This document discusses abnormal uterine bleeding (AUB). It begins by defining normal menstrual cycles and explaining the hormonal regulation of menstruation. It then describes different types of abnormal bleeding patterns seen in AUB, including menorrhagia, metrorrhagia, and oligomenorrhoea. Organic and functional causes of AUB are outlined. The document focuses on the pathophysiology, endometrial changes, and management of anovulatory and ovulatory dysfunctional uterine bleeding. Diagnostic tests for AUB and differential diagnoses for adolescents and reproductive-aged women are also reviewed. Treatment options for AUB include medical therapies like hormones and lifestyle modifications, as well as surgical interventions.

1. ABNORMAL UTERINE BLEEDING
PROF. M.C.BANSAL.
MBBS.MS.MICOG.FICOG.
FOUNDER PRINCIPAL & CONTROLLER;
JHALAWAR MEDICAL COLLEGE AND
HOSPITAL JHALAWAR.
EX. PRINCIPAL & CONTROLLER;
MAHATMA GANDHI MEDICAL COLLEGE
AND HOSPITAL , SITAPURA, JAIPUR

2. Normal Menstrual Cycle
 Menstration is a cyclic physiological phenomena
 starting at the age of Menarche (10-12years) till
establishment of Menopause (45-55 yrs).
 It is regulated by hypothalmo-pituitary- ovarian
hormones secreted in pulsatile and cyclic
pattern.
 Also influenced by endometrial response top
these (E& P ) hormones and coagulation
cascade.
 Cycle lenghth-21-35 days , mean menstrual
blood loss -30-40 ml , duration of bleeding
(period0---2-8 days.

3.  Volume of blood flow is assessed by number of pads / tampons used
whether the pads are fully/ partially soaked , presence of clots. It can
be better assessed by pictorial charts--
Pad Area Soaked 1st day 2nd
Da
y
3rd Day 4th Day 5th
day
6th
Day
7th
Day
X 1 // / /
X 5 /// //
X20 ///
Total Points 89(<1oo)- Nor
mal
blood Loss
Tampons
soaked X1
// // / /
x 5 ///
D X 15
Total Points
//////
111
Excessive
blood loss

4. Pituitary

6. Cyclical Changes in Menstruation

8. ovary

9. Double Cell Theory of
Estrogen Production

10. Menstruating Endometrial

11. Proliferative Endometrial

12. Early Secretary Phase
ENDOMetrium

13. Late Secretary Phase of Endometrium

14. Arrest of Menstrual bleeding
 # mechanisms---
1 Haemostasis by plate let plug and clot formation – starts
soon the bleeding starts and open BV are plugged .once
Blood vessels are plugged , fibrin deposition occurs ---
Fibrinolysis also go hand in hand to balance and keep the
blood loss fluid.
2.Prostaglandin Mediation – Archadonic acid and Pg
synthetase enzyme produce PGs ---pge2 –vasodilator,
PGf2a--- vaso constrictor andThromboxane – vaso
constrictor. Estrogen produce PGE2 and PGF2a in ratio of
1:1 in proliferative phase ; while Progesterone produce
PGE2 and PGF2a + thromboxane (a2) in a: 2 ratio in
premenstrual phase so balance is shifted towards
vasoconstricton which help in contrl of bleeding.

15. Arrest of Menstrual bleeding
--
3.Tissue Repair --- starts from the mouths of
open endometrial glands in the denuded
areas , endothelium out grows and covers the
raw area under the influence of Epithelial
Growth Factor ( EGF) and blood vessels
regrow due toVascular endothelial Growth
Factor (VEGF).Thus the raw area of
remaining basal endometrium is completely
epithelized under Estrogen effect.

16. Abnormal uterine bleeding
Organic Causes Functional Uterine bleeding(DUB)
Deseases Of GenitalTract—
Pregnancy related irregularity
Abnormal Bleeding from GenitalTract without
any demonstrable organic cause.
IUCD Related Irregularity Diagnosis is made by excluding organic cause
.
Benign Conditions-- Altered Hypothalamus-pituitary-ovarian-
Fibroids, its polyps Function
Endometriosis (external;
Adenomyosis
Altered endometrial response to Sex
Hormones
Endometrial Polyp altered proprtion of estrogen and progestrone
production and their effect on Endometrial
Malignant Lesions phasing may cause DUB.
Endometrial
Cervical
Vaginal
Ovarian

17. Menstrual Patterns IN DUB
 Regularity—1. regular ,2 irregular , absent.
 Frequency---1. frequent < 21 days, 2. Normal
21-35 days,3. Infrequent >35 days.
 Duration– Normal 2-8 days , Prolong > 8 days
.shortened <2 days .
 Volume – normal 20 -80ml , Heavy > 80
ml, Light < 15 ml

18. Terminology
 Menorrhagia –Regular cycle with prolonged or
heavy flow.
 Polymenorrhoea – frequent cycles but normal
bleeding .
 Poly menorrhagia – frequent cycles with heavy
bleeding .
 Metrorrhagia ----Inter menstrual Bleeding .
 Oligomenorrhoea—Infrequent cycle with normal
bleeding .
 Hypomenorrhoea—Regular normal cycle with
light Bleeding.

19. Classification of DUB
1. Anovulatory –
Metropathia Haemprrhagica.
Threshold Bleeding.
2.Ovulatory ---
Idiopathic ovulatory Menorrhagia.
Luteal Phase Defect.

20. Anovulatory DUB
 In some adolescent girls and perimenopausal women,
Ovarian follicles develop(FSH Stimulation) and
produce estrogen in variable amount leading to
proliferation of endometrium .
 Dominant follicle may not develop due to insufficient
LH surge – no ovulation—no development of carpus
Luteum ---no progesterone --- no secretary changes in
endometrium ; estrogen still secreted by follicles
(grannulosa cells) .
 Unopposed estrogenic Stimulation and some time
hyper ( super threshold ) level of estrogen results in
over growth of endometrium(hyperplasia) ----resulting
in prolonged cycle and increased blood loss during
period.

21. Anovulatory DUB
 When endometrium over grow s its blood
supply , lack of progesterone causes
decrease PGE2 vasodilators initially and
Avascular necrosis of functional
endometrium occur , endometrium is shade
off Lack of vasoconstrictors--- PGf2a and
thromboxane results in excessive blood loss
which is pain less and prolonged for 20-
30days (As irregular shading of endometrium
continues for such a long time ).
 Persistent Follicles under go the formation of
follicular cysts.

22. Anovlatory DUB Metropathia Hamorrhagica
 Accounts for 80% of DUB; at Pubertal and perimenopausal age
,Patient has variable period of amenorrhoea followed by
prolong, heavy , painless bleeding .
Prroplonged Un opposed Estrogen
Proliferative Endometrium
Simple Hyperplasia
Complex Hyperplasia
Complex Hyperplasia with Atypia
Adenocarcinoma

23. Endometrium in Metyrpathia
Haemorrhagica
 Usually reveals cystic hyperplasia( simple
hyperplasia with out atypia) called swiss
cheese appearance .
- Hyperplastic glands and strauma.
- Cystic or irregularly dilated glands.
- Thick walled , tortuous , dilated spiral
arterioles and veins.
- Infarction and thrombosis of blood vessels.
- Necrosis of functional endometrium .

24. Metropatha Hamorrhagica

25. Progress And Course of Metropathia
Haemorrhagica
 Incidence of malignancy ---
simple cystic Hyperplasia---1%
Complex hyperplasia with atypia---29%
It is further increased in perimenopausal
women who are obese, diabetic,on E2 therapy,
hypertensive and relatively infertile , H/O Ca
endometrium in family and had PCOD.
Young Girls who are obese with or with out PCOD
are prone to have metropathia Haemorrhagica
of early changes which are reversible with
progesterone / Ocs therapy.

26. Simple Endometrial hyperplasia

27. Atypia (hyperchromatic,
large, variable size and
shape Of Nucleus)

28. Endometrial Hyperplasia with
Nuclear Atypia

29. Complex Hyperplasia

30. The endometrial adenocarcinoma in the polyp at the left
is moderately differentiated, as a glandular structure
can still be discerned. Note the hyperchromatism and
pleomorphism of the cells, compared to the underlying
endometrium with cystic atrophy at the right.

31. Threshold Bleeding
 This is often seen in peri menopausal women .
There is insufficient development of ovarian
follicles resulting in low estrogen level not able
to sustain endometrium or trigger LH surge ( no
ovulation ).
 Such women can have prolonged and excessive
bleeding due to absence of progesterone and
lack of PGF2a and thomboxane.
 Bleeding PV in these women can be controlled
with cyclic E2 + P CombinationTherapy as both
are at low level .

32. Ovulatory DUB
 More common in women of reproductive age
group (21-40 years ) .
 Accounts for 20% cases of DUB.
 Patient usually present Cyclic excessive
bleeding / premenstrual spotting.
 Periods are associated with Pain .

33. Idiopathic Adulatory
Menorrhagia (DUB )
 An alteration in ratio of PGE2 and PGF2a ( vaso
dilator : vaso constrictor )occurs in some women
despite of ovulation and normal progesterone
production from carpus luetium .
 Increase in PGE receptors in endometrium ,
reduction in thrombxane production and
increased fibrinolytic activity has also been
demonstrated in these women .
 PgF2a causes Dysmenorrhea.
 HP report of endometrium reveals secrtory
changes

34. DUB: Classification, Pathophysiology And Endometrial
Changes
OVULATORY
Idiopathic
Ovulatory
Menorrhagia
Corpus Luteum
insufficiency
Normal
Progesterone
Altered PG E : PG F
Menorrhagia
Secretory
Endometrium
Reduced
Progesterone
Reduced PG F2
Premenstrual
Spotting
(Polymenorrhoea)
Irregular ripening
ANOVULATORY
Metropathica
Haemorrhagica
Prolonged Oestrogen
No Progesterone
Reduced PG F2
Amenorrhoea
followed by bleeding
Hyperplastic
Endometrium
Threshold
Bleeding
Low Oestrogen
No Progesterone
Reduced PG F2
Polymenorrhoea/
Polymenorrhagia
Proliferative
Endometrium

35. Luteal Phase Defect
 In adequate Functioning of carpus luteum can
result in--
-- in sufficient and erratic production of
Progesterone.As well as alteration in the
ratio of PGE : PGF
---resulting in irregular and patchy screttory
changes in the endometrium
Both pathophysiological deficit leads to
irregular ripening and or irregular shading
of endometrium .

36. History Taking In DUB
 Age
 Age at menarche.
 Parity.
 Menstrual History—regularity, frequency, duration of
bleeding ,Volume of blood loss.
 Post coital bleeding ?
 Dysmenorrhoea – spasmodic / congestive .
 Dyspareunia.
 O.H.---fertility / infertility/ gravidity / parity etc.
 AssociatedVaginal Discharge .
 RescentAbortion / delivery / ectopic pregnancy .
 IUCD insertion , ocs, hormone therapy/ drugs.
 Symptoms of thyroid disease.
 Symptoms of any bleeding disorder.

37. Examination
 General Physical .
 Pallor.
 thyroid.
 BMI .
 Signs of PCOD .
 Speculum Examination.
 PV examination --- uterine, position, size. Shape
surface , consistency ,tenderness and mobility .
 Furnaces for any anneal mass /tenderness/
indurations

38. Investigations
 LaboratoryTests HB ,T/DLC, BT. CT, PT , PPT, platelets
count , ESR, Fasting Blood Sugar,,T3-T4-TSH.– to know
degree of anemia, to exclude coagulation disorders and
leukemia's, Diabetes and thyroid disorders.
 TVS /abdominal USG –to exclude Genital tract lesions like
fibroids, endometrial thickening , endometriosis, PCOD ,
polyps , IUCD pregnancy related conditions anneal mass
etc .
 Soon Historiography– intra cavity lesions like polyp fibroid
.
 Dilatation Curettage--- Endometrial sampling for HPR---
type of endometrial ; secretary , LPD, proliferative /
hyperplasia , inflammation like tuberculosis and
precancerous or cancer lesion .
 Hysteroscopy---diagnostic as wells therapeutic use in
IUCD sub mucous fibroid , polyps .

39. Endometrial curette

42. Differential Diagnosis—
Adolescent---DUB
Differential Diagnosis Symptoms and signs Investigations
Bleeding Disorder s previous history Present BT, CT , Platelet count , PT
APTT
Thyroid dysfunction
PCOD (hormonal disorder
but ovarian enlargement
can be detected )
Thyroid enlargement
,Resident of Goiter endemic
area, clinical symptoms and
signs present.
Obesity,Acne ,
hirsutism,Acanthyosis etc
T3 ,T4 andTSH profile.
USG, FSH/LH ratio ,serum
prolactn and SerumE2 level
on day 2 of menses.

43. Differential diagnosis in Reproductive Age
Group
Differential diagnosis Symptoms & Signs Investigations
Evacuation of vascicular
mole,
PostAbortal Bleeding , ch.
Ectopic ,Post delivery
bleeding , retained IUCD
H/o recent abortion , missed period ,
delivery/ insertion of IUCD / Medical
abortion Pill
urine Pregnancy
test, USG
Fibroid Uterus Menorrhagia/ Poly menorrhagia ,
congestive dysmenorrhea , irregular
enlarged uterus but not tender.
USG
Endometriosis/
Adenomyoma
Menorrhagia/ Poly menorrhea , cutting
pain during menses / coital pain
,Infertility. Enlarged (Localized in
adenomyoma) RV RF Fixed and tender
uterus and adenexa/ mass.
USG
Chronic PID Poly menorrhagia, congestve
dysmenorrhoea,leucorrhea chronic pain
in lowe abdomen and sacral region.
Tender uterus , fixed / restricted mobility
USG

44. Differential Diagnosis In
Perimenopausal Age Group
Differential Diagnosis Symptoms And Signs Investigations
Fibroid Uterus
Adenomyosis
Multipara, menorrhagia ,
congestive dysmenorrhea
Uterus bossed and
irregularly Enlarged firm to
hard and not tender.
Menorrhagia, multipara ,
congestive dysmenorrhoea .
Uterus regularly enlarged
soft and tender
USG
USG
Endometrial Carcinoma Nullipara, obese ,
hypertensive , delyed
menopause , diabetic ,
family history +/_ , PCOD ,
Irregular /freuent cycles
Fractional Curretage and
endometrial HP Examination

45. Treatment
 General Measures –> Rx of anaemia , life style
modification ---weight reduction by diet control and
exercise .
 Definitive Rx-
Medical –
1.Non Hormonal like Antifibrinolytics, PG synthesis
inhibitors , Capillary fragility inhibitors.
2. Hormonal ---Progesterone—oral , IM,
Progesterone bearing IUCD.
Estrogen +progesterone combination.
Estrogen only.
3. Others ---Danazoloe , GnRH analoges /
Omeloxifene.,Testosterone.
Surgical-- &c , EndometrialAblation , Hysterectomy

46. Management Of AUB According to Endometrial TVS

47. Management Of AUB In Endometrial
TVS

48. Algorithm for USG based Triage for AUB
case

49. DUB management in Reproductive Age Group
Abnormal bleeding
Clinical Evaluation
Normal Abnormal
Medical Rx USG
Response No Response Rx Accordingly
Cont. For USG
3-6 months/ Polyp Normal
LNG –IUS
Response No Response
Hysterectomy
hysteroscopic
polypoidectomy
Endo . Ablation
LNG -IUS= Levonorgstrel intra
uterine system

50. Management of DUB in Adolescent Girls
Abnormal Bleeding
Clinical Evaluation
? Bleeding disorder /Thyroid dysfunction/ PCOD
NO YES Investigate & Rx
Profuse bleeding Moderate Bleeding
High Dose Progesterone Cyclical combined Ocs for
Followed By E+P combination 3-6 months
for 3-6 Months

51. DUB Management in Perimenopausal age
group
Abnormal Uterine Bleeding
clinical Evaluation
Risk Factors for Hyperplasia , carcinoma , irregular acyclic Bleeding
NO Yes
Low Dose
OCS
USG, Fractional Curretage, endometrial HP
examination
Atypical Hyperplasia Simple Hyperplasia
Hysterectomy
Low Dose Ocs / cyclical
Progesterone

52. Drugs used in RX of DUB
NonHormonal Drugs Dose
Antifibrinolytic
Tranexamic Acid
500mg tid/qid for 3-5 days
PG synthetase Inhibitors
Mefenamic Acid 500mg tid for 3-5days.
Capillary Fragility inhibitors
Ethamsylate 500mg qid for 4-5 days

53. Hormone therapy in DUB
Hormone Dose
PROGESTEROGENS—
Norethisterone / Medroxipogesterone/
Duphaston—to arrest bleeding-----------
Cyclically----------------------
10mg 6hrly for24-48 hrs
follwed by 10 mg /day for 15-
25 days
10mg daily from 10th -25th day
for 3-6 cycles.
Estrogen + Progesterone combintion
Ethinyl estradiol + norethysterone / norgestrel/
20-30 ug + o.5-0.75mg
cyclically daily starting on 4th
day to 25th day of cycle –for 3-
6 cycles.
Estrogen only---Ethinylestradiol 50ug /day for 5 days
danzole 100-200mg /day for 3-6
months.
GnRHAnaloges
Ormiloxifene
3.6mg IM once in 4 weeks
60mg twice weekly for 12
weeks

54. Progesterone Intra Uterine System
 The commonly used progesterone is
Levonorgestrel bearing IUCD (LNG-IUS).
 It can reduce the blood loss up to 90%.
 It is effective contraceptive too( 5years).
 It is as effective as endometrial ablation avoiding
surgical management like hysterectomy.
 LNG-IUS delivers 20 ug levonorgestrel daily to
endometrium .
 It causes glandular atrophy and stromal
decidualization.
 It has minimal action on Hypothalmo-pituitary –
ovarian axis.
 Nosystemic side effect.

55. LNG –IUS

56. Surgical Treatment of DUB
 Conservative
-Dilatation & Curretage—routine / Fractional
-Endometrial ablation.
 Redical
-Hysterectomy
Total
Pan Hysterectmy.
Total with unilateral salping overiotomy/
shalpingo oophrectomy.

57. Endometrial Ablation
 Ablation means == elimination
1. Indication
failed medical therapy .
Young women desires to preserve uterus.
Poor surgical risk for hysterectomy (non
carcinoma lesion of endometrium)
2. Contra Indications
Desire for fertility
Large uterine cavity -- <12cm.
Endometrial hyperplasisia with Atypia.
Suspected malignancy of genital tract.
Multiple or large fibroids/ nonfunctional ovarian
cysts.

58. Endometrial ablation Techniques
 First GenerationTechniques
Endometrial laser .
Trans cervical resection .
Roller wall electro coagulation .
 Second generationTechniques
Thermal Ballon Ablation .
Microwave ablation .
Radiofrequency induced ablation .
Hydrotherma ablation .
Electrode mash
Cryo Ablation .
Laser interstitial therapy.

59. Thermo Ablation Of
Endometriun

62. Cryo ablation of Endometrium

63. Disadvantages of !st generation Ablation
Technique.
 Require skilled person.
 Require long training.
 Require general anasthesia.
 More chances of uterine perforation and fluid
over load.
Long term results of Ablation---
30% women remain amenorrhi0ec .
40-50 % women have reduced bleeding during
their menstrual periods.
10-20 % women reqquire hysterectomy due to
failure e.g. no relief from bleeding.

64. Hysterectomy Indications
 Endometrial hyperplasia with atypia.
 Failed Medical therapy in women over the
age of 40-45.
 Failed endometrial Ablation.
 Other pelvic pathology that needs surgery

65. Summary of DUB management
Age Group USG Endometrial
Sampling
Medical
Management
syrgery
Adolescent Abdominal to
rule out any
organic cause
Seldom done Usually sffice Seldom
Reproductive frequetly
done abd /
TVS
may be
required as
perTVS report
Always 1st line Secod line of
RX
Perimenopaus
al
Abd /TVS Should be
done
Mostly 1st line
of Rx
Some time !st
Line Of Rx

66. Key Points
 AUB can be due to organic disease or functional
disorder.
 It can occur in any age group –adolescent/ reproductive
or perimenopausal .
 Dub is diagnose by exclusion of organic lesions by
clinical and investigatory methods.
 Drug Rx (non hormonal –then hormonal should be given
first as majority of cases will get desired response.
 LNG –IUS has revolutionized the medical management
and has reduced the need of surgical Rx.
 If medical management fails – endometrial ablation can
be done.
 If there are contra indication for Ablation and or it fails
hysterectomy can be done in Perimenopausal women .
Rx of DUB Is to Be Individualized Approach