Abnormal uterine bleeding is a common gynecological problem defined as abnormalities in menstrual cycle length, flow duration, or amount. It can be caused by organic lesions, anovulatory cycles, medications, or dysfunctional uterine bleeding. Evaluation involves history, physical exam, lab tests and imaging to determine the cause and guide treatment. Treatment options include general measures, medical therapy like hormones, and surgical interventions like endometrial ablation or hysterectomy if conservative treatments fail.

1. ABNORMAL
UTERINE
BLEEDING
Audi Adibah
Nashriq Aiman
Nurul Hidayu

2. • It is a common gynecological problem.
• Defined as any abnormalities of cycle
length, duration of flow, and amount of
menstrual bleeding.
ABNORMAL UTERINE
BLEEDING (AUB)

3. Menstrual Period Characteristics
Normal Abnormal
Duration 4-6 days <2d, >7d
Volume 30-35cc >80cc
Cycle length 21-35d <21d, >35d
Average Iron loss: 16mg

4. 4
Menstrual
Abnormalities
Amenorrhea
Dysmenorrhea
Menorrhagia
Oligomenorrhea
Menometrorrhagia
Metrorrhagia
Absence of menstruation
Painful cramping
Prolonged bleeding
> 7 days or > 80 cc
occurring at regular intervals Cycles longer than 6-7 weeks
Irregular and excessive
bleeding during or between
periods
Bleeding between periods
Polymenorrhea
Cycles shorter than 3 weeks

5. Causes of abnormal uterine bleeding according to age group
Age group Causes
Pre-puberty Precocious puberty ( hypothalamic, pituitary, or ovarian origin)
Adolescence Anovulatory cycles , coagulation disorders
Reproductive age - Complications of pregnancy ( abortion, ectopic pregnancy, trophoblastic
diseases)
- Organic lesions ( leiomyomas, adenomyosis, polyps, endometrial hyperplasia ,
carcinomas)
-Dysfunctional uterine bleeding
-Anovulatory cycles
-Ovarian dysfunctional bleeding (i.e. inadequate luteal phase)
Perimenopausal -Dysfunctional uterine bleeding
-Anovulatory cycles
- organic lesions( hyperplasia, polyps, carcinoma)
Postmenopausal -Endometrial atrophy
-Organic lesions ( carcinoma, hyperplasia, polyps)

6. Organic cause
– Systemic Etiology
– Reproductive tract disease
– Iatrogenic
– Diagnosis of exclusion
– No anatomic abnormality
– No demonstrable organic cause
– Based on patient history

7. Associated with ovulatory cycles
• Organic cause
– Systemic Etiology : - Coagulation defect
- Leukemia
- ITP
-- Reproductive tract disease : -Gestational events
(Abortions, Ectopic pregnancies & Trophoblastic
disease)
- Malignancies
(Endometrial, Ovarian, Cervical & Vaginal)
- Benign
(Atrophy, Leiomyoma, Polyps, Cervical lesions,
Foreign body)
– Iatrogenic : -Intra-uterine device
-Oral and injectable steroids
-Psychotropic drugs

8. Associated with Anovulatory cycles
– The most frequent cause of dysfunctional bleeding is anovulation
(failure to ovulate)
– Anovulatory cycles result from subtle hormonal imbalances and are
most common at menarche and in the perimenopausal period.
Less commonly, anovulation is the result of:
– Endocrine disorders, such as thyroid disease, adrenal disease, or pituitary
tumors
– Ovarian lesions, such as a functioning ovarian tumor (granulosa cell
tumors) or polycystic ovaries
– Generalized metabolic disturbances, such as obesity, malnutrition, or
other chronic systemic diseases

9. Dysfunctional Uterine Bleeding
(DUB)
A state of abnormal uterine bleeding (AUB) without any clinically
detectable organic, systemic, and iatrogenic cause.
DUB is defined as ABNORMAL uterine bleeding with NO
demonstrable organic cause.
• It is the most common cause of AUB.
• Two types: -Anovulatory (90%)
-Ovulatory (10%)

10. Anovulatory DUB (90%)
• Most women with DUB do not ovulate
• In these women, there is continuous estrogen production
without corpus luteum formation and progesterone production.
• This gives rise to continuously proliferating endometrium
which may outgrow its blood supply or lose nutrients with
varying degrees of necrosis.
Cause: Hypothalamic – Pituitary – Ovarian hormonal axis imbalance

11. Ovulatory DUB (10%)
• Progesterone secretion is prolonged because
estrogen levels are low.
• This causes irregular shedding of the uterine lining
and break-through bleeding.

12. The physiological mechanism of hemostasis in normal menstruation are:
Platelet adhesion
formation
Formation of platelet plug with fibrin to seal
the bleeding vessels.
Localized vasoconstriction
Regeneration of
endometrium
Biochemical mechanism involved are: In increased endometrial ratio of
PGF2α/PGE2. PGF2α causes vasoconstriction and reduces bleeding. Progesterone
increases the level of PGF2α from arachidonic acid. Levels of endothelin, which is a
powerful vasoconsinctor is also increased.

13. Pathophysiology of DUB
• Due to high level of estrogen and no progesterone production
• decreased synthesis of PGF2α and the ratio of PGF2α/PGE2 is low
• Thus, no vasoconstriction and causing bleeding prolong.
• low level of thromboxane in the endometrium = menorrhagia
• dysfunction of hypothalamo-pituitary-ovarian axis (endocrine origin)

14. Polyp
Adenomyosis
Leiomyoma
Malignancy
Coagulopathy
 common in adolescent women present
with heavy period; Von Willebrand’s
Disease
Ovulatory dysfunction
 common in adolescent - anovulatory
bleeding
 reproductive age – PCOS
 Perimenopausal women – 2ry to
declining ovarian function
Endometrial Process
Iatrogenic
Common in
perimenopausal
women
FIGO CLASSIFICATION
Differential Diagnosis

15. MANAGEMENT

16. • Source of bleeding (vagina ,urethra or rectum?)
• excessive bleeding is assessed by number of pads used, passage of clots (size and number), and duration of
bleeding.
• pattern of bleeding
 Period not predictable & irregular – could be ovulatory dysfunction (2ry to PCOS or peri-menopausal
anovulation
 Intermenstrual bleeding – Anatomic source (submucosal fibroids or uterine polyp)
 Always had very heavy period – Could be coagulopathy
• assess the blood loss by admitting the patient during period.
• Any emotional upset or psychosexual problem should be elicited tactfully
• Use of steroidal contraceptives or IUCD insertion should be enquired.
• History of abnormal bleeding from the injury site, epistaxis, gum bleeding, or that suggestive of PID should be
enquired.
HISTORY

19. Excessive weight gain
• Look for signs of PCOS: Hirsutism & acne
• Sign of thyroid disease & evidence of insulin resistance
In suspected bleeding disorder
• Look for petechiae, ecchymosis, skin pallor or swollen joints
• In a suspected case of thrombocytopenic purpura, tourniquet test is performed
Pelvic Examination
• Bimanual examination including speculum examination to assess the size and
contour of the uterus
PHYSICAL EXAMINATION

20. LAB EVALUATION
A complete blood count (CBC) is recommended for women with AUB to
look for anemia
It is recommended to perform a sensitive urine pregnancy test whenever
indicated, or if pregnancy is suspected.
Bleeding time, platelet count, prothrombin time, and partial thromboplastin
time are recommended in all adolescents and in adults with a positive
screen for coagulopathies. Further testing for von Willebrand disease,
ristocetin cofactor activity, factor VIII activity, and von Willebrand factor
antigen is recommended in consultation with a hematologist.
TSH test is done when clinically indicated

21. LAB EVALUATION
Imaging Recommendations on imaging
 Ultrasonography is mandatory in AUB to evaluate uterus, adnexa and
endometrial thickness
 Doppler ultrasonography: In suspected arteriovenous malformation,
malignancy cases and to differentiate between fibroid and adenomyomas
 Hysteroscopy: For diagnosis and characterization of intrauterine
abnormalities
 MRI: To differentiate between fibroids and adenomyomas and for mapping
exact location of fibroids while planning conservative surgery and prior to
therapeutic embolization for fibroids
 Endometrial Biopsy – to rule out endometrial hyperplasia or endometrial
cancer
 Suggested for women > 40 years old who have the risk factors such as
obesity & diabetes.

22. HOW TO
TREAT ?
I. General
II. Medical
III.Surgical intervention

23. Rest is advised during bleeding phase. Assurance and sympathetic
handling are helpful particularly in adolescents. Anemia should be
corrected energetically by diet, hematinics, and even by blood
transfusion.
General

24. Medical
• Hormones: With the introduction of potent orally active progestins, they became
the mainstay in the management of DUB in all age groups and practically replaced
the isolated use of estrogens and androgens.
• Progestins: The common preparations used are norethisterone acetate and
medroxyprogesterone acetate
• Progestins have an antiestrogenic action
• The preparations are used:
• Cyclic therapy
• Continuous therapy
• To stop bleeding and regulate the cycle : Norethisterone preparations (5 mg
tab) are used thrice daily till bleeding stops, which it usually does by 3–7 days.

25. • In ovular bleeding: Any low dose combined oral pills are
effective when given from 5th to 25th day of cycle for 3
consecutive cycles. It causes endometrial atrophy
• It suppress the hypothalamo-pituitary axis
• Normal menstruation is expected to resume with restoration of
normally functioning pituitary–ovarian-endometrial axis
• It serves as a contraceptive as well.
Cyclic Therapy

26. • In ovular bleeding, where the patient wants pregnancy or in cases of irregular shedding or
irregular ripening of the endometrium, dydrogesterone (oral progestogen) 1 tab (10 mg) daily or
twice a day from 15th to 25th day may cure the state.
• This regimen is less effective than 5th to 25th day course. However, it does not suppress
ovulation.
• In anovular bleeding: Cyclic progestogen preparation of medroxyprogesterone
acetate (MPA) 10 mg or norethisterone 5 mg is used from 5th to 25th day of cycle for
3 cycles.
Cyclic Therapy

27. Continuous Therapy (progesterone)
• Progestins also inhibit pituitary gonadotropin secretion and
ovarian hormone production. Medroxyprogesterone acetate 10
mg thrice daily is given and treatment is usually continued for
at least 90 days.

28. Intrauterine progestogen: Levonorgestrel intrauterine
system (LNG-IUS)
• Induce endometrial glandular atrophy, stromal decidualization and endometrial
cell inactivation. It is effective for 5 years.
• It has minimal systemic absorption. Reduction of blood loss is up to 97
percent. In addition to its many other health benefits it is an effective
contraceptive measure.
• LNGIUS is recommended as a first line therapy for a woman with HMB in the
absence of any structural or histological abnormality.

29. Other drugs
• Mifepristone
• Anti-fibrinolytic agents – eg. tranexamic acid
• GnRH agonists
• Desmopressin – use for clotting disorder
• NSAIDS – Mefenamic Acid

30. SURGICAL MANAGEMENT OF DUB
• Uterine curettage
• Hysterectomy
• Endometrial Ablation (however
endometrial hyperplasia must be rule
out first by endometrial biopsy

31. Uterine Curettage
• It is done predominantly as a diagnostic tool for elderly women but at
times, it has got hemostatic and therapeutic effect by removing the
necrosed and unhealthy endometrium.
• It should be done following ultrasonography for detection of
endometrial pathology.
• The indication is an urgent one, if the bleeding is acyclic and where
endometrial pathology is suspected. Ideally hysteroscopy and directed
biopsy should be considered both for the purpose of diagnosis and
therapy.

32. Hysterectomy
• Hysterectomy is justified when the conservative treatment fails or contraindicated and
the blood loss impairs the health and quality of life.
• Presence of endometrial hyperplasia and atypia on endometrial histology is an
indication for hysterectomy.
• The decision can be made easily as the patient is approaching 40.
• Hysterectomy may be done depending on the route by vaginal, abdominal, or
laparoscopic assisted vaginal method.
• In this regard, the factors to consider are: uterine size, mobility, descent, previous
surgery, and presence of comorbidities (obesity, diabetes, heart disease, or
hypertension).
• Healthy ovaries may be preserved at the time of hysterectomy especially those under
45 years of age.

34. Abnormal Uterine Bleeding in Women of Childbearing Age

35. Initial Approach to Abnormal Uterine Bleeding in
Perimenopausal Patients

36. Abnormal Uterine Bleeding in Postmenopausal Women

37. Thank You
REFERENCE
1. American College of Obstetricians and Gynaecologists
(ACOG)
2. Ten Teachers 19th Edition
3. Federation of Obstetric and Gynaecological Societies of
India (FOGSI)