Any uterine bleeding outside the normal volume, duration, regularity or frequency is considered AUB

1. ABNORMAL
UTERINE
BLEEDING (AUB)

2. NORMAL MENSTURATION
◦Cycle interval 28 days(21-35)
◦Menstrual flow 4-5 days
◦Menstrual blood loss 35 ml(20-80ml)

3. DEFINITION
◦Any uterine bleeding outside the normal volume,
duration, regularity or frequency is considered
abnormal uterine bleeding (AUB)

4. Causes- PALM COEIN
Structural cause
◦ Polyp
◦ Adenomyosis
◦ Leiomyoma
Submucosal myoma
Other myoma
◦ Maliganancy and hyperplasia
Nonstructural systemic causes
◦ Coagulopathy
◦ Ovulatory dysfunction
◦ Endometrial
◦ Iatrogenic
◦ Not yet identified

5. PATTERNS OF
ABNORMAL
UTERINE
BLEEDING

6. Menorrhagia (Hypermenorrhea)
◦Menorrhagia is defined as cyclic bleeding at
normal intervals; the bleeding is either excessive
in amount (> 80 ml) or duration (>7 days) or both.
◦Causes
Organic or functional

7. Common causes of menorrhagia
◦ Fibroid uterus
◦ Pelvic endometriosis
◦ Adenomyosis
◦ Chronic tubo-ovarian mass

8. ORGANIC
◦ Pelvic pathology
Fibroid uterus
Adenomyosis
Pelvic endometriosis
IUCD in utero
Chronic tubo-ovarian mass
Tubercular endometritis
Retroverted uterus – due to congestion
Granulosa cell tumor of the ovary

9. ◦Systemic
◦Liver dysfunction (cirrhosis)- failure to conjugate
and thereby inactivate the estrogens
◦Congestive cardiac failure
◦Severe hypertension

10. ◦ Endocrinal
◦ Hyperthyroidism
◦ Hypothyroidism
◦ Hematological
◦ Idiopathic thrombocytopenic purpura
◦ Leukemia
◦ Von Willebrand’s disease
◦ Platelet deficiency
◦ Deficiency of clotting factors (V, VII, X, XI, XIII)
◦ Women with anticoagulation therapy

11. Functional
◦Due to disturbed hypothalamo-pituitary-ovarian-
endometrial axis. Common cause of abnormal
vaginal bleeding includes all the causes of organic,
systemic and also the nonmenstrual causes of
bleeding.

12. Diagnosis
◦ Long duration of flow
◦ Passage of big clots
◦ Use of increased number of thick sanitary pads
◦ Pallor
◦ Low level of haemoglobin

13. Treatment
◦The definitive treatment is appropriate to the
cause for menorrhagia.

14. Polymenorrhea (epimenorrhea)
◦Polymenorrhea is defined as cyclic bleeding where
the cycle is reduced to an arbitrary limit of less
than 21 days and remain constant at that
frequency. If the frequent cycle is associated
with excessive and/or prolonged bleeding, it is
called epimenorrhagia.

15. Causes
◦Dysfunctional : It is seen predominantly during
adolescence, preceding menopause and following
delivery and abortion.
◦Ovarian hyperemia as in pelvic inflammatory
disease (PID) or ovarian endometriosis

16. Metrorrhagia(Itermenstrual bleeding)
◦ Metrorrhagia is defined as irregular, acyclic bleeding from the
uterus.
◦ Bleeding from any part of the genital tract is included under
this. Irregular bleeding in the form of contact bleeding or
intermenstrual bleeding.
◦ Causes of contact bleeding
◦ Carcinoma cervix
◦ Mucus polyp of cervix
◦ Vascular ectopy of the cervix
◦ Infections
◦ Cervical endometriosis

17. Causes of acyclic bleeding
◦ DUB
◦ Submucosal fibroid
◦ Uterine polyp
◦ Carcinoma cervix and
endometrial carcinoma
Causes of intermenstrual bleeding
◦ Urethral caruncle
◦ Ovular bleeding
◦ Breakthrough bleeding in pill use
◦ IUCD in utero
◦ Decubitus ulcer
◦ Progesterone only contraceptive
use

18. Treatment
◦Treatment is directed to the underlying pathology.
◦Malignancy is to be excluded prior to any
definitive treatment.

19. Oligomenorrhea
◦ Menstrual bleeding occurring more than 35 days apart and
which remains constant at that frequency is called
oligomenorrhea.
◦ Causes of oligomenorrhea
◦ Age related – during adolescence and preceding menopause
◦ Obesity
◦ Stress and exercise related
◦ Endocrine disorder
◦ Androgen producing tumors – ovarian, adrenal
◦ Tubercular endometritis
◦ Drugs – Phenothiazines, Cimetidine, Methyldopa

20. Hypomenorrhea
◦When the menstrual bleeding is scanty and lasts
for less than 2 days, it is called hypomenorrhea.
◦Causes
◦Local
◦Endocrinal
◦Systemic

21. Dysfunctional uterine
bleeding(DUB)
◦ Dysfunctional uterine bleeding is defined as a state of
abnormal uterine bleeding without any clinically
detectable organic, systemic and iatrogenic cause.
◦ The abnormal bleeding (DUB) may be associated with or
without ovulation and accordingly grouped into:
Ovular bleeding (20%)
Anovular bleeding (80%)

22. Ovular bleeding may present with
(20%)
Polymenorrhea
Oligomenorrhea
Functional menorrhagia

23. Polymenorrhea
◦ It is due to speeded follicular growth with
hyperstimulation of FSH and/or shortened luteal phase
due to premature lysis of corpus luteum

24. Oligomenorrhea
◦ It may be due to ovarian unresponsiveness to FSH. The
proliferative phase is prolonged with normal secretory
phase.

25. • Functional menorrhagia
Irregular shedding of the endometrium
Irregular ripening of endometrium

26. ◦ Irregular shedding of endometrium
◦ In irregular shedding, desquamation is continued for a
variable period with simultaneous failure of regeneration
of the endometrium

27. ◦ Irregular ripening of the endometrium
◦ There is poor formation and inadequate function of
corpus luteum. Secretion of both oestrogen and
progesterone is inadequate to support the endometrial
growth.

28. Anovular bleeding(80%)
• In absence of growth limiting progesterone due to
anovulation, corpus luteum does not formed.
• Continuous unopposed production of oestradiol, it
stimulate overgrowth of endometrium, endometrium
thickens and outgrows its blood sulpply, necrosis and
irregular bleeding occurs.

29. INVESTIGATIONS
The investigation aims at:-
• To confirm menstrual abnormality as stated by patient.
• To exclude systemic, iatrogenic and organic pelvic
pathology.
• To identify possible etiology of DUB.
• To work out the definite therapy protocol.

30. Investigations
◦ History taking
◦ Internal examination
◦ Special investigations
- Blood values Trans-vaginal sonography (TVS)
- Saline infusion sonography
- Hysteroscopy
- Endometrial biopsy
- Diagnostic D&C
- Laparoscopy

31. MANAGEMENT
◦ Management depends on:
 Age
Desire for child bearing
Severity of bleeding
Associated pathology

32. GENERAL MEASURES
• Rest advised during bleeding phase.
• Assurance and sympathy
• Anemia should be corrected appropriately by diet,
hematinics, and even by blood transfusion.
• Any systemic or endocrinal abnormality should be
investigated accordingly.

33. MEDICAL MANAGEMENT
◦ Majority of DUB cases responds well to conservative treatment
during adolescence and early reproductive period.
 NONHORMONAL MANAGEMENT –
i) Prostaglandin synthetase inhibitors- Mefenemic acid 150-600 mg,
oral in divided doses during bleeding phase.
• NSAIDs may be used as second line medical treatment. NSAIDs
may reduce menstrual blood loss by 25-40%
ii) Antifibrinolytic agents: Tranexamic acid, reduces menstrual blood
loss by 50%. It mainly used in IUCD induced menorrhagia

34. HORMONAL MANAGEMENT
◦ Norethisteroneacetate
• Medroxyprogesterone acetate (MPA)
• Progestin releasing IUCD:LNG-IUCD ( 5 years effect)

35. Other hormonal contraceptives
◦ Combined pill - estrogen and progesterone pill
• Danazol
• GnRh agonist
• Desmopressin
• Dydrogesterone in ovular DUB.

36. SURGICAL MANAGEMENT
◦ Uterine curettage - Hemostatic and therapeutic effect by
removing necrosed and unhealthy endometrium . USG guided D&C
for detection of endometrial pathology.
◦ Endometrial ablation / resection- Destruction of endometrium
using various methods like- thermal balloon with hot normal saline
87° C for 8-10 min. Other methods are trans cervical resection of
endometrium, laser resection, Novasure radio frequency, rollar
ball ablation.
◦ Hysterectomy Removal of uterus done by various route by
vaginal, abdominal, laparoscopic assisted vaginal route, etc.