- Abnormal uterine bleeding (AUB) refers to any irregularity in menstrual cycle patterns, including changes in frequency, duration, or amount of bleeding. - Heavy menstrual bleeding (HMB) is the most common presentation of AUB, affecting 60% of cases. It interferes with a woman's quality of life. - The FIGO classification system categorizes AUB into structural causes (polyps, adenomyosis, leiomyomas, malignancy) and non-structural causes (coagulation disorders, ovulatory dysfunction, endometrial issues, iatrogenic causes, unclassified causes).

1. - Dr. UJJWAL KHULLAR
ABNORMAL
UTERINE
BLEEDING

2. ABNORMAL UTERINE BLEEDING…
• It is Defined as any variation from the normal
menstrual cycle , and includes-
- changes in regularity and frequency
- in duration of flow , or
- in amount of blood loss
HMB- IS MOST COMMON CLINICAL PRESENTATION OF
AUB. INCIDENCE- 60%
Earlier known as DUB , refered to AUB which is not caused by
structural lesions of uterus.

3. ACUTE AND CHRONIC AUB
• HMB- excessive menstrual blood loss which
interferes with the women`s physical , mental ,
social and quality of life , which can occur alone
or combination with others.
• ACUTE AUB- an episode of bleeding in non-
pregnant women , sufficient to require immediate
intervention to prevent further blood loss.
• CHRONIC AUB- Bleeding that is abnormal in duration ,
volume , and/or frequency and has been present for at
least 3 months.

4. CLINICAL TYPES -
• Polymenorrhoea: frequent (<21 d) menstruation, at
regular intervals
• Menorrhagia: Excessive (>80 ml) & / or prolonged
menstruation, at regular intervals
• Metrorrhagia: Excessive (>80 ml) & / or prolonged
menstruation at irregular intervals.
• Menometrorrhagia: both.
• Intermenstual bleeding: episodes of uterine bleeding
between regular menstruations
• Hypomenorrhoea: scanty menstruation.
• Oligomenorrhea: infrequent menstruation (>35 d)

5. PREVALENCE-
World- 3%-30% in reproductive age
India- 18-20% in reproductive age
Prevalence increases with age- 24% in 36-40 yrs.
15% of all gynae OPD patients
25% of all gynae surgeries.

6. PATHOPHYSIOLOGY
• VASOCONSTRICTION- PG F2 alpha – contraction of uterus
THROMBOXANE A2- platelete activator
LEUKOTRIOENES- inflammatory mediator
PG D2- inflammatory and plt aggregation
• VASODILATORS- PG E2 – vasodilator and smooth muscle
relaxation
• PG I2- prevents formation of platelet plug
, vasodilator
NORMAL- PGF2 ALPHA > PGE2>PGD2
HMB- PGE2>PGF2 ALPHA > PGD2

7. • Structural changes in the Spiral arterioles
and venous sinuses of endometrium.
• Abnormal vascularity of Endometrium.
• Delayed regeneration of endometrium.
• Excessive Endometrial tissue necrosis by
hydrolytic enzymes from Golgi- Lysosomal
complex.
• Deficient formation and release of
ENDOMETRIAL VASOCONSTRICTOR
SUBSTANCE.

8. CLASSIFICATION OF SEVERITY
MILD
• Longer menses (<7days) or shorter cycles (<3
weeks) for 2 months in succession , with slightly or
moderately increased bleeding, Hb usually normal
(>12g/dL) or mildly decreased (10-12 g/dL)
MODERATE
• Moderately prolonged or frequent (every 1-3 weeks
and >7 days) menses , with moderate to heavy
bleeding and a hb- >10g/dL
SEVERE
• Heavy bleeding with a hemoglobin level of <10g/dL

10. ETIOLOGY OF AUB

12. FIGO CLASSIFICATION SYSTEM FOR CAUSES OF
ABNORMAL UTERINE BLEEDING IN THE
REPRODUCTIVE YEARS

13. ADVANTAGES OF PALM-COEIN
• Simplified and unified terminology
• Allows clear focus of treatment concepts
• Facilitates clinical and scientific research collaboration.
• Provides the basis to structure more effective clinical
teaching
• Serves to enhance and clarify communication within
and between specialties.

14. ACC. TO FIGO CLASSIFICATION…
• Abnormal Uterine Bleeding (AUB): quantity,
regularity and/or timing.
• Acute AUB: episode of heavy bleeding that is of
sufficient amount to require immediate intervention to
prevent further blood loss.
• Chronic AUB: AUB present for most of previous 6
months. Acute AUB can be spontaneous or in context
of chronic AUB.
• Intermenstrual Bleeding (IMB): bleeding between
clearly defined cycles.

15. • Heavy Menstrual Bleeding (HMB): excessive
menstrual blood loss affecting quality of life – physical,
emotional, social.
• Objective HMB: blood loss > 80ml/ cycle, 60% of these
women will have evidence of iron deficiency anaemia.
• Subjective HMB: 50% of women presenting with heavy
menses will have measured blood loss within normal
limits , but must still be considered abnormal, and
investigated accordingly.

17. FIGO CLASSIFICATION

18. AUB-P (POLYPS)
• Epithelial proliferation arising from endometrial stroma or
glands.
• Responsible for 57-60% cases.
• History of intermenstrual bleeding.
• Treatment :-
• Hysteroscopic polypectomy (Sent for hiostopathology)
• Recurrent polyps :- LNG-IUS.
• If hiostopathology shows malignancy :- Treat like
endometrial cancer.

19. AUB- A (ADENOMYOSIS)
• Growth of endometrial tissue in the myometrium.
• MRI is gold standard.
• Management :-
• LNG-IUS :- first line therapy.
• Adeno-myomectomy.
• Hysterectomy.

20. AUB-L (LEIOMYOMAS)
• Benign fibromuscular tumors of myometrium.
• MRI used for exact mapping of fibroid before planning surgery.
• Classification :-
 Submucous myoma (SM – Type 0 , 1 , 2)
 Type 3 :- Myomas which just touch the endometrium but do
not disturb the cavity.
 Type 4 :- Myomas which have myometrium between intramural
myoma and endometrium on one side and myoma and serosa
on other side.
 Type 5, 6, 7 :- intramural myomas growing towards serosa.
 Type 8 :- Does not include myomertrium and include cervical,
broad ligament and parasitic leiomyoma.

21. Management :-
• Medical management : - for small (< 4 cm ) fibroids
and to delay hysterectomy.
- NSAID (Mefenemic acid 500 mg thrice a day )
- Tranexamic acid , Combined OCP’S , GnRH
analogues.
- Ulipristal 5 mg daily for 3-4 months.
- Mifepristone 25 mg daily for 4 months.
• Uterine artery embolization.
• Myomectomy :- for large fibroids causing infertility.
• Hysterectomy .

22. AUB- M (MALIGNANCY)
Includes –
• ENDOMETRIAL HYPERPLASIA
• ENDOMETRIAL CANCER.

23. NON - STRUCTURAL ABNORMALITIES
• C – Coagulopathy
• O – Ovulatory Dysfunction
• E – Endometrial
• I – Iatrogenic
• N – Not yet classified

24. AUB- C (COAGULOPATHY)
• AUB caused by systemic diseases of hemostasis (13% cases ).
• Includes von Willebrands disease , purpuras , hemophilia.
• Management : -
• NSAIDS are avoided.
• Tranexamic acid.
• Combined OCP’S or progestogens.
• Endomterial ablation.
• Hysterectomy.

25. AUB-O (OVULATORY DISORDERS)
ETIOLOGY-
• Polycystic Ovarian Syndrome (PCOS)
• Hypothyroidism
• Hyper- prolactinemia
• Mental stress
• Obesity
• Anorexia
• Weight loss
• Extreme exercise
• Adolescence
• Menopausal transition

26. METROPATHIA HEMORRHAGICA
Special type of AUB in
40-45 yrs
perimenopausal women.
Feature- amenorrhoea for
6-8 weeks f/b painless
HMB
Reason-
HYPERESTROGENISM
t/t- progesteron
Uterus is bulky and
uniformly enlarged with
myohyperplasia (upto
25mm)
Endometrium- thick ,
polyps
HPE- cystic glandular
hyperplasia – SWISS
CHEESE

27. AUB- I (IATROGENIC)

28. AUB – N ; NOT YET CLASSIFIED
• Disorders that would be identified or
defined only by biochemical or
molecular biology assays…
• Arterio-venous malformations
• Myometrial hypertrophy
• Category for new etiologies

29. HISTORY TAKING
• AGE- premenarcheal
puberty
reproductive age
perimenopausal
menopausal
Rule out local causes of bleeding.
• MENSTRURAL HISTORY bleeding pattern
frequency
irregularity
HMB
intermenstural bleeding- cervical polyp , submucous.
asso. With Dysmenorrhea – endometriosis and PID
pre menstural symptoms
relation with Coitus
amount of bleeding is assessed by the number of pads used and clots.

31. HISTORY CONTI…
• history of AMENORRHOE followed by BLEEDING PV.
pregnancy related
anovulatory bleeding like PCOS
• DYSPAREUNIA- endometriosis
PID
post coital bleeding
local pathology
• ANAEMIA- h/o palpitation , breathlessness , weakness
• OBS. HISTORY- h/o PCOD , endometriosis , h/o recent abortion ,
MTP, h/o of last child birth ,
lactation

32. • PAST HISTORY-
Diabetes
HTN
Thyroid ds.
Coagulation disorders
• FAMILY HISTORY-
Endomeyrial cancer
Coagulation ds
Obesity
PCOS
DM
Perimenopausal age

33. • CONTRACEPTION HISTORY-
IUCD
Combined OCPs- and its IRREGULAR intake.
Recent h/o Tubectomy
• h/o HORMONE INTAKE and other drugs-
Antipsychotic
Corticosteriods
Anticoagulants- warfarin and heparin
• TREATMENT HISTORY-
H/O blood transfusion

34. • GENERAL PHYSICAL EXAMINATION-
All signs of Anaemia
Edema
Weight- obesity- BMI high >27, in thyrotoxicosis, there is
weight loss.
Features of PCOS- hirsutism
acne and
acanthosis nigricans.
SKIN-
BRUSING
PETECHIAL H`AGE

35. • EYE- exophthalmous in thyrotoxicosis
• enlarged thyroid gland , anaemia
• GUMS- Gingival bleeding
• BREAST- galactorrhea
SYSTEMIC EXAMINATION
Pulse rate- Anaemia, heart disease , hypothyroidism
BLOOD PRESSURE- HTN causes HMB
CVS- S1 and S2 and added murmers – heart disease , anaemia
RESPIRATORY SYSTEM – added sounds for T.B

36. PER ABDOMEN EXAMINATION
PER ABDOMEN EXAMINATION
UPPER ABDOMEN enlarged liver and spleen
LOWER ABDOMEN any mass- uterine fibroid
pregnancy
ovarian tumour – like granulosa
cell tumour , sex cord tumour.

38. VAGINAL EXAMINATION
Local examination-
Look for local source of infection from vulva , vagina , urethra , anal canal.
PER SPECULUM-
CX- cervicitis
errosions
endocervical polyp
fibroid polyp
Cu-T thread
DISCHARGE-
Foul smelling mucoid ds. – PID
Very foul smelling ds. + blood tinged- malignancy
Brownish ds.- missed abortion.

39. ON BIMANUAL EXAMINATION-
Size of uterus – enlarged and soft if pregnancy.
rule out- fibroids , adenomyosis, endometrial Ca
, uterine sarcoma.
ADNEXAE-
Tenderness and fixed uterus – endometriosis , PID.
PER RECTAL AND PER URETHRAL EXAMINATION-
Rule out the exact bleeding site

40. INVESTIGATIONS
• UPT- rule out pregnancy
• CBP with platelet count – type of anaemia
• Coagulation profile and BT/CT – bleeding disorders
• WET PREP- cervical secretions,- showns RBCS ,
neutrophils in CHRONIC CERVICITIS and
infection.
• PAP SMEAR SCREENING- see abnormal
endocervical gland and endometrial calls
• OTHERS- Sr. TSH , free testosterone , prolactin
and progesterone levels.

43. UTERINE EVALUATION

44. ULTRASONOGRAPHY
• Transvaginal / transabdominal USG
• SIS
• TV-CDS- transvaginal colour doppler
sonography.
ENDOMETRIAL BIOPSY
D & C
Metal curettes
Flexible plastic curettes (PIPELLES) by
aspiration

45. METHODS OF ENDOMETRIAL
SAMPLING
• it is done in the secreatory phase – D24 - D26
• Karman`s cannula no. 4 is used. Procedure is done in minnor
OT without local anesthesia or pain killer. Other devices used
are Vabra aspirator or Pipelle.
sample to be sent in 10% formalin solution
it helps to diagnose- ENDOMETRIAL HYPERPLASIA AND
ENDOMETRIAL CANCER.
• HYSTEROSCOPY GUIDED ENDOMETRIAL SAMPLING

47. GENITAL KOCH
• INCIDENCE- 1% among the gynae patients attending OPDs.
• Menorrhagia or irregular bleeding in genital TB is probably due to
ovarian involvement , pelvic congestion or endometrial lesions.
• TREATMENT- AntiTB Treatment .
HYPOTHYROIDISM
• It can be associated with pubertal AUB.
• Incidence myxoedema 32-80%
• Menorrhagia is the most frequent presenting complaint.
• Responds promptly to THYROID replacement therapy
• THYROXINE has direct effect on SPIRAL ARTERIOLES and on
HEMOSTASIS at menstruation.

48. IDIOPATHIC THROMBOCYTOPENIC PURPURA
• 80% patient have menorrhagia.
• Acute ITP is most commonly seen in young girls and is mostly
IMMUNOLOGICAL THROMBOCYTOPENIA – caused by
immunocomplexes containing viral antigens that binds to PLATELET ,
Fc receptors , or by antibodies produced against viral antigens that
cross react with platelets.
• May be asso. with infectious mononucleosis , acute toxoplasmosis ,
CMV infection , viral hepatitis and HIV
• Rule out – leukemia , Von willebrands ds
• T/t – steroids
• Avoid NSAIDs
• Severe cases - Splenectomy

49. PCOS
• 30% cases are associated with irregular bleeding
• CHRONIC ANOVULATION- is due to INCREASE plusatility of GnRH
which results in ELEVATED LH levels and INCREASED ovarian
Androgen production.
• Increase in LH causes menstrual irregularity and oily skin
• Peripheral conversion of androstenedione oestrone , causing
HYPEROESTROGENIC effect , which causes Menstrual irregularity.
• TREATMENT- combined oral contraceptives (COC) as it in LH and
circulating testosterone level. SHBG and binds to testosteron.
• For AUB- MEDROXYPROGESTERONE ACETATE 10mg OD for 10
days every month.
• DROSPIRENONE(YASMIN) 3MG OD 21 days EFFECTIVE

50. MANAGEMENT OF AUB
1. Women with severe anovulatory HMB may be severely
ANAEMIC and DEHYDATED.
2. They require immediate intervention like correction of Anaemia
and fluid resuscitation by :-
IV fluids like dextrose saline
saline
Hemaccel
blood transfusion

51. CONTROL OF HAEMORRHAGE (ACUTE AUB)
Conjugated equine
estrogen (premarin) 25mg
iv 4 hrly for 3 doses
Less acute bleeding-
premarin orally 2.5mg 6
hourly
CENTCHROMAN- 60mg
TWICE A WEEK for 12weeks
f/b- 60mg once a week for 6
months.
Combined OCPs- 30-
50mcg ethinylestradiol 6-8
hrly for 7 days f/b 1 OD till
bleeding stops
Medroxyprogesterone acetate-
10mg- 4hrly -4days
10mg- 6hrly -4days
10mg- 8hrly- 3days
10mg- 12hrly- 14days
Inj. Tranexamic acid-
10mg/kg/iv 8 hrly till
bleeding stops
f/b oral 1gm TDS 5days

52. MANAGEMENT OF CHRONIC AUB
• Treatment of anaemia is by hematinics –
iron (ferrous sulphate 100mg BD + folic acid + Vit. D)
• Life style modification , weight reduction , diet , exercise in case
of PCOD related to AUB.
• MEDICAL TREATMENT- this is mainstay of treatment and
should be given in all AUB before surgical treatment

53. NON- HORMONAL TREATMENT
MOA- TRANEXAMIC ACID is an Anti
fibrinolytic drug , which blocks binding
site of lysine on plasminogen
*There is increases in fibrinolytic
activity of endometrium
*It reduces bleeding by 40-50%
DOSE- 500mg TDS for 5 days
Contraindication- h/o
thromboembolic disease
ANTI-FIBRINOLYTIC
AGENT

54. NSAIDS
• Inhibits cyclooxygenase enzyme
• Helps reduse bleeding and dysmenorrhea
• Dose – 500mg TDS FOR 5 DAYS
Capillary
fragility
inhibitors
• ETHAMSYLATE , 500mg TDS + mefenamic acid/
Tranenexamic acid.
• Helps to reduce bleeding in AUB
Diosmin
• Phlebotomic and vascular protective
• Dose- 300-600 mg TDS for 5 days

55. HORMONAL TREATMENT
progestogens
Very effective for
AUB-O , both ovulatory
and anovulatory.
Regesterone or
Medroxy
progesterone acetate
Dose- 5mg TDS on
D5-D25 (oral)
Injectable DMPA –
150MG 3 monthly
s/e- weight gain
Bloating
headache

56. LNG-IUS
TOTAL- 54 MG
RELESES- 20MCG/day
EFFECTIVITY- 3 yrs
Reduces 70-95% blood
loss in 3 months use
Uses- fertile women
Drawbacks-
High cost
46% women underwent
hysterectomy
Difficult insertion
Ectopic pregnancy
Contraindication-
Abnormal uterine cavity
Breast or genital malignancy
STDs
Liver disease
MIRENA

57. COMBINED OCPS
MOA- endometrial atrophy , decreases
prostaglandin synthesis and endometrial
fibrinolysis
• reduces blood loss by 50%
• additional benefit - contraception
DOSE- 30 mcg ethinyl estradiol + 75mcg
progestogen is given cyclically D5- D25 for 4-6
months.
• Useful in AUB- E and AUB-O

58. OTHER DRUGS
ANDROGENS- Danazol , MOA- hypoestrogenic
and hyperandrogenic. Causes endometrial
atrophy . Decreases blood loss by 50%
DOSE- 100-200MG daily
GnRH anologues (leuprolide , goserelin) causes
pituitary down- regulation , severe
hypoestrogenism and endometrial atrophy and
amenorrhoea
DOSE – goserelin 3.6mg every 28 days for 3-6
months
CENTCHROMAN- SELECTIVE ESTROGEN
RECEPTOR MODULATOR , DOSE- 60mg twice
weekly for 4-6 months.

59. SURGICAL TREATMENT
1) CONSERVATIVE SURGERY
- DILATATION AND CURRETAGE
- ENDOMETRIAL ABLATION TECHNIQUES
- UTERINE ARTERY EMBOLIZATION
- MYOMECTOMY
2) DEFINATIVE SURGERY
- VAGINAL HYSTERECTOMY
- LAPAROSCOPIC HYSTERECTOMY
- ROBOTIC SURGERY
- VAGINAL HYSTERECTOMY

60. ENDOMETRIAL ABLATION OR
RESECTION TECHNIQUE
• Attempt is to permanently remove / destroy the uterine llining
INDICATION- AUB REFRACTORY TO MEDICAL T/T
YOUNG WOMEN NOT WANTING ANY CHILDREN
WOMEN HIGH RISK FOR HYSTERECTOMY
CONTRAINDICATIONS
• Pregnancy
• Women wanting to preserve fertility
• Acute upper genital tract infection
• Gynaecological malignancy
• Women at high risk for endometrial cancer
• Distorted uterus
• Post menopausal women
• IUCD
• PAST H/O uterine surgery

61. FIRST GENERATION TECHNIQUE
• PRE-OP- norethisterone 5mg TDS for 6 weeks is given to
make Endometrium ATROPHIC and effective for ablation
• TRANSCERVICAL RESECTION OF ENDOMETRIUM
(TCRE) USING ELECTRICAL DIATHERMY
• Rooler ball electrocoagulation
• Endometrial laser ablation using Nd YAG laser.
• DISTENSION MEDIUM- glycine
S/E- Fluid over load- pulmonary edema hyponatremia , HTN-
which is life threatning
• Done under G.A
• Entire ENDOMETRIUM is either resected or
electrocoagulated with roller ball / laser.

62. COMPLICATION-
Complications of GA
Because of GLYCINE - Fluid over load- pulmonary edema
hyponatremia , HTN- which is life threatning
Infection
Embolism
Anaphylactic reaction
SECOND GENERATION
• Microwave endometrial ablation (MEA)
• Thermal ballon endometrial ablation
• Radio frequency induced ablation

63. DEFINATIVE SURGERY
When medical treatment and conservative surgeries fails-
HYSTERECTOMY
Indications-
Women >40yrs , family completed
Failure of medical t/t
Failure of conservative surgery
Sever AUB
Complex atypical hyperplasia

64. CONCLUSION
• AUB is one of the major problems of adolescent
gynecology and anovulatory HMB is the commonest
presentation of AUB.
• Anovulatory cycles are generally physiologic and
resolve spontaneously in most adolescents as the HPO
axis matures.
• HMB may be due to coagulopathy and every adolescent
with HMB should be questioned for bleeding disorders.
• Once hemodynamic stability is controlled and provided
, the patient must be evaluated for severity of ANAEMIA
and possible causes of HMB.

65. • Identify severity of anaemia and it`s underlying
cause and determine the treatment.
• Beside IRON supplementation , COCs , Progestin
only drugs , IV Estrogen and / or hemostatic agents
can be used for treatment
• Find out the specific cause and treat it.
• Reassurance and Counselling of young girls is very
important

66. •THANK YOU