Abnormal uterine bleeding (AUB) is bleeding from the uterus that is longer than usual or that occurs at an irregular time. Bleeding may be heavier or lighter than usual and occur often or randomly. AUB can occur: As spotting or bleeding between your periods.

1. Abnormal uterine
bleeding
Yasmine Mahmoud

2. Normalvalues
Duration of bleeding:
3-8 days
Amount of bleeding:
30-80 ml
Length of cycle:
21-35 days, average 28 days

3. Causes:
▪ Abnormal uterine bleeding is a symptom and not a
disease. Its causes include the following:
▪Early pregnancy complications (abortion, ectopic
pregnancy, hydatidiform mole).
▪Pelvic inflammatory disease (PID).
▪Benign tumors (uterine fibroids,cervical polyps
endometriosis, adenomyosis)
▪malignant tumors ( endometrial and cervical
carcinoma)
▪Dysfunctional uterine bleeding.

4. Clinicaltypes:
1. Menorrhagia (regular & cyclical):
- cyclical bleeding at normal intervals which is excessive in
amount or duration.
- causes: general: hypertension, anticoagulant therapy,
liver cirrhosis benign organic disease of genital
tract(fibroids, adenomyosios, PID) and may be
dysfunctional (ovulatory).
Treatment:1- treatment the causes and general measures
2-Non-hormonal:Anti-fibrinolytic, Anti-prostaglandins,
Hemostatic agents e.g. Dicynone
3-Hysterectomy:age>40y, failure of medical treatment

5. Clinical types:
2. Polymenorrhoea (regular & cyclical):
- Cyclical bleeding which is normal in amount but occurring at too-
frequent intervals of less than 21 days.
- cause: ovarian endometriosis, PID, DUB.
--- Commonly associated with menorrhagia

6. Clinicaltypes:
3. Polymenorrhagia:
- Cyclical bleeding which is both excessive and too frequent.
- Caused by: DUB, PID.
4. Metrorrhagia (irregular or acyclical):
- bleeding of any amount which acyclical occurring
irregularly or continuously not related to menstruation.
- causes(organic) : ulceration or infection of benign tumors,
malignancies (perimenopausal) complications of early
pregnancy, irregular use of contraceptive pills, anovular
DUB.
5. Menometrorrhagia: prolonged and irregular bleeding

7. Clinicaltypes:
5. Intermenstrual bleeding:
- often dysfunctional (fall in oestrogen secretion
following ovulation); 60% of ovulatory women have
erythrocytes in their cervical mucus if examined.
- common with cervical and endometrial polyps,
fibroids and cervical carcinoma

8. DysfunctionalUterineBleeding(DUB)
It is an abnormal bleeding from the uterus in the absence of
organic disease of the genital tract.
It is characterized by dysfunction of the uterus, ovary,
pituitary, hypothalamus or other part of reproductive system.
the pattern of bleeding is mainly heavy & regular
(menorrhagia) but it could be irregular uterine bleeding or
intermenstrual bleeding.

9. ClassificationofDUB:
Primary DUB:
Abnormal bleeding from the uterus where there is no
disease of the genital tract, no other disease responsible for
the bleeding, no IUCD and no history of sex hormone
administration.
Secondary DUB:
Abnormal bleeding from the uterus secondary to:
1. IUCD
2. Administration of sex hormones.
3. organic disease outside the genital tract e.g.
hypothyroidism, bleeding disorders.

10. PathophysiologyofprimaryDUB:
Depends on the pattern of bleeding and the age of the
patient.
Ovulatory DUB (heavy regular bleeding & painful):
1-Dsfunction polymenorrhea: short cycles due to- short follicular phase,
short luteal phase
-present in young women after menarche and it may occur
before menopause and after delivery.
-Treatment:
-Oral progesterone from day 15 for 10 days to prolong the
cycle.

11. 2-Dysfunction menorrhagia
Heavy or prolonged menstrual losses at normal intervals can be the
result of corpus luteum defects which present in the following ways:
1- Irregular ripening of the endometrium:
due to poor formation and function of corpus luteum
2- Irregular shading of the endometrium: due to incomplete and slow
degeneration of the corpus luteum (Halbans disease)

12. PathophysiologyofprimaryDUB:
Anovulatory DUB (heavy irregular bleeding):
- Occurs after menarche and before menopause.
- There is persistent proliferative endometrium in the
second half of the cycle.
1- Metropathia hemorrhagia (Schroeder's disease)
Short period of amenorrhea followed by excessive, prolonged,
painless bleeding.
the cause of bleeding :(estrogen withdrawal bleeding) decrease
estrogen level, exhaustion of the graffian follicale.

13. Diagnosis:
signs:A soft symmetrically enlarged uterus, an enlarged cystic ovary
Investigation: ultrasonography, hysteroscopy, endometrial biopsy
Treatment:
General measures
Medical management: non-hormonal and hormonal
Surgical :D&C, endometrial ablation, hysterectomy, radiotherapy-
when hysterectomy is contraindicated

14. 2- Threshold bleeding: acyclic bleeding
The ovary produces small amount of estrogen that fluctuated
above and below the threshold level required to support the
endometrium.
Endometrium biopsy shows thin endometrium and poorly
developed proliferative phase.

15. DiagnosisofDUB:
The diagnosis is by exclusion.
History: Age of the patient, menstrual history, pattern and
amount of menstrual loss.
Examination: abdominal and pelvic examination
Ultrasound (TAS & TVS).
Hystrescopy.
Endometrial biopsy (to exclude hyperplasia & carcinoma).
Hormonal assays: progesterone, LH, FSH and thyroid
function test.
Blood tests: CBC, clotting screen

16. ManagementofDUB:
Medical management:
1. Non-hormonal therapy:
- Non-steroidal anti-inflammatory drugs (NSAID); e.g.
mefenamic acid (ovulatory DUB).
- Antifibrinolytic drugs; e.g. tranexamic acid (to inhibit the
increased plasminogen activators & plasmin).
2. Combined oral contraceptive pills.
- low-dose oestrogen-progestogen is used (regulate the
cycle and reduce the amount of blood loss).
- progestogen dominant pills is used in progesterone
deficiency and oestrogen dominant pills are used in
oestrogen deficiency.

17. MedicalmanagementofDUB:
3. Progestogens:
- used in anovulatory cycles to reduce the blood loss.
- Norethisterone (primulot N) 5 mg tid and medroxy-progesterone acetate
10 mg tid.
4. Levonorgestrel-releasing IUCD:
- Induces endometrial atrophy with reduction of blood loss.
5. Androgens and gonadotrophin releasing hormone (GnRH)
- used when the above medical therapy has failed or surgery is
contraindicated.
- Androgens: danazol & gestrinone→ amenorrhoea by negative feedback
and direct action on endometrium and
- Gonadotrophin releasing hormone (GnRH)→ hypogonadal state

18. SurgicalmanagementofDUB:
Endometrial ablation (resection):
carried out under direct hysteroscopic vision using fluid for
distension and irrigation. The techniques include:
1. Laser ablation.
2. Endometrial loop resection using electrodiathermy.
3. Rollerbal electrodiathermy ablation.
4. Thermal balloon ablation.
Hysterectomy:

19. Nursing Diagnosis Goal Intervention Evaluation
Risk for fluid volume
deficit r/t active fluid
loss (abnormal
bleeding)
Patient will
experiences adequate
fluid volume and
electrolyte balance as
evidenced by urine
output greater than
30 ml/hr, heart rate
(HR) is 100 beats/min,
consistency of weight,
and normal skin
turgor.
Monitor and
document vital signs.
Monitor serum
electrolytes and urine
osmolality and report
abnormal values.
Administer parenteral
fluids as ordered.
Encourage patient to
drink prescribed fluid
amounts.
Monitor active fluid
loss from bleeding,
maintain accurate
input and output.
After nurses done the
interventions, patient
shows some
progresses which are
urine output greater
than 30 ml/hr, heart
rate (HR) is 100
beats/min,
consistency of weight,
and normal skin
turgor.

20. Nursing Diagnosis Goal Intervention Evaluation
Impaired gas
exchange r/t altered
oxygen supply
secondary to blood
loss
Patient will maintains
optimal gas exchange
as evidenced by
normal arterial blood
gases (ABGs)
•Monitor respiration’s
rate, depth and rhythm
•Monitor vital signs
•Assess for signs and
symptoms of
hypoxemia:
tachycardia,
restlessness,
diaphoresis, headache,
lethargy, and confusion
•Assess for changes in
orientation and
behavior
•Assess skin color for
development of
cyanosis.
•Maintain oxygen
administration device
as ordered, attempting
to maintain oxygen
saturation at 90% or
greater.
•Facilitate patient to
high-Fowler’s position.
Patient will maintain
normal arterial blood
gases.
Normal adult arterial
pH= 7.35-7.45
pCO2 = 35-45 torr
pO2 = >79 torr
Normal adult venous
pH = 7.31-7.41
pCO2 = 41-51 torr
pO2 = 30-40 torr

21. Nursing Diagnosis Goal Intervention Evaluation
Acute pain r/t lower
abdominal cramps e/b
patient’s facial
expression
The lower abdominal
pain level will reduce
to optimum level.
•Monitor pain
characteristics
•Teach the use of non-
pharmacologic
techniques
•monitor signs and
symptoms associated
with pain
•positioning according
patient comfort
•Provide rest periods
to facilitate comfort,
sleep, and relaxation
After nursing actions
are taken, level of pain
complained by patient
had reduced to
optimum level and
patient feel comfort.

22. Nursing Diagnosis Goal Intervention Evaluation
Fear related to
excessive bleeding e/b
restlessness of patient
and patient’s
complain.
The patient will report
fear and anxiety are
reduced to a
manageable level.
Patient will be able to
rest without being
restless.
Identify patient’s
perception of threat
represented by the
situation
Encourage patient to
acknowledge and
express fears
Provide opportunity
for discussion of
personal feelings or
concerns and future
expectations.
Identify previous
coping strengths of the
patient and current
areas of control or
ability
Encourage use of
relaxation technique
like deep breathing,
guided imagery
After nursing
intervention is done,
the patient has report
fear and anxiety are
reduced to a
manageable level.
Patient is not restless.