This document discusses abnormal uterine bleeding (AUB), including definitions, prevalence, assessment, causes, and management. Some key points: - AUB is irregular bleeding that affects 10-30% of reproductive-aged women. It has many potential causes and can seriously impact quality of life. - Assessment involves history, physical exam, blood tests, imaging like ultrasound and potentially biopsy. The Pictorial Blood Assessment Chart scores bleeding to indicate if it is heavy. - Causes vary by age but include issues like fibroids, polyps, hormonal imbalances, and cancer. The 2018 FIGO classification system standardized terminology. - Initial treatment is usually medical like hormones, NSAIDs, or tran

1. Dr. Sunita Chandra

3. ABNORMAL UTERINE BLEEDING (AUB)
WHAT’S NEW ?

5. DEFINITION
Abnormal uterine bleeding (AUB) is a broad term that describes
irregularities in the menstrual cycle involving frequency, regularity,
duration, and volume of flow outside of pregnancy.
A normal menstrual cycle has a frequency of 24 to 38 days, lasts 5
to 9 days, with 5 to 80 milliliters of blood loss.
 Variations in any of these 4 parameters constitute abnormal uterine
bleeding.
 Affects 10-30% of reproductive aged women
 Upto 50% of perimenopausal women
Higher incidence occurring around menarche and menopause

6. HMB,defined by National Institute for Health and Cinical Excellence
as
“excessive menstrual blood loss ,which interferes with a woman’s
physical,social,emotional and/or material quality of life”

7. HOW COMMON IS ABNORMAL UTERINE BLEEDING?
Abnormal uterine bleeding is not always reported by women
experiencing symptoms. Because of this, 3% to 35% of
women worldwide may have abnormal uterine bleeding. It is
estimated that about 17.9 % of women in the India are
impacted by abnormal uterine bleeding.
PREVALENCE

8. RESEARCH ARTICLE: OBSERVATIONAL STUDY
PREVALENCE of abnormal uterine bleeding according to new International
Federation of Gynecology and Obstetrics classification in Chinese women of
reproductive age
A cross-sectional study
Sun, Yu MSca; Wang, Yuzhu MScb; Mao, Lele PhDc; Wen, Jiaying MScd; Bai, Wenpei MDa,*
Volume 97 - Issue 31 - p e11457 August 2018Conclusion:
AUB is a common symptom of gynecological conditions, which seriously affects the
quality of life of women. Currently, there is no report on the study of the etiology of a
new classification of gynecological conditions in China. This study has found that AUB-
O is the most common cause of AUB in 15- to 55-year-old Chinese women. The most
frequent bleeding pattern is a changing menstrual cycle, sometimes accompanied by
an increase in the volume of flow or prolonged periods. AUB-P is the most common
cause of structural changes, and the most common manifestation is a prolonged
period followed by an increase in volume. The prevalence rates of AUB-L and AUB-A
rank third and fourth, respectively. Their major bleeding patterns are increased by the
amount of HMB and the extension of period, respectively, and they are associated with
age, with the highest prevalence between 40 and 49 years.

9. Barriers to seeking consultation for abnormal uterine bleeding:
systematic review of qualitative research
Claire Henry, Alec Ekeroma & Sara Filoche
BMC Women's Health volume 20, Article number: 123 12 June 2020
Conclusions
For 20 years women have consistently reported poor experiences in accessing
care for AUB. The findings from our review indicate that drivers to impeding
access are multiple; therefore any approaches to improve access will need to
be multi-level – from comprising local sociocultural considerations to improved
GP training.

10. ASSESSMENT
Patient perception
 Hb conc. <12gm%
No of pads or tampons used ( >1pad / 3 hr)
Pictorial blood assessment chart (PBAC)

11. PICTORIAL BLOOD ASSESSMENT CHART (PBAC)
(Score > 100 points indicates HMB)

12. CHILDHOOD
• Vagina rather than uterus is
the more common cause
1. Vulvovaginitis
2.Neoplastic
3.Trauma
Investigation : Examination
under anesthesia -Vaginoscopy
1.Anovulation
2.Coagulation defects
3.Thyroid disorder
ADOLESCENCE
CAUSES

13.  Reproductive age
1. HMB – freq. problem
2. Bleeding related to pregnancy
3. STD’s are on the rise – chlamydia T- PID
4. Leiomyomas & endometrial polyp
 Peri-menopause
1. Anovulatory bleeding
2. Benign & Malignant neoplasms on the rise

14. MENOPAUSE
Atrophy of endometrium & vagina
Endometrial hyperplasia
Cervical neoplasms
Estrogen replacement

15. COMMON DIFFERENTIAL BY AGE
13-18 19-39 40- Menopause

16. 16

17. FIGO CLASSIFICATION SYSTEM FOR CAUSES OF ABNORMAL UTERINE BLEEDING
IN THE REPRODUCTIVE YEARS
RECENT UPDATES 2018
Structural abnormality
No structuralabnormality
Polyp
Adenomyosis
Leiomyoma
Malignancy &
Hyperplasia
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not Yet Classified

18. FIGO LEIOMYOMA SUB - CLASSIFICATION SYSTEM

19. NEW FIGO DEFINITIONS 2018

20. OTHER CHANGES IN THE NEW 2018 CLASSIFICATION
L - 3 is submucous, 4 is 100% IM
M - Malignancy & atypical endo.hyperplasia(EIN)
C - Coagulopathy (drug induced not included)
O - Ovulatory disorders - anovulation
E - Endometrial causes - ovulatory AUB, endometritis
I - Iatrogenic + drug induced, sec to anticoagulants
N - Not otherwise classified - AVMs,LS isthmocoele,myometrial
hyperplasia and endometritis

21. NOTATION: EACH CASE HAS 1 IDENTIFIED ABNORMALITY

22. NOTATION: >1 POSITIVE CATEGORY

23. ACC.TO FIGO CLASSIFICATION…
 Abnormal Uterine Bleeding (AUB): quantity, regularity and/or timing.
 Acute AUB: episode of heavy bleeding that is of sufficient amount to
require immediate intervention to prevent further blood loss.
 Chronic AUB: AUB present for most of previous 6 months. Acute
AUB can be spontaneous or in context of chronic AUB.

24. DIAGNOSIS
 History –menstrual history,obs his,wt loss,pain,discharge,bladder and bowel
symp,current med and social history
 Physical examination
 Complete blood count with GBP
Acute – check Hb PCV
Chronic -erythocyte indices
Profound anaemia ? Cause failure to improve
Iron indices :-
 S.Ferritin
 S.iron
 Total Fe binding capacity

25. DIAGNOSIS
Cytological exam- Pap smear screening
Endo cervical curettage /brush
Colposcopy
Endometrial biopsy
Can identify – endometrial hyperplasia & neoplasia

26. ENDOMETRIAL SAMPLING IS NECESSARY FOR
Age >45
Obesity
PCOS
Failure of treatment
Persistent bleeding

27. IMAGING
T V S
HYSTEROSCOPY
MRI
SONOHYSTEROGRAPHY(Tvs with intrauterine contrast)

28. TRANS VAGINAL SONOGRAPHY
Gives valuable information about - Endometrium &
Myometrium

29. TRANSVAGINAL COLOR DOPPLER SONOGRAPHY ( TV-CDS)
• Endometrial polyps have
one arterial feeding vessel.
• Submucous fibroids have
several vessels arising
from inner myometrium

30. TIPS FOR ENDOMETRIAL PATH. ON USG
 Punctate cystic areas within endometrium  polyp
 Hypoechoeic masses that distort the endo. & originate from inner layer
of myometrium  sub mucous fibroid
 Indicative of malignancy
 -Hypo and hyperechoic areas within the endometrium
 -Irregular endomyo. junction interface
 -Cavity with fluid collection

31. SALINE INFUSION SONOGRAPHY (SIS)
Useful in evaluating:
Myometrium
Endometrium
Endometrial cavity (polyps & sub-mucous fibroids)

32. CONTRAINDICATION FOR SIS
Pregnancy or suspected pregnancy
Pelvic infection
Unexplained pelvic tenderness (ACOG 2008)

33. PROCEDURE OF SIS
Small catheter threaded thro. cx os into endometrial cavity
Differentiates lesions as being
- endometrial
- sub mucous
-intra mural
Not useful in diffuse lesions like hyperplasia & cancer

34. OFFICE HYSTEROSCOPY (DIA 3.5MM)
Limitations
In endometrial hyperplasia (curettage required)
Cx stenosis limits introduction
Heavy bleeding limits proper examination
Very rarely perforation & infection seen

35. In summary TVS is a logical first step & subsequent
evaluation requires individualization

36. ESTABLISHING CAUSE
INSTITUTING APPROPRIATE THERAPY
MANAGEMENT

37. 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.

38. MEDICAL TREATMENT
⦿ Hormones
› Es+Pr (COCP)
› Progestogens
› LNG IUS
› GnRHa
› Estrogen
⦿ Progesterone Receptor
Modulator
› Ulipristal acetate,Mifepristone
⦿ ANTIFIBRINOLYTICS
› TRANEXAMIC ACID (TA)
⦿ NSAIDs
› Mefenamic acid (MA)
› Naproxen, Ibuprofen, Aspirin
BMJ. 2007 May 26; 334(7603): 1110–1111.
RCOG. National evidence-based clinical guidelines. The initial
management of menorrhagia London: RCOG, 1998

39. 39
Suggested treatment options for abnormal uterine
bleeding based on PALM etiology

40. SUGGESTED TREATMENT OPTIONS FOR ABNORMAL
UTERINE BLEEDING BASED ON COEIN ETIOLOGY
40
COEIN
• LNG-IUS or Tranexamic acid, NSAIDS followed
by COCs or Cyclic oral progestins
• Medical / Sx treatment failed or contraindicated:
GnRH with add back hormone therapy
• When steroidal and other options are
unsuitable: Ormeloxifene

41. TREATMENTS FOR WOMEN WITH NO IDENTIFIED PATHOLOGY,
FIBROIDS LESS THAN 3 CM IN DIAMETER, OR SUSPECTED OR
DIAGNOSED ADENOMYOSIS
41
 Consider an LNG-IUS as the first treatment for AUB in women [2018]
 If a woman with HMB declines an LNG-IUS or it is not suitable, consider the
following pharmacological treatments:
 Non-hormonal: Tranexamic acid NSAIDs (non-steroidal anti-inflammatory drugs)
 Hormonal: combined hormonal contraception OR cyclical oral
progestogens. [2018]

42. NON-STEROIDAL INFLAMMATORY DRUGS
Medscape General Medicine.199468;1(1).
 Ideal NSAID would be a selective inhibitor of vasodilating PGs, permitting the
vasoconstrictor PGs to inhibit the excessive menstrual blood loss
 Such a selective inhibitor is not yet available
 NSAIDs reduce blood loss by 25–30%, but not all women respond similarly
 Commonly used are mefenamic acid and naproxen but are less effective than
tranexamic acid
 NSAIDS have shown only minimal effect in anovulatory menorrhagia
 Side-effects include minor gastrointestinal disturbance and headaches
• Non-Invasive Management of Gynecologic Disorders. pp: 65-66

43. TRANEXAMIC ACID
J. Obstet. Gynaecol. Res. Vol. 35, No. 4: 746–752, Aug4u9st2009.
 Reduces blood loss by 50%
 However, many women remain menorrhagic and many are non-
compliant due to daily dosing
 Large doses of tranexamic acid are required
 Incidence of GI side-effects, intermenstrual bleeding are relatively
high
 Risk of thrombogenic disorders is a concern
Clinical Gynecologic Endocrinology and Infertility. pp: 564–565.

44. GNRH AGONISTS
Takeuchi H et al5.22000
 Utility should really be for short-term use
 Particularly useful in the treatment of leiomyoma, which can
reduce considerably in size when ovarian hormone levels are
suppressed
 May be used prior to surgical intervention in women with
fibroids, or for those in whom surgery is not suitable or desirable
 Studies have demonstrated excellent efficacy, with an
amenorrhea rate of up to 90% with GnRH agonist use
 Danazol is not frequently used because of its androgenic and
long-term lipid profile side-effects

45. ORAL CONTRACEPTIVES
 Action is probably mediated through endometrial atrophy. OCPs suppress pituitary
gonadotropin release, thus inhibiting ovulation
 High doses of estrogen are associated with an increased risk of
thromboembolism
 These should be avoided in women with thrombosis or a family history of idiopathic
venous thromboembolism
 The most common side-effects include weight gain, abdominal discomfort,
and mid-cycle breakthrough bleeding
 Not suitable in patients desiring pregnancy
Clinical Gynecologic Endocrinology and Infertility. pp: 560–561.

46. PROGESTIN THERAPY
 Most commonly used hormonal therapy given during luteal
phase.
 Norethisterone is the most commonly used oral
progestogen in the treatment of HMB
 “ Progestins modulate the effect of estrogen on target cells
and metabolism of estrogen, the endometrium is maintained
in a state of antimitosis and antigrowth. “

47. CLASSIFICATION OF PROGESTINS
(SYNTHETIC DERIVATIVES OF PROGESTERONE)

48. Norethisterone was more
effective and better
tolerated compared to
COC
N= 60 young girls from
age of menarche to 19
years with menorrhagia
Dr Shashwat
Jani.
NORETHISTERONE VS. COC PILLS IN PUBERTY
MENORRHAGIA
48
In+lof Basic & Clinical Pharmacology 2012 ;1 (3):191-195

49. 49
Study says, Norethisterone, begun on or before cycle day 12, is
superior for women who desire to avoid breakthrough bleeding and
maintain fertility when compared to OCPs

50. 1.RAPID CONTROL OF BLOOD LOSS
• Hormonal prodrugs (prohormones) exert their specific effects only after biotransformation
• Transformation is a matter of approximately half an hour
• Thus desired action will be delayed in the process of Bio-transformation 50
Norethisterone acetate (NETA) is a prodrug where as
Norethisterone (NET) is pharmacological active drug

51. 51
Norethisterone Tmax is 1.17 Hrs, Norethisterone Acetate Tmax is 2 Hrs
• Tmax is the time required to reach max concentration in plasma
• Onset of action is dependent on Tmax, lesser the Tmax faster the action
Jurgen Hammerstein et. Al., Prodrug: Advantage or disadvantage? Am J Obstet Gynecol 1990;163:2198-203

52. 52
BREAKTHROUGH BLEEDING RISK IS MUCH MORE WITH NORETHISTERONE
ACETATE COMPARED TO PLAIN NORETHISTERONE

53. Norethisterone Norethisterone
Acetate
Rapid Control of Blood
Loss
1.17 Hrs2 2 Hrs2
Reduced risk of
breakthrough bleeding Minimal3 68% (3 Times
Higher risk) 3
Predictable Withdrawal
Bleeding
2-4 Days1 3-7 Days4
1. Prescribing Information - Norethisterone
2. Jurgen Hammerstein et. Al., Prodrug: Advantage or disadvantage? Am J Obstet Gynecol 1990;163:2198-203
3. O. M. Delale et. Al., Norethindrone Acetate in the Medical Management of Adenomyosis. Pharmaceuticals 2012, 5, 1120-1127
4. Prescribing Information – Norethisterone Acetate
NORETHISTERONE VS NORETHISTERONE ACETATE

54. Norethisterone Medroxyprogesterone
Acetate
Rapid Control of Blood Loss 1.17 Hrs2 2 Hrs –4 Hrs5
Reduced risk of breakthrough
bleeding Minimal3 Common5
Predictable Withdrawal
Bleeding 2-4 Days1 3-7 Days5
1. Prescribing Information - Norethisterone
2. Jurgen Hammerstein et. Al., Prodrug: Advantage or disadvantage? Am J Obstet Gynecol 1990;163:2198-203
3. O. M. Delale et. Al., Norethindrone Acetate in the Medical Management of Adenomyosis. Pharmaceuticals 2012, 5, 1120-1127
4. Prescribing Information – Norethisterone Acetate
5. Prescribing Information – Medroxyprogesterone Acetate
NORETHISTERONE VS MEDROXYPROGESTERONE ACETATE

55. Progestin
Potency
Experimental
Norethisterone 1
Medroxyprogesterone Acetate 0.09
Norethisterone is 11 times more potent than Medroxyprogesterone Acetate
COMPARISON OF NORETHISTERONE POTENCIES OVER MPA (ORAL DOSES)

56. MPA HAS DETRIMENTAL EFFECTS ON BONE
 Medroxyprogesterone suppresses ovarian production of estrogen.
 Estrogen is protective against bone loss, and can lead to deterioration of
bone mass
 MPA also can decrease osteoblast differentiation by occupying the
glucocorticoid receptor
 While MPA has been linked to osteoporosis, other progestins, including
nortestosterone and norethindrone, may have a positive effect on bone mass
https://www.uspharmacist.com/article/drug-induced-osteoporosis

57. Tr
SUMMARY OF MEDICAL TREATMENTS FOR ABNORMAL UTERINE
BLEEDING
Treatment Drug & Regimen Efficacy Contraception

58. SURGICAL CARE
Most cases of abnormal uterine bleeding (AUB) can be treated medically. Surgical
measures are reserved for situations when medical therapy has failed or is contraindicated.
Dilation and curettage
Hysterectomy
Endometrial ablation

59. UTERINE ARTERY EMBOLISM
DUB with excessive loss
Coagulopathic disorders
Uterine fibroid

60. ENDOMETRIAL DESTRUCTIVE PROCEDURES
( NOT SO WIDELY USED NOW)
Patient with menorrhagia within 5yrs of conservative procedures
land up with an hysterectomy
1/3rd of these are anatomically normal uterus
After ablation 70-80%  flow - 20% amen.
A word of caution – not advocated in high risk for endo .ca

61. ABNORMAL UTERINE BLEEDING AND COVID-19
FIGO MDC SARS-CoV-2 Response
Nonpregnant Women in the Reproductive Years with Abnormal Uterine Bleeding
 During this time, visits to health care providers (HCPs), clinics and hospitals should be minimized to preserve resources for
the pandemic and to limit dissemination of this coronavirus (SARS-CoV-2) and spread of COVID-19 disease.
 There is no reason to think that this SARS-CoV-2 has any impact on abnormal uterine bleeding (AUB) of any type including
the symptoms of heavy and/or irregular menstrual bleeding.
 All women, but especially those with the symptom of heavy menstrual bleeding (HMB) are at risk for iron deficiency and iron
deficiency anemia and should ensure at the very least that dietary iron intake is adequate and supplemented with oral iron if
appropriate. To minimize nausea and, perhaps increase absorption alternate day dosing of 60-130 mg of elemental iron may
be the most useful.
 Those with acute HMB with passage of clots should contact an appropriate HCP urgently for instructions.
 Those with the recurrent symptom of cyclic (q 24-38 days) HMB. This would include FIGO System 2 (PALM-COEIN) causes
such as AUB-A, Lsm, -C and -E that could potentially be alleviated (unless there are contraindications) by the use of
appropriate doses of tranexamic acid or multidose progestins such as continuous medroxyprogesterone acetate, preferably
under remote guidance from an appropriate HCP.

62. SUMMARY
 Abnormal uterine bleeding is common among women worldwide
 A detailed history is an important first step in evaluating a woman who
presents with AUB, familiar with the normal pattern of menstruation,
including frequency, regularity, duration, and volume of flow
 PALM COEIN is a useful acronym for common etiologies of AUB, with
PALM representing structural causes and COEIN representing non-
structural
 Treatment is based on etiology, desire for fertility, and medical
comorbidities
 Norethisterone is the most commonly used oral progestogen in the
treatment of HMB with rapid styptic action and minimal chances of
breakthrough bleeding

63. APPROACH CONSIDERATIONS
In July 2013, The American College of Obstetricians and Gynecologists issued updated guidelines for the
treatment of abnormal uterine bleeding caused by ovulatory dysfunction. They included the following
recommendations :
Surgery should be considered only in patients in whom medical treatment has failed, cannot be tolerated,
or is contraindicated
Endometrial ablation is not acceptable as a primary therapy, because the procedure can hamper the later
use of other common methods for monitoring the endometrium
Regardless of patient age, progestin therapy with the levonorgestrel intrauterine device should be
considered; contraceptives containing a combination of estrogen and progesterone also provide effective
treatment

64. Low-dose combination hormonal contraceptive therapy (20-35 μg ethinyl estradiol) is the
mainstay of treatment for adolescents up to age 18 years
Either low-dose combination hormonal contraceptive treatment or progestin therapy is generally
effective in women aged 19-39 years; high-dose estrogen therapy may benefit patients with an
extremely heavy menstrual flow or hemodynamic instability
Medical treatment for women aged 40 years or older can, prior to menopause, consist of cyclic
progestin therapy, low-dose oral contraceptive pills, the levonorgestrel intrauterine device, or
cyclic hormone therapy
Contd….

65. If medical therapy fails, patients should undergo further testing (eg, imaging or
hysteroscopy)
An in-office endometrial biopsy is preferable to dilation and curettage (D&C)
when examining a patient for endometrial hyperplasia or cancer
If medical therapy fails in a woman in whom childbearing is complete,
hysterectomy without cervical preservation may be considered
Contd….