Abnormal uterine bleeding (AUB) is irregular bleeding that occurs without recognizable cause. It reflects disrupted hormonal stimulation of the endometrial lining. AUB is common, especially in adolescents, perimenopausal women, and those with structural issues like polyps or fibroids. Evaluation involves history, exam, labs, and imaging to identify structural or non-structural causes. Treatment depends on severity but commonly includes medical options like birth control pills, NSAIDs, or hormonal drugs before considering surgery.

1. Abnormal Uterine
Bleeding (AUB)

2. Definition
Abnormal uterine bleeding is irregular uterine bleeding that
occurs in the absence of recognizable pelvic pathology,
general medical disease, or pregnancy. It reflects a
disruption in the normal cyclic pattern of ovulatory
hormonal stimulation to the endometrial lining.

3. Epidemiology
One of the most common health concerns of women.
Because most cases are associated with anovulatory menstrual cycles,
adolescents and perimenopausal women are particularly vulnerable.
About 20% of affected individuals are in the adolescent age group.
50% of affected individuals are aged 40-50 years.
In a study of 400 perimenopausal women, the most common type of
bleeding pattern was menorrhagia (67.5%), and the most common pathology
was simple endometrial hyperplasia without atypia (31%).

4. Classification

5. Structural Causes
 Polyps – AUB (P)
◦ endocervical or
endometrial
 Detected by ultrasound or
sonohysterography
 Often irregular, light bleeding

6. Structural Causes
 Adenomyosis –AUB (A)
 Controversial as a cause of
bleeding
 Diagnosed with ultrasound,
MRI, pathology

7. Structural Causes
Leiomyoma – AUB (L)
Submucous
Intramural
Subserosal
 Diagnosed with exam,
ultrasound, MRI, CT
 Heavy, regular bleeding

8. Structural Causes
 Malignancy and
hyperplasia – AUB (M)
 Diagnosed by biopsy
 Irregular bleeding

9. Non-structural causes COEIN
 Coagulopathies or bleeding disorders
 Ovulatory dysfunction
 Endometrial
 Iatrogenic sources (medications, smoking)
 Not yet classified

10. Causes of AUB - Anovulatory
 Most common cause of AUB
 Many reasons for anovulation
Physiologic
PCOS
Stress, weight change, exercise
Endocrine
Thyroid, PRL
Secreting tumors

11. Clinical Features
 Breast tenderness
 Nausea
 Urinary frequency
 Fatigue
 Excessive vaginal bleeding with severe pain or cramping
 Excessive vaginal bleeding with passage of tissue
 Weight gain (PCOS)

12. Diagnosis
 History
 Acute vs Chronic
 Characterize bleeding pattern
 Menstrual bleeding history
 Family History: AUB/ bleeding disorders
 Meds: warfarin, heparin, NSAID, OCP
 Physical
 PCOS: obesity, hirsutism, acne
 Thyroid dysfunction: cold/heat intolerance, dry skin, lethargy, proptosis
 DM: acanthosis nigricans
 Bleeding disorder: petechiae, pallor, signs of hypovolemia
 Pelvic exam

13. Investigations
 Labs
 Pregnancy test
 CBC
 Targeted screening for bleeding disorder (when indicated)
 TSH
 Gonorrhea/Chlamydia in high risk patients
 Imaging:
 TVUS
 Sonohysterography
 Hysteroscopy
 MRI
 Endometrial biopsy

14. Management
 Medical management should be initial treatment for most
patients
 Need for surgery is based on various factors (stability of
patient, severity of bleed, contraindications to med
management, underlying cause)
Type of surgery dependent on above + desire for future fertility
 Long term maintenance therapy after acute bleed is controlled

15. Treatment - Acute
 Unstable
 High dose hormones vs D&C
◦ IV estrogen – 25 mg IV q 4-6 hours x 24 hrs
 Endometrial balloon tamponade
 Stable
 Oral meds
Monophasic OCPs – One TID for seven days, then daily for at
least one cycle
Medroxyprogesterone– 20 mg TID for seven days, then daily for
at least three weeks
Tranexamic acid– 1.3 mg TID on days 1-5 of cycle

16. Chronic Treatment Considerations
 Etiology and severity of bleeding (eg, anemia, interference with daily
activities)
 Associated symptoms (eg, pelvic pain, infertility)
 Contraceptive needs or plans for future pregnancy
 Contraindications to hormonal or other medications
 Medical comorbidities
 Patient preferences regarding medical versus surgical and short-term
versus long-term therapy

17. Non-surgical treatment Options
 Expectant management
 NSAIDs
 Antifibrinolytic agents - Tranexemic acid
 Hormonal methods
 Combination methods
 Levonorgestrel IUD
 Cyclic progestin
 GnRH agonists (leuprolide)
 Metformin and other insulin-sensitizing drugs for irregular bleeding
in women with polycystic ovary syndrome

18. Surgical Management Options
 D&C
 Endometrial Ablation
 Uterine Artery Embolization
 Hysterectomy