB-M includes both malignancy (leiomyosarcoma, endometrial cancer) and
endometrial hyperplasia. They are further “sub-classified” by the appropriate
WHO or FIGO system.
TREATMENT:
1. Endometrial hyperplasia without atypia
• LNG-IUS (first line therapy), MPA 10–20 mg/day or norethisterone 10–15 mg/day (
continuous for minimum 6 months).
• F/ U EB after 6 months till at least two consecutive 6-monthly negative biopsies.
• Surveillance with annual EB’s in Pt. having high risk factors for relapse.
• Hysterectomy is recommended in Pt. :
 Not willing for follow up
 Non-regression or relapse
 Progression to atypia during follow up
 With persistence of bleeding symptoms.
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23. 2. Endometrial hyperplasia with atypia
• High risk of progression to endometrial cancer
• Total extra facial hysterectomy (Lap) is the treatment of choice.
• If the woman want to preserve her fertility or is at high risk for surgery,
LNG IUS ( first line), Oral progestins are second-best alternative
• Follow up biopsy every 3 months till 2 negative biopsies followed by 6-12 monthly
biopsies till hysterectomy.
3. Pt. with diagnosed endometrial malignancy
• standard treatment protocol should be followed.
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24. 5. Coagulopathy (P0 A0 L0 M0 – C0 O E I N or AUB–C )
Abnormal uterine bleeding associated with any of systemic
disorders of haemostasis is designated as AUB-C.
TREATMENT
1. Pt. diagnosed with coagulopathy
 Tranexamic acid is first line treatment (maximum dose 1gm 6 hourly).
 Oral contraceptives or LNG-IUS is second line therapy.
2. Recombinant factor VIII, vWF or specific factor deficiency : replace
(von-Willebrand disease - desmopressin via intranasal, IV or SC route).
3. NSAIDs are strictly contraindicated (due to adverse effects on platelets
and liver functions).
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25. 6. Ovulatory Disorders (P0 A0 L0 M0 – C0 O1 E0 I0 N0 or AUB-O)
Ovulatory disorders leading to AUB (unopposed estrogen effects) :
• Peri-menarchal and perimenopausal women
• Endocrinopathies such as PCOD, hypothyroidism, and hyperprolactinemia
• Other factors including mental stress, obesity, anorexia, weight loss, and extreme
exercise.
TREATMENT:
1. Oral contraceptives for 6-12 months - first line of therapy.
2. Cyclic progestins from Day 5 to 26 or norethisterone for 21 days.
3. Cyclical luteal phase progestins are not recommended.
4. LNG IUS can also be offered.
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26. 7. Endometrial Causes (P0 A0 L0 M0 – C0 O0 E1 I0 N0 or AUB-E)
AUB - E is due to primary endometrial dysfunction depending upon local
production of vasodilators and vasoconstrictors.
• According to FIGO , there are no tests to be performed in this situation.
• AUB-E remains a diagnosis of exclusion.
Treatment options available are similar to that for AUB-O.
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27. 8. Iatrogenic (P0 A0 L0 M0 – C0 O0 E0 I1 N0 OR AUB-I)
• Iatrogenic causes of AUB include exogenous therapy leading to unscheduled
endometrial bleeding and is associated with the use of exogenous steroids (ie,
estrogen / progestin therapy, GnRH agonists and antagonists, aromatase
inhibitors, SERM, SPRM, IUCD
• AND other drugs e.g. anticonvulsants - valproic acid and antibiotics - rifampicin
and griseofulvin, anticoagulant drugs such as warfarin, heparin, LMWH,
phenothiazines and tricyclic antidepressants.
• The use of an intrauterine device may cause a low- grade endometritis which
may also contribute to AUB.
TREATMENT:
If medicinal intake is suspected to be the cause of AUB, switch to a better
alternative if available or plan insertion of LNG-IUS.
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28. 9. Not Otherwise Classified (P0 A0 L0 M0 – C0 O0 E0 I0 N1 or AUB-N)
Abnormal bleeding associated with the remainder of rare or ill-defined causes are
categorized as AUB-N.
Eg. arteriovenous malformations, caesarean scar defects or isthmocele,
endometrial pseudo aneurysm, myometrial hypertrophy and chronic endometritis
(not precipitated by an intrauterine device).
TREATMENT
1. LNG-IUS - first line therapy
2. Alternatively COC’s
3. Non-hormonal options like NSAIDs or tranexamic acid for cyclical AUB.
4. Conservative surgical options such as endometrial ablation may be considered in low
risk women when medical therapy fails.
5. In women with arterio-venous malformation, uterine artery embolization is the
treatment of choice.
6. Hysterectomy is last resort when all other treatments have failed.
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29. Changes in the PALM COEIN system 2
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30. CONCLUSION
The PALM-COEIN system is designed as a practical system for use by
clinicians worldwide for an easy and consistent evaluation of AUB.
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31. Management of AUB Case
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32. History
It is important to rule out pregnancy in any women
presenting with AUB in reproductive age group.
Other key points:
• Normal cyclicity, amount and duration of menstrual flow prior to onset of
complaints.
• Detailed history of present abnormal cycle and associated complaint of pain
or lump abdomen, vaginal discharge, fever etc
• History of use of contraceptives, medicines like anticoagulants, tamoxifen etc.
• History suggestive of medical disorder like thyroids disorder, DM,
hypertension.
• Family history of malignancy.
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HISTORY COND.
History suggestive of any of underlying disorder of hemostasis becomes
screen positive for coagulopathies which includes:
1. History of heavy menstrual flow since menarche.
2. One of the following:
• PPH
• Bleeding associated with dental work
• Surgery – related bleeding
3. Atleast two of the following symptoms:
• Atleast one episode of bruising per month
• Atleast one episode of epistaxis per month
• Frequent gum bleeding
• Family history of bleeding symptoms

34. Examination
• Vitals, pallor, icterus, lymph nodes.
• BMI, thyroid enlargement, breast examinations, acne and hirsutism.
• Abdominal examination: for palpable masses and free fluid
• Speculum examination to look for source and amount of bleeding , nature of
vaginal discharge and state of cervix and vagina. Take pap smear if indicated.
• Vaginal, rectal or combined examination to confirm the abdominal and
speculum findings.
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35. Investigations
1. Urine pregnancy test to rule out pregnancy related event.
2. Blood test
• CBC and P/S for anaemia
• Coagulation profile
• S. TSH, and liver function test if clinically indicated.
• Any other specific to the case.
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36. Investigations contd.
3. IMAGING
a) Ultrasound pelvis (TVUS):
• Post menstrual – TVS detecting structural abnormalities ET, status of
myometrium, fibroids, adenomyomas and adnexal masses.
b) Ultrasound – doppler:
• To differentiate between fibroids and adenomyomas.
• Suspected case of AV- malformations and malignancy.
c) 3 D USG
• For mapping fibroid if hysteroscopy not available.
d) Hysteroscopy:
• To identifying intracavitary lesions and taking directed biopsies.
e) Saline infusion ultrasonography:
• To differentiate thickened endometrium from endometrial polyps where
hysteroscopy is not available.
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37. Investigations contd.
f. MRI:
• Indicated prior to conservative surgery for fibroids in order to map the exact
number and location of fibroids.
• To differentiate fibroids from adenomyomas.
• In suspected case of malignancy.
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38. Evaluation of Endometrium
• If > 40 years
• If < 40 year with high risk factor like obesity, hypertension,
PCOS, diabetes, endometrial thickness >12mm on USG, use of
tamoxifen for HRT or breast cancer, family history of malignancy
of ovary, breast, endometrium or colon.
• In women with persistent AUB that is unexplained or
unresponsive to treatment.
• Endometrial aspiration is procedure of choice for obtaining
endometrial sample for histopathological diagnosis.
If ET is more on USG but EB shows inadequate tissue or
atrophic: do hysteroscopy
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Thank you