Abnormal uterine bleeding

1. ABNORMAL
UTERINE BLEEDING

2. NORMAL MENSTRUAL CYCLE
• Follicular phase
• Onset of menses to LH surge
• 14 days (varies)
• Dominant follicle
• greatest number of granulosa cells and FSH receptors
• Ovulation
• Luteal phase

3. • Follicular phase
• Ovulation
• 30-36 hours after LH surge
• Luteal phase
• LH surge to menses
• 14 days (constant)

4. NORMAL MENSTRATION
• Every 28 days +/- 7 days
• Mean duration is 4 days.
• More than 7 days is abnormal
• Average blood loss with menstruation is 35-50cc

5. TYPES OF AUB
Menorrhagia : abnormally long or heavy menses, lasting > 7 days and or
blood loss > 80 mL (the most common type ) now called HMB heavy
menstrual bleeding
Oligomenorrhea: infrequent menses, occurring at intervals > 35 days.
Polymenorrhea: frequent menses, occurring at intervals < 24 days.

6. Metrorrhagia :menses occurring at irregular intervals.
PMB: bleeding more than 1 year after cessation of periods.
PCB: bleeding after sex

7. HEAVY MENSTRUAL BLEEDING
• Previously called menorrhagia
• HMB is defined as a blood loss of greater than 80 ml per period
• Of women of reproductive age, 20–30% suffer from HMB
• Causes : PALM COEIN
• Despite appropriate investigations, often no pathology can be identified (DUB )
(its diagnosis of exclusion )

8. CAUSES

9. INVESTIGATIONS
• Hb (initial and for all )
• speculum examination of the cervix, with swabs for microbiology and cervical smear if
indicated
• transvaginal ultrasound scan (TVUSS)
• endometrial biopsy (EB) as necessary
• outpatient hysteroscopy and biopsy may be indicated.
• Coagulation profile if indicated (teenager or positive family history or related symptoms as
easily bleed )
• Hormone testing should not be performed.
• Thyroid function tests should only be carried out
• when the history is suggestive of a thyroid disorder

10. INDICATIONS FOR OUTPATIENT
HYSTEROSCOPY
• EB biopsy attempt fails
• EB biopsy sample is insufficient for histopathology assessment.
• •TVUSS is inconclusive, for example to establish the exact location of a
submucosal or intramural fibroid.
• There is an abnormality on TVUSS amenable to treatment (e.g. suggested
endometrial polyp or submucosal fibroid)

11. WHEN TO DO A BIOPSY
• age over 45
• treatment failure
• PMB and endometrial thickness on TVUSS >4 mm.
• risk factors for endometrial pathology (obese , PCO ….etc )
• cut-off of 4 mm endometrial thickness on TVUSS for postmenapausal
• Prior to ablation by hystereoscopy

12. SYMPTOMS ASSOCIATED WITH HMB

13. MANAGEMENT
•Medical
•Surgical

14. MEDICAL TREATMENT
• LNG-IUS, Mirena™
Mean reductions in mean blood loss (MBL) of around 95% are achieved by 1
year
First line treatment if not contraindicated as breast cancer
Not suitable for women wishing to conceive
Suitable for DUB after excluding malignancy

15. MEDICAL TREATMENT
Tranexamic acid
an antifibrinolytic that reduces blood loss by 50% and is taken during menstruation
NSAID :
mefenamic acid, which inhibits prostaglandin synthesis and reduces blood loss by
30%

16. MEDICAL TREATMENT
COCP (not if wishes to conceive )
progesterone :
Norethisterone, taken 15 mg daily in a cyclical pattern from day 6 to day 26 of the
menstrual cycle.
Not if wishes to conceive

17. MEDICAL TREATMENT
• Gonadotrophin-releasing hormone (GnRH) agonists:
Last medical option
Taken for a short period
Maye taken to shrink fibroid pre-op
Supress ovarian function and induce amenorrhea
Lead to osteoporosis and menopause like symptoms (hot-flushes )
If prolonged use, need backup therapy with estrogen and progesterone HRT

18. SURGICAL TREATMENT
Endometrial ablation
• uterus no bigger than 10 weeks’ size and with fibroids less than 3 cm.
• The first-generation techniques including transcervical resection of the
endometrium with electrical diathermy or rollerball ablation
• newer second-generation techniques including:
• Impedance controlled endometrial ablation (Novosure™).
• Thermal uterine balloon therapy.
• Microwave ablation (Microsulis™)

20. SURGICAL TREATMENT
• Umbilical artery embolization
• Myomectomy
• Hysterectomy

21. POSTMENOPAUSAL BLEEDING

22. • 5–10% of women with PMB have an underlying gynaecological malignancy
• Most common cause is genital atrophy
• Careful inspection of the external genitalia and speculum examination will exclude
vulval, vaginal and cervical cancer
• transvaginal ultrasound (cut off thickness 4 mm )
• hysteroscopy and/or endometrial biopsy
• Other causes may include HRT and endometrial hyperplasia (progress to cancer in
25-50 % )