Abnormal uterine bleeding is a common gynecological problem that can affect women of all ages. It is defined as bleeding outside of normal menstrual parameters of volume, regularity, duration, and frequency. The document outlines the normal menstrual cycle and parameters of abnormal bleeding. It then describes the PALM-COEIN classification system for etiologies of abnormal uterine bleeding, including structural causes like polyps, adenomyosis, and leiomyomas (PALM) and non-structural causes like coagulopathies, ovulatory dysfunction, and endometrial factors (COEIN). Evaluation and management approaches are discussed for each etiology.

1. Abnormal UterineBleeding
AUB
DR K MANJU
PROFESSOR
(OBSTETRICS AND GYNAECOLOGY)
PMCH, PATNA

2. Abnormal Uterine Bleeding:
Introduction
• Common problem in FEMALES
• It has a substantial effect on health related quality of life
• Any bleeding from the uterus which is outside the
• normal volume
• regularity
• duration
• or frequency
is considered ABNORMAL UTERINE BLEEDING (AUB)

3. Normal Uterine Bleeding
• Normal uterine bleeding- Menstruation: cyclical
phenomenon regulated by HORMONES
• Reproductive aged women- From Menarche to Menopause
• Frequency – 21days to 35 days
• Duration – 2 to 8 days
• Flow –35 ml (20ml -80 ml)
• Pad used –3 to 6 pad /day

4. Blood loss-
Frequency
• Frequent: <21 days(>4/90
days)
• Normal:21-35 days
• Infrequent: >35 days (1-2/90
days)
Duration
• Prolonged:>8 days
• Normal:2-8 days
• Shortened:<2 days
Volume
• Heavy: >80 ml
• Normal: 20-80 ml
• Light: <20 ml
Key menstrual parameters

5. Menstrual Cycle
• FOLLICULAR PHASE: Begins
with menses ends with LH
hormone surge
• OVULATION PHASE: 30 to 36
hrs. Begins with LH surge and
end with OVULATION
• LUTEAL PHASE:14 days.
Begins with the end of the LH
surge and ends with onset of
menses
• MENSTRUAL PHASE

7. Arrest of bleeding…
• Hemostasis
• Platelet plug & clot formation:
Coagulation cascade
• Prostaglandin mediated
vasoconstriction:
Arachidonic acid cascade
• Tissue repair:
Re-epithelialization

8. Bleeding is abnormal if...
• It occur at interval of 21 days or less, or
35 days or more
• Last longer than 8 days
• Menstrual Blood Loss (MBL) of 80 or
more

9. Abnormal Uterine Bleeding: Incidence
• One of the common disorder in gynae and accounts for 30 to 40%
cases in OPD
• Can occur in women of all age
• Reproductive age 25-30 %
• Perimenopausal age 50 %
• Factors that impact the incidence most greatly are age &
reproductive status
• Uncommon in prepubertal girls and post menopause, where as rate
of abnormal bleeding increases significantly in adolescent,
perimenopausal and reproductive age groups

10. Terminology- Types Of Bleeding
• Heavy menstrual bleeding (HMB): Regular cycles, prolonged or
heavy bleeding
• Irregular bleeding: Cycles <21 or >35 days
• Intermenstrual bleeding (IMB): Small amounts of bleeding in
between regular cycles
• Amenorrhea: Absence of menstruation

11. Older Classification /Terminology
• DYSFUNCTIONAL UTERINE BLEEDING (DUB) – Abnormal Uterine
bleeding in absence of pelvic organic disease or syst disorder
• MENORRHAGIA –EXCESSIVE /Prolong bleeding, cycle- regular.
• METRORRHAGIA – Irregular, acyclical bleeding .
• POLYMENORRHEA – Frequent <21 days cyclical bleeding
• OLIGOMENORRHEA –Infrequent >35days
• AMENORRHEA- Absence of menstruation
• HYPOMENORRHEA – Scanty menstruation

12. New Terminology
AUB: Abnormal uterine bleeding, defined as-
excessive menstrual blood loss which interferes with women’s
physical, emotional, and quality of life
Heavy Menstrual Bleeding (HMB)
 Acute- An episode of heavy bleeding that is of sufficient quantity
to require immediate intervention to prevent further blood loss
 Chronic- bleeding that is abnormal in duration regularity, volume
or frequency
Intermenstrual Bleeding (IMB)
Small amount of bleeding in between regular cycle

13. AUB Patterns described as..
AUB- HMB
- Menorrhagia replaced by Heavy menstrual bleeding
HMB
AUB- IMB
- Metrorrhagia replaced by –Intermenstrual bleeding
- IMB –Cyclical or acyclical

14. AUB: Classification
• By FIGO (International Federation of Gynecology and Obstetrics), 2011
• Approved by ACOG (American College of Obstetrics and Gynecology),
2013
• For non pregnant reproductive age women
• PALM-COEIN etiological classification system (ACRONYM)
• PALM- consists of structural abnormalities
• COEIN- includes conditions that are unrelated to structural abnormalities

15. PALM-COEIN Etiological Classification
System:
PALM
• P- Polyp
• A- Adenomyosis
• L- Leiomyoma
 Submucosal Myoma
(LSM)
 Other (LO)
M- Malignancy and
Hyperplasia
COEIN
• C- Coagulopathy
• O- Ovulatory
dysfunction
• E- Endometrial
• I- Iatrogenic
• N- Not Yet Classified

16. AUB documentation as per PALM-COEIN
Etiological Classification
• AUB documented as
• PATHOLOGY being PRESENT – 1, or
• PATHOLOGY being ABSENT – O
• Multiple pathologies are documented simultaneously e.g.-
adenomyosis, hyperplasia and coagulopathy in a single
patient may be cited as –
• P0A1L0M1–C1O0E0I0N0, or
• Simplified- AUB-A,-M,-C

17. AUB Etiology- Structural causes
“PALM”
1. AUB–P: POLYP (P1A0L0M0–
C0O0E0I0N0)
Endometrial Polyp- localized outgrowth of the
endometrium stroma & glands
• Most common cause of AUB in reproductive and
postmenopausal women
• usually BENIGN but occasionally MALIGNANT
• Symptoms- HMB ,IMB, post menopausal bleeding
Cervical Polyp- From cervical gland
• BENIGN
• Symptoms- post coital bleeding or IMB
Cervical polyp

18. AUB–P (Polyp) PALM
• Polyp- suspected by history of IMB & thick
endometrium on USG
• MANAGEMENT:
• Medical management - ineffective
• Younger women – polypectomy. HPE to exclude
malignancy
• Women with multiple or recurrent endometrial polyp
with no fertility desire – hysteroscopic
polypectomy may be followed by LNG-IUS (if
benign polyp)
• Hysterectomy
Endometrial polyp

19. 2. AUB-A: ADENOMYOSIS
• Presence of Ectopic Endometrial gland and
Stroma in the Uterine Myometrium.
• Usually occur in MULTIPAROUS women of
PERIMENOPAUSAL AGE
• Symptoms- HMB, Secondary
dysmenorrhoea, chronic pelvic pain
• Sign- Uterus uniformly enlarged <14 wk
• USG-
• Asymmetrical thickening of uterine wall
• Loss of clear endo-myometrial border
• Myometrial cyst
AUB STRUCTURAL Etiology- PALM
AUB-A: Adenomyosis

20. AUB-A (ADENOMYOSIS) PALM
• Confirmed by evidence of Endometrial tissue
beneath the endometrial myometrial junction on HPE
AUB-A- usually refractory to medical treatment
Definitive cure:
• Surgery
• Conservative surgery- Resection of
Adenomyoma, myometrial reduction, Hysteroscopic
resection
• HYSTERECTOMY
Endometrial tissue consisting of
endometrial glands and stromal cells
within the myometrium

21. AUB-A (ADENOMYOSIS) PALM
Newer therapy -
• Endometrial ablation,
• UAE (Uterine Artery Embolization),
• MRg-FUS (Magnetic Resonance-Guided Focused Ultrasound)
• Medical- NSAIDs, COC (combined oral contraceptive), Danazol,
LNG-IUS, GnRH analogues, Aromatase inhibitor, Danazol loaded
IUS

22. AU b–L- leiomyoma -most common
benign tumour of uterus
• Leiomyoma can be –
• Submucous ,
Intramural & Subserous
• Bleeding pattern depends on –
SIZE, LOCATION and NUMBER of tumour
Diagnosed –history, clinical exam &USG
Aub–l- structural etiology palm
leiomyoma

23. 3. AUB-L: LEIOMYOMA
• Subclassified as
- those with at least ONE Submucous
leiomyoma, AUB-L-SM and
- those having NO Submucous
leiomyoma AUB-L-O [OTHER]
• Commonest cause of AUB in
Reproductive age
• Symptoms- HMB, IMB, irregular
bleeding
AUB STRUCTURAL Etiology- PALM
AUB-L: Leiomyoma

24. AUB-L (LEIOMYOMA) PALM
Management- Individualized
Medical-
- For small asymptomatic myoma at any age
- to control bleeding while waiting for surgery
- control bleeding (to correct anaemia)
- preoperative to reduce vascularity
- approaching menopause
Drugs- NSAID, COC, progestins- oral, LNG-IUS, Mifepristone, Danazol,
Gestrinone, SERM- Raloxifene & Ormeloxifene, SPERM- Ulipristal, GnRH
analogue- cabergoline , Aromatase inhibitor- anastrozole
SURGERY- MYOMECTOMY , HYSTERECTOMY
Myomectomy

25. NEWER THERAPY- in selected cases
• Uterine artery embolization
• Hysteroscopic resection- Submucosal myoma <4cm
• Laproscopic uterine artery ligation/ myomectomy
• Laproscopic myolysis
- Thermal myolysis
- Cryomyolysis
- Laser myolysis
- Radio-frequency myolysis
• MRg-FUS (Magnetic Resonance-Guided Focused Ultrasound) or HIFU
high intensity focused USG
AUB-L (LEIOMYOMA) PALM
Uterine artery embolization

26. AUB-L (LEIOMYOMA) PALM-myolysis
MRg-fus
Laproscopic myolysis Radio frequency myolysis
Magnetic Resonance-Guided Focused Ultrasound

27. AUB STRUCTURAL Etiology- PALM
AUB-M: Malignancy and hyperplasia
4. AUB-M: Malignancy and hyperplasia
• Endometrial Hyperplasia –
with ATYPIA or without ATYPIA
• Endometrial Carcinoma
-Usually presents with HMB OR Irregular
bleeding -in
- Peri menopausal age group
- Post menopausal women
Endometrial hyperplasia
Endometrial Carcinoma

28. .Other cancer of genital tract – may present
with AUB
• Cervical cancer –Occur in younger age [mid
40s], associated with IMB, PCB
• Vulval, Vaginal cancer- RARE, but can present
with bleeding
AUB-M (Malignancy and hyperplasia)
PALM
Cervical Cancer

29. AUB-M (Malignancy and hyperplasia)
PALM
STANDARD PROTOCOL
• AUB-M with endometrial hyperplasia with ATYPIYA
- Hysterectomy- standard treatment
- Conservative treatment with high dose Progestin- exceptional case,
risk of carcinoma always
• AUB-M with endometrial hyperplasia without ATYPIA: Hormones
LNG IUS -first line
Progestin- oral MPA
• Preventive Hysterectomy- considered in high risk group:
older age, early age of menarche, diabetes, obesity,history of breast cancer,
family h/o of endometrial cancer

30. AUB Etiology: Not Associated with structural
Abnormalities “COEIN”
1. AUB-C: COAGULOPATHY
• Disorders of blood coagulation
• Common disorders are
• Von Willebrand disease
• Thrombocytopenia ,
• Hemophilia, Leukaemia
• HEAVY Bleeding occurs at Menarche
• Family history present
• History of easy bruising
• Chronic liver disease- decrease in coagulation factor synthesis–HMB
• Anticoagulant use (warfarin) , APA ,VT can cause AUB

31. AUB-C (COAGULOPATHY) COEIN
• Medical management - effective
• Tranexamic acid
• LNG-IUS
• NSAID -Contraindicated –can alter PLT function & liver
function
• IM Injectable preparation –contraindicated
• Consult Haematologist

32. AUB Etiology NON STRUCTURAL- COEIN
AUB-O: Ovulatory Dysfunction
2. AUB-O: Ovulatory Dysfunction
• Common cause of AUB
• Previously classified as “ANOVULATORY DUB”
• Ovulatory Dysfunction-result from abnormal functioning of the
HYPOTHALAMIC-PITUITORY-OVARIAN AXIS
• Seen in
- Adolescent girls < 20 yrs: due to immaturity of HPO
axis & failure of positive feedback of estradiol to cause LH
surge
- Perimenopausal women > 41yrs: Due to lack of
synchronization between the component of HPO axis as
women approaches menopause

33. AUB-O (Ovulatory Dysfunction) COEIN
• Disorder of ovulation like-
Oligo ovulation, Anovulation, PCOD & Corpus luteum dysfunction
may result in AUB.
May be Associated with Obesity, Mental Stress,
Anorexia, Weight Loss, Hypo & Hyperthyroidism,
Hypo prolactinemia
• Spectrum of menstrual problems-
Prolonged HMB or Scanty, irregular bleeding
Short cycle with normal or heavy bleeding,
period of amenorrhea followed by painless, profuse, prolonged or
scanty bleeding
Polycystic ovaries

34. Contd..
Pathogenesis: ANOVULATION
• Low level of oestrogen→ No LH surge → NO OVULATION → NO corpus
luteum formation → NO PROGESTERON production → Decrease level of
PGF2α, other PGs & Thrombxanes → Increase Fibrinolysis → Painless
bleeding [no vasoconstrict]
• Presence of developing follicle → prolonged supply of Estrogen →
Endometrial proliferation & Hyperplasia → Fragile Endometrial with no
stromal support → continuous prolonged bleeding followed by → amenorrhea
AUB-O (Ovulatory Dysfunction) COEIN
No LH Surge
No ovulation
No corpus luteum
No progesterone
→

35. May be associated with –
- Follicular cyst of the ovary
- Endometrial hyperplasia
Prolonged amenorrhea- Endometrium shows CYSTIC
HYPERPLASIA, [SWISS CHEESE appearance]
“Metropathia hemorrhagica”, “Schroeder’s disease”
• Characteristic
- Hyperplastic gland &stroma
- Cystic or irregularly dilated gland
- Increase in Vascularization
- Necrosis of Superficial Endometrium
- Tortuous & Dilated SPIRAL ARTERIOLES and veins
AUB-O (Ovulatory Dysfunction) COEIN

36. Endometrial hyperplasia, simple. Proliferation of
endometrial glands and stroma without cytologic atypia.
AUB-O (Ovulatory Dysfunction) COEIN

37. • Combined Oral Contraceptive [COC]–first line treatment if
pregnancy not desired
• Cyclical Progesterone therapy-
• Cyclical Norethisterone for 21 days [day5 -25 ]x 3 cycle
• Cyclical Progestin luteal phase- for 10-14 days [ 15-25 ]-3
cycle
• LNG-IUS
Adolescent –both & Hormonal & non Hormonal treatment
AUB-O (Ovulatory Dysfunction) COEIN

38. 3. AUB-E: ENDOMETRIAL DYSFUNCTION
Primary Disorder of ENDOMETRIUM- cause of AUB
• Formerly known as OVULATORY DUB
• AGE 21 –40 YRS
• Clinical features
- HMB, Dysmenorrhea
- Normal Uterus
• Pathogenesis- Increase production of vasodilators PGE2
- Alteration in ratio PGF2α :PGE2
- Increase in Fibrinolytic activity
AUB Etiology NON STRUCTURAL COEIN
AUB-E: ENDOMETRIUM

39. • Diagnosis of EXCLUSION- after ruling out other identifiable abnormalities
in women with normal ovulatory cycle
• HPE: Endometrium reveals SECRETORY changes as OVULATION &
PROGESTERON normal
• Management: same as AUB –O, but only 21 days therapy is effective
• Chronic inflammation of the ENDOMETRIUM with or without associated
PID- Uncommon cause of AUB
AUB-E (ENDOMETRIAL Dysfunction)
COEIN
DUB may or may not be associated with OVULATION
• Anovular bleeding- 80%: AUB-O [Anovulatory DUB]
• Ovular bleeding - 20%: AUB-E [Ovulatory DUB]

40. 4. AUB-I: Iatrogenic
Exogenous therapy leading to unscheduled endometrial bleeding
-Exogenous steroids, estrogen & progestin therapy, GnRH,
Aromatase inhibitors, SERM, SPRM
-Intra Uterine Devices/ systems– IUCD, LNG-IUS
Symptoms: IUCD- HMB, LNG IUS- IMB & irregular bleeding
-Pharmacologic Agents- Anti convulsant- Valproic acid,
Antibiotics- Rifampicin
AUB Etiology NON STRUCTURAL COEIN
AUB-I: Iatrogenic

41. AUB –I (MANAGEMENT) COEIN
• Whenever possible: change Medication causing AUB
• Give Alternative therapy
• If Alternative not available – LNG-IUS can be used

42. 5. AUB-N: Not yet classified/ ill defined cause
- Congenital or acquired A-V Malformation
- Caesarean scar Defect
- Endometrial pseudo aneurysm
- Chronic Endometritis
• Treatment-
• Hormonal: LNG-IUS, COC
• A-V Malformation- Uterine Artery Embolization
• Non Hormonal- NSAID, Tranexamic acid
• GnRH Agonist with ADD-BACK therapy
• Conservative surgery[Ablation] & Hysterectomy- last resort
AUB Etiology NON STRUCTURAL -COEIN
AUB-N: Not yet classified
All these can cause AUB

43. AUB: Clinical Evaluation
HISTORY & PHYSICAL EXAM- help in diagnosis
HISTORY - THOROUGH
- Age, Menarche, Parity
- Menstrual pattern- regularity, frequency, duration & volume
- Menstrual calendar for bleeding pattern
- Dysmenorrhea , vaginal Discharge
- Post coital bleeding – polyp, carcinoma cervix
- Dyspareunia – Adenomyosis
- Infertility, Abortion, IUCD ,OC Pill,

44. AUB- History
• Information about –use of any medication , likely
to be the cause for AUB
• Screen for coagulopathy –Positive screen test if-
History of heavy bleeding at MENARCHE
History of PPH or Bleeding associated with Dental or any other
surgery
• Two of the following symptoms
• ≥ one episode of bruising/month
• ≥ one episode of epistaxis/ month
• frequent Gum bleeding or family history of bleeding symptom

45. GENERAL PHYSICAL EXAM –
• Pallor, Thyroid enlargement,
• Sign of PCOS- Hirsutism, Acanthosis Nigricans,
acne, BMI, Obesity
• ABDOMINAL EXAM– any mass
• SPECULUM EXAMINATION- exclude local
lesion: Polyp, erosion, growth
• BIMANUAL EXAMINATION-
• Uterine size, contour, tenderness, fixity
• Adnexal Mass/ Tenderness/ Induration
AUB: Clinical Evaluation
examination
Acanthosis nigricans
Hirsutism

46. AUB: Investigation –LAB testing
• Complete blood count [CBC] –for all
• Coagulation profile- platelet count, Bleeding time
• Prothrombin time ,partial thromboplastin time
• - Indicated in all young girl & women with
Positive screen test for coagulopathies
• Testing for –Von Willebrand disease [Hematologist]
• Thyroid function test–young girl, if needed
• Hormonal assay- LH, FSH, TESTOSTERONE,17HP,
Androstenedione, Prolactin level
• Pregnancy test –exclude

47. AUB : Investigation -IMAGING
• ULTRASOUND – Evaluate: UTERUS, ADENEXA, ENDOMETRIUM
-to help in diagnosis of myoma, polyp, adenomyosis & endometrial
thickness.
• DOPPLER ULTRASONOGRAPHY- In Suspected A-V malformation
- Malignancy & to differentiate between FIBROID &ADENOMYOSIS
• 3D-USG-To evaluate Intra-cavitary & Myometrial lesion
• SALINE INFUSION SONOGRAPHY [SIS]- Suspected intra-cavitary
lesion e.g. polyp
- USG performed after introduction of saline in to the uterine cavity
[Sonohysterography]

48. Aub- investigation--HPE
• Endometrial sampling for Histopathology [HPE]-
Women > 40 yrs
Women < 40yrs –having high risk factor for MALIGNANCY
• Like –Irregular bleeding, obesity, Hypertension, PCOS,
• Endometrial thickness >12mm, Diabetes,
• Family History of Malignancy–ovary, breast ,endometrium, colon
• Use of Tamoxifen
• Late Menopause
• exposure to unopposed estrogen
• AUB –unresponsive to medical therapy

49. AUB: Investigation- HPE
Endometrial aspiration –preferred method OF
• Endometrial sampling for HPE
Devices like VABRA Aspirator PIPELLE or Karman’s canula no 4- used
Easy to use with adequate sampling, Minimally invasive tech esp in
perimenopausal women
Can detect > 90% of endometrial Cancer
Premenstrual phase –preferred for procedure
• Endometrial curettage & Biopsy –for sampling & HPE –not choice
• Hysteroscopic directed endometrial sampling
• HYSTEROSCOPY –Better evaluation of endometrial lesion

50. AUB –INVESTIGATION
• HYSTEROSCOPY- not in all cases
- Helpful for diagnosing intra-cavitary lesion, type of Myoma
 MRI- not superior to others in overall diagnostic potential
 CERVICAL CYTOLOGY- Performed in all women to exclude
CIN

51. AUB: MANAGEMENT
Depends On Several Factors
 Age
 Severity of bleeding
 Etiology
 Desire of fertility
 Contraceptive needs
 Medical Comorbidities
Treatment Options
• General Measures
• Medical
• Conservative Surgery: Ablation
• Major Surgery: Hysterectomy

52. AUB Management:
General Measures
• Rest
• Treatment of ANAEMIA
• Oral iron
• Blood, PCV
• Lifestyle modification
- Weight reduction
- Diet
- Exercises

53. AUB Management: Definitive treatment
as per etiology: PALM – SURGICAL, COEIN –MEDICAL
• Should be initiated only after the
etiology is established
Endometrial Polyp &
Submucosal Myomas
HYSTEROSCOPIC RESECTION
/HYSTERECTOMY
Medical t/t ineffective
Adenomyosis HORMONES- Oral/ LNG-IUS;
HYSTERECTOMY
Intramural Myoma MEDICAL / SURGICAL
Endometrial Cancer with
Atypical Hyperplasia
HYSTERECTOMY
Hyperplasia without Atypia MEDICAL

54. AUB-COEIN- Management medical
MEDICAL TREATMENT: Hormonal & Non-Hormonal
First line management for
- AUB-C, AUB-O, AUB-E with HMB, IMB, Irregular
bleeding,
- bleeding without STRUCTURAL abnormalities,
to reduce blood loss

55. AUB –coein MANAGEMENT
MEDICAL
management
Non Hormonal:
• Antifibrinolytics: Tranexamic acid
- Well tolerated
- Dose- 1 gm /daily for 3 to 4 days
• PG Synthetase inhibitors: NSAIDS
- Ibuprofen, Naproxen & Mefenamic acid
- 500mg X 3 daily
- can be used in combination with
- Tranexamic acid as FIRST line

56. Progestin only- Oral, Injectable, IUS
- ORAL: Medroxyprogesterone, Norethisterone, Norethindrone
- Injectable: Medroxy Progesterone depot,
- IUS: Progesterone
Estrogen- Progestin combination
- Cycle control excellent.
- Low dose preparation cyclically –safe in nearly all age group for 3-6
cycle
AUB- coein MEDICAl management
HORMONAL

57. Estrogen only- seldom used, in AUB-O,
- young girl with atrophic endometrium
- conjugated equine oestrogen 25mg iv 6 hourly to prime endometrium
(usually not available)
- Ethinyl oestradiol 50 ug for 5days followed by combination O+P therapy
cyclically.
AUB MEDICAL -HORMONAL

58. Others:
• Danazol: antigonadotropin
- AUB- E100-200 mg daily x 3 month continuous
- if recurrent symptoms and those waiting for hysterectomy
• GnRH analogues
- Subtherapeutic dose- reduces blood loss, Therapeutic dose- amenorrhea
- Subcutaneously, intra nasally or im injection 3.6mg monthly
-only when waiting for surgery or to prepare endometrium for Ablative
Procedure
• Ormeloxifene-SERM- 60 mg x2 wkly- 3month –reduces blood loss
• Desmopressin – used in Von-willebrand’s disease & factor 8 deficiency
-
AUB MANAGEMENT: MEDICAL
HORMONAL

59. AUB-COEIN: GENERAL
MANAGEMNET GUIDELINE
• Tranexamic acid- first line therapy. Other non hormonal option- NSAIDs
• LNG-IUS – Desiring Contraception
• COC 2ND LINE therapy
• Cyclical oral Progestin [day 5-26] for 21days T/T of AUB-E
• Cyclical Luteal phase Progestin- orally10-14 days,[ day 15 to 25 ] for
AUB -O
• Ormeloxifene- Saheli: SERM- Where steroids contraindicated
• GnRH agonist with Add-back hormone- last resort
• Endometrial Ablation- if failure to medical or high risk for hysterectomy.-
Endo-Ablation replaced by LNG-IUS
• All AUB pts- HAEMATINICS to prevent ANAEMIA

60. AUB : SURGICAL-management
ABLATION /RESECTION
Conservative surgery: Endometrial Ablation
Indications: AUB-E or AUB-O with
- Failed medical therapy
- Young women with desire to preserve the uterus
- Poor surgical risk for hysterectomy
Contraindications–
- Desire for fertility
- Large uterus >12 wk
- Endometrial Hyperplasia
- Multiple/ large myoma
- Suspected malignancy
- Postmenopausal women
Endometrial ablation surgically destroys the
endometrial lining of uterus with goal to reduce
menstrual flow.

61. AUB Management:
Surgical- Ablation
TECHNIQUES: TWO
• Resectoscopic Endometrial Ablation- 1st
-Hysteroscopy & Anesthesia
• Transcervical Endometrial resection
• Endometrial Laser ablation
• Roller ball Electro coagulation
• Non Resectoscopic Endometrial Ablation -2nd
• Thermal Balloon ablation- most popular technique.
• Microwave Endometrial ablation
• Radio-frequency induced ablation
• Hydro-thermal ablation
• Cryotherapy
• LASER Interstitial therapy
Resectoscope

62. Radiofrequency ablation Plasma energy (ionized argon)
Cryotherapy
Types of Ablation
Resectoscopic techniques
Non Resectoscopic techniques
Transcervical resection
Laser ablation
Roller blade ablation

63. AUB Management : Ablation
Complications
• More with RESECTOSCOPE technique
• Efficacy of endometrial ablation is similar to LNG-IUS
(LNG-IUS has replaced Ablation)
• Complications –
- Uterine Perforation
- Haemorrhage
- Intrauterine scarring& hematometra
- Fluid overload & Pelvic infection
Also known as GLOBAL ABLATION technique, since entire endometrial
cavity is usually destroyed

64. DISADVANTAGES OF
RESECTOSCOPIC TECHNIQUES
 Long learning curve
 Requires general anaesthesia & skilled operator
 Has higher risk of complications
Demerits of Resectoscopic technology led to development
of Non Resectoscopic technique.

65. AUB Management:
Surgery- Hysterectomy
HYSTERECTOMY INDICATIONS:
 Failed Medical Therapy in perimenopausal
women
 Failed Endometrial Ablation
 Complex atypical hyperplasia in older women
 Other pelvic pathology needing concomitant
surgery

66. AUB MANAGEMENT: ACUTE
BLEEDING
• Treatment relies on- Etiology of bleeding, medical problem, fertility
desire & clinical stability. Pregnancy-EXCLUDE
• Medical therapy- Tranexamic acid, oral/ iv- 500- 1000mg [4gm/d]
• Progestin- oral norethisterone, Medroxyprogesterone- high dose
• COC (Combined Oral Contraceptive) cascade
• Conjugated equine estrogen iv 25 mg 4hrly
• Hospitalization – if unstable & serious
• Treat Anaemia

67. AUB : MANAGEMENT IN ADOLESCENT GIRLS

68. AUB : MANAGEMENT IN REPRODUCTIVE WOMEN

69. AUB : MANAGEMENT IN PERIMENOPAUSAL WOMEN