2. Abnormal Uterine Bleeding (AUB)
AUB Is defined as bleeding from the genital tract that is out of the
normal menstrual cycle in terms of
Duration of stay
Frequency
Amount
Quality
The normal menstrual cycle results from a complex feedback
system involving the hypothalamus, pituitary, ovary, and uterus
The normal menstrual cycle length may be defined as varying
Comes 24 to 35 days
Stays from 2 to 7 days
Flowing less than 80 mL per cycle (average normal amount of
menstrual blood loss is 30 to 40 mL per cycle)
2
3. CONT…
The normal menstrual cycle is a tightly coordinated cycle of stimulatory
and inhibitory effects that results in the release of a single mature
oocyte from a pool of hundreds of thousands of primordial oocytes
The first day of menses represents the first day of the cycle (day 1)
The cycle is then divided into two phases, follicular and luteal
The follicular phase begins with the onset of menses and ends on the
day of the luteinizing hormone (LH) surge
The luteal phase begins on the day of the LH surge and ends at the
onset of the next menses
14 to 21 days are in the follicular phase and 14 days in the luteal phase
3
4. CONT…
Menorrhagia
refers to excessive or prolonged menstrual bleeding
It is technically defined as blood loss greater than 80 mL per
cycle and/or menstrual periods lasting longer than seven days
In ovulatory women, menorrhagia is typically due to an anatomic lesion
(eg, fibroid)
Anovulation is also a common cause of menorrhagia
Metrorrhagia and menometrorrhagia
Metrorrhagia refers to light bleeding from the uterus at irregular
intervals
Menometrorrhagia refers to heavy bleeding from the uterus at irregular
intervals (Menorrhagia+ Metrorrhagia)
4
5. CONT…
Polymenorrhea
Refers to regular bleeding that occurs at an interval less than 24 days
Oligommenorrhea
Refers When menstruation comes in greater than 35 days
Hypomenorrhea (cryptomenorrhea)
Small bleeding (bleeding less than 2 days)
Intermenstrual bleeding
Refers to bleeding that occurs between menses or between expected
hormone withdrawal bleeds in women using some forms of hormonal
contraception or postmenopausal hormone therapy
5
6. CONT…
Premenstrual spotting
Refers to light bleeding preceding regular menses
Amenorrhea
Refers to absence of bleeding for at least three usual cycle lengths
Postcoital bleeding (Contact bleeding)
Refers to vaginal bleeding that is noted within 24 hours of vaginal
intercourse
6
7. CONT…
Causes of AUB
The causes of abnormal uterine bleeding can be divided into
Structural causes – Ovulatory bleeding
Level of sex hormones and gonadotropins are normal
Mensus is cyclic
7
8. CONT…
Hormonal causes – Anovulatory bleeding
Sex steroids are produced, but not cyclically so bleeding is
irregular
Chronic estrogen production unopposed by adequate
progesterone production allows continued proliferation of the
endometrium which leads to breakthrough bleeding
8
9. CONT…
Causes of ovulatory bleeding
A. Pregnancy associated complications
B. Anatomic uterine lesions
Neoplasm - Lieomayoma, endometrial cancer cervical cancer
Infection - STI
Mechanical causes - intrauterine device, perforation
Partial outflow obstruction - congenital müllerian defect, Asherman
syndrome
9
10. Dysfunctional uterine bleeding (DUB)
It is abnormal uterine bleeding with out any structural abnormality in
the genital tract
Excessive noncyclic endometrial bleeding unrelated to anatomical
lesions of the uterus or to systemic disease
So the cause is said to be hormonal abnormality
It is more useful to think of dysfunctional uterine bleeding as
anovulatory bleeding
80-90% is due to dysfunction of the H-P-O axis 10
11. Patho physiology
no ovulation
↓
no corpus luteum
↓
no progesterone secretion
↓
unopposed estrogen stimulation of endometrium
↓
endometrium become out of phase and start to shade
11
12. Evaluation and Diagnosis of AUB
History
Physical examination
Laboratory studies
Pregnancy test
Complete blood count
Thyroid-stimulating hormone (TSH) and prolactin
Coagulation profile
12
13. P/E focus on
V/s
HEENT( anemia)
Abdomen
Mass and enlarged irregular uterus suggests myoma
Symmetrically enlarged ux is more typical of adenomyosis or
endometrial CA
GUS
Consistency and surface of CX
Any mass on the CX or VX
Adenexal mass
13
15. CONT…
Cytologic Examination
Cervical and endometrial cancers can cause AUB
Pap smear (for cervical ca)
Depending on the pap smear results, colposcopy or endometrial biopsy
or both may be indicated
A special instrument called a colposcope lighted, highly magnified
view of the tissue of the cervix, vagina, and vulva.
The colposcope is placed close to the body, but it does not enter the
body
15
16. CONT…
ULTRASONOGRAPHY
In post menopausal mothers endometrial thickness <4mm
excludes endometrial ca in 95-97%
Endometrial thicknesses >5 mm warrant additional evaluation
with hysteroscopy, or endometrial biopsy
Endometrial thickness of >15mm independent of cycle in
premenopausal mother endometrial ca should be rulled out by
endometrial biopsy
16
17. CONT…
Normal endometrial cancer thickness premenopausal
During menstruation: 2-4 mm
Early proliferative phase (day 6-14): 5-7 mm
late proliferative / preovulatory phase: up to 11 mm
Secretory phase: 7-16 mm
17
18. CONT…
Saline-Infusion Sonography
This simple, minimally invasive, and effective sonographic procedure
can be used to accurately evaluate the myometrium, endometrium,
and endometrial cavity
To perform SIS, a small catheter is squeeze through the cervical os
into the endometrial cavity
Through this catheter, sterile saline is infused, and the uterus is
distended
Sonography is then performed using a transvaginal technique
This method allows visualization of common masses associated with
abnormal uterine bleeding such as endometrial polyps, submucosal
myomas, and intracavitary blood clots
18
20. CONT…
Hysteroscopy
This procedure involves inserting an optic endoscope, usually 3 to 5
mm in diameter, into the endometrial cavity
The uterine cavity is then distended with saline or another medium for
visualization
In addition to inspection, biopsy of the endometrium allows histologic
diagnosis of visually abnormal areas and has been shown to be a safe
and accurate means to identify pathology
The main advantage of hysteroscopy is to detect intracavitary lesions
such as leiomyomas that might be missed using transvaginal
sonography or endometrial sampling
20
21. Treatment of Abnormal Uterine Bleeding
The cause of the abnormal bleeding should determine the
treatment options available to the patient
Hormonal or medical conditions causing the bleeding should be
addressed
Structural causes are often addressed surgically
21
22. CONT…
Management of DUB
The management of DUB has several goals
1. Maintenance of hemodynamic stability
2. Correction of acute or chronic anemia
3. Return to a pattern of normal menstrual cycles
4. Prevention of recurrence
5. Prevention of long-term consequences of anovulation
22
23. CONT…
Management for mild DUB
Management of mild DUB consists of observation and reassurance
They should follow-up in three to six months
Although hemoglobin concentration is usually normal (>12 mg/dL) in
mild DUB iron should be given
23
24. CONT…
Mx of moderate DUB
1) Not in Active bleeding
Managed in the outpatient setting
Combined OCP
Progesterone only pills
Medroxyprogestrone 10 mg po/d from in the last 10days of the cycle
24
25. CONT…
2) Currently bleeding - a combination of estrogen and progestin rather
than to progestin-only preparations, as estrogen provides hemostasis
1tab TID until the bleeding stops
1tab BID for 5 days
1tab daily to complete 21 days course
If the bleeding persist despite 3month hormonal RX other causes
should be ruled out
25
26. CONT…
MX of sever DUB
Hospitalization
Stabilization
Blood transfusion
Hormone RX
26
27. CONT…
Combined ocp (high dose estrogen )
1tab qid for 4 day
1tab tid for 3 day
1tab bid for 21 day
Give antiemetic 1hr before
27
28. CONT…
Surgical methods
Are last options in a lady who doesn’t respond to hormonal therapy
• D&C
• Endometrial destructive procedures
• Hysterectomy
28
29. CONT…
Endometrial ablation
Surgical destruction of the endometrium. The endometrium must be
destroyed or resected to the level of the basalis ,which is approximately
4 to 6 mm deep, depending upon the stage of the menstrual cycle
Endometrial ablation is performed with a disposable device which is
inserted into the uterine cavity and delivers energy (radiofrequency) to
uniformly destroy the uterine lining
Or endometrial ablation or resection performed under hysteroscopic
visualization with electrosurgical instruments
29
30. CONT…
Endometrial ablation is contraindicated in women with the following
conditions or characteristics
Pregnancy
Known or suspected endometrial cancer
Desire to preserve fertility
Active pelvic infection
Intrauterine device in place
Previous transmyometrial uterine surgery
After resection or ablation, 70 to 80% of women experience
significantly decreased bleeding
30
31. CONT…
Hysterectomy
Removal of the uterus is obviously the most effective treatment
for bleeding and overall patient satisfaction rates approximate 85%
Disadvantages to hysterectomy include more frequent and severe
intraoperative and postoperative complications compared with
either conservative medical or ablation procedures
Operating time, hospitalization, recovery times, and costs are also
greater
31
34. Uterine Myoma
Uterine leiomyomas (fibroids or myomas) are the most common
pelvic tumor in women
They are benign tumors arising from the smooth muscle cells of the
myometrium
They arise in reproductive age women and typically present with
symptoms of abnormal uterine bleeding or pelvic pain/pressure
Uterine fibroids may also have reproductive effects (eg, infertility,
adverse pregnancy outcomes)
34
35. CONT…
TERMINOLOGY AND LOCATION
Fibroids are often described according to their location in the uterus,
although many fibroids have more than one location designation
1) Intramural myomas
These leiomyomas develop from within the uterine wall
They may enlarge sufficiently to distort the uterine cavity or serosal
surface
Some fibroids can be transmural and extend from the serosal to the
mucosal surface
2) Submucosal myomas
These leiomyomas derive from myometrial cells just below the
endometrium
These neoplasms often protrude into the uterine cavity
35
36. CONT…
The extent of this protrusion is classified
A type 0 fibroid is completely intracavitary, type I has less than 50% of
its volume in the uterine wall, whereas a type II has 50 % or more of its
volume in the uterine wall
Types 0 and I are hysteroscopically resectable, although significant
hysteroscopic expertise may be needed to resect type I masses
3) Subserosal myomas – These leiomyomas originate from the
myometrium at the serosal surface of the uterus. They can have a broad
or pedunculated base and may be intraligamentary (ie, extending
between the folds of the broad ligament)
4) Cervical myomas – These leiomyomas are located in the cervix, rather
than the uterine corpus
36
40. CONT…
RISK FACTORS
Race — The incidence rates of fibroids are typically found to be
two- to three-fold greater in black women than in white women
Early menarche (<10 years old)
Parity (having one or more pregnancies extending beyond 20
weeks) decreases the chance of fibroid formation
It has been seen that the postpartum remodeling of the uterus
may have the effect of clearing smaller fibroids
Early age at first birth decreases risk and a longer interval since last
birth increases risk
Hormonal contraception — Use of low dose contraceptives (OCs)
does not cause fibroids to grow, therefore administration of these
drugs is not contraindicated in women with fibroids
40
41. CONT…
Obesity
Diet and alcohol use
Smoking — Smoking decreases the risk of having fibroids through an
unknown mechanism
Hypertension is associated with an increased leiomyoma risk
41
42. CONT…
Clinical Manifestations
Symptoms attributable to uterine myomas can generally be classified
into three distinct categories:
Abnormal uterine bleeding
Pelvic pressure and pain
Reproductive dysfunction
42
43. CONT…
Abnormal uterine bleeding
Abnormal uterine bleeding is the most common symptom
Heavy and/or prolonged menses is the typical bleeding pattern with
myomas
Intermenstrual bleeding and postmenopausal bleeding
are NOT characteristic of myomas and should be investigated to
exclude endometrial pathology
43
44. CONT…
The presence and degree of uterine bleeding are determined
by the location of the fibroid and size
Submucosal myomas that protrude into the uterine cavity are
most frequently related to significant menorrhagia
women with intramural myomas also commonly experience
heavy or prolonged menstrual bleeding
44
45. CONT…
Pelvic pressure and pain
Bulk-related symptoms — The myomatous uterus is irregularly
shaped, in contrast to the pregnant uterus, and can cause specific
symptoms due to pressure from myomas at particular locations
As examples, urinary frequency, difficulty emptying the bladder, and,
rarely, urinary obstruction can all occur with fibroids
symptoms sometimes arise when an anterior fibroid presses directly
on the bladder or a posterior fibroid pushes the entire uterus forward
Fibroids that place pressure on the rectum can result in constipation
Back pain may be related to the presence of myomas
45
46. CONT…
Dysmenorrhea
Dysmenorrhea is also reported by many women with fibroids.
This pain in many women appears to be correlated with heavy
menstrual flow and/or passage of clots
Dyspareunia
among women with fibroids, anterior or fundal fibroids are the most
likely to be associated with deep dyspareunia
Number and size of fibroids do not appear to influence the incidence or
intensity of dyspareunia
46
47. CONT…
Effects on reproduction — Leiomyomas that distort the uterine
cavity result in difficulty conceiving a pregnancy and an increased
risk of miscarriage
leiomyomas have been associated with adverse pregnancy
outcomes (eg, placental abruption, fetal growth restriction, and
preterm labor and birth)
47
48. CONT…
DIAGNOSIS
Pelvic examination
Pelvic examination should be performed
On bimanual pelvic examination, an enlarged, mobile uterus with an
irregular contour is consistent with a leiomyomatous uterus
The size, contour, and mobility of the uterus should be noted, along
with any other findings (eg, adnexal mass, cervical mass)
Infrequently, on speculum exam, a prolapsed submucosal fibroid may
be visible at the external cervical os
48
49. CONT…
Ultrasound
Transvaginal ultrasound has high sensitivity (95 to 100 %) for
detecting myomas in uteri less than 10 weeks' size
But Localization of fibroids in larger uteri or when there are many
tumors is limited
This is the most widely used modality due to its availability and cost-
effectiveness
Saline infusion sonography (sonohysterography) improves
characterization of the extent of protrusion into the endometrial cavity
by submucous myomas and allows identification of some intracavitary
lesions not seen on routine ultrasonography
49
51. CONT…
DIFFERENTIAL DIAGNOSIS
A normal nonpregnant uterus weighs approximately 70 g
The differential diagnosis of an enlarged uterus includes both benign
and malignant conditions:
Uterine adenomyosis or adenomyoma
Pregnancy
Hematometra
Endometrial carcinoma
51
52. CONT…
One characteristic that may distinguish adenomyomas from
leiomyomas is the presence of dysmenorrhea as a prominent
symptom
Adenomyomas are generally more difficult to excise than leiomyomas
Pregnancy is readily distinguishable from other uterine masses with
measurement of a serum human chorionic gonadotropin and/or pelvic
sonography
Hematometra, a collection of blood within the uterine cavity, occurs
most often following after an intrauterine procedure and/or in women
with cervical stenosis and is diagnosed with pelvic imaging
Endometrial carcinoma may also result in abnormal uterine bleeding
and a uterine mass, However, the diagnosis is typically made with
endometrial sampling and imaging usually shows a thickened
endometrium 52
53. CONT…
Hematometra, a collection of blood within the uterine cavity, occurs
most often following after an intrauterine procedure and/or in women
with cervical stenosis and is diagnosed with pelvic imaging
Endometrial carcinoma may also result in abnormal uterine bleeding
and a uterine mass, However, the diagnosis is typically made with
endometrial sampling and imaging usually shows a thickened
endometrium
53
54. CONT…
Natural History
Premenopausal women
With modern pelvic imaging, achieved an increased appreciation of
the variability of growth and shrinkage of leiomyomas among women
of reproductive age
Prospective studies have found that between 7 to 40 % of fibroids
regress over six months to three years
Postmenopausal women
Relief of menstrual bleeding symptoms related to fibroids occurs at
the time of menopause, when menstrual cyclicity stops and steroid
hormone levels decline
Most women have shrinkage of leiomyomas at menopause
54
55. CONT…
Postmenopausal Women on hormone therapy
Use of postmenopausal hormone therapy may cause some women
with leiomyomas to continue to have symptoms after menopause
The risk of symptoms may depend, on the location of the fibroid
(higher if submucosal )
55
57. CONT…
Expectant Management
Women who have no symptoms from their fibroids
An initial imaging study (usually an ultrasound) to confirm that a
pelvic mass is a fibroid and not an ovarian mass
After an initial evaluation, perform annual pelvic exams and, in
patients with anemia or menorrhagia, check a complete blood count
If symptoms or uterine size are increasing, proceed with further
evaluation and patient counseling
57
58. CONT…
Medical Therapy
Medical therapy provides adequate symptom relief in some women,
primarily in situations where bleeding is the dominant
Estrogen-progestin contraceptives — clinical experience
suggests some women with heavy menstrual bleeding associated with
leiomyomas respond to OC therapy
Gonadotropin-releasing hormone agonists - the most effective
medical therapy for uterine myomas
These drugs work by initially increasing the release of gonadotropins,
followed by desensitization and downregulation to a
hypogonadotropic, hypogonadal state that clinically resembles
menopause
58
59. CONT…
Surgical
Indications for surgical therapy:
Severe Abnormal uterine bleeding or bulk-related symptoms
Infertility or recurrent pregnancy loss
I) Hysterectomy
(1)women with acute hemorrhage who do not respond to other therapies
(2) women who have completed childbearing
II) Myomectomy
Is an option for women who have not completed childbearing or
otherwise wish to retain their uterus
Although myomectomy is an effective therapy for menorrhagia and
pelvic pressure, the disadvantage of this procedure is the risk that more
leiomyomas will develop from new clones of abnormal myocytes 59
