The document is a comprehensive overview of abnormal uterine bleeding (AUB), detailing its importance, classifications, causes, and diagnostic methods. It discusses various treatment options, including medical management, surgical interventions, and specific hormonal therapies, along with guidelines for effective management. Additionally, it emphasizes the significance of lifestyle modifications and the need for thorough examinations to rule out serious conditions like endometrial cancer.

1. Dr.Suresh Babu Chaduvula
Professor
Department of Obstetrics & Gynaecology
GIMSR
Visakhapatnam
Andhra Pradesh, India

2. 1.What is the importance of learning
AUB?
2. What is normal menstruation?
3. What is Abnormal menstruation?
4. FIGO classification
5. Diagnosis
6. ACOG/ RCOG guidelines for the
treatment

3.  1-2 % untreated anovulatory AUB may
develop endometrial cancer.
 Unnecessary curettages.
 Unnecessary Hysterectomies.
 Proper work up and Medical management is
most appropriate in majority.

6.  Any deviation from normal frequency [21-35
days], amount of bleeding [30-80 ml],
duration [3-7 days] in women of reproductive
age.
 Menstrual bleeding that is unpredictable,
abnormally heavy or abnormal in timing.

7.  1. Acute Emergent:
 Bleeding is characterised by a significant loss
that results in hypovolemia or shock
 2. Chronic:
 Menstrual abnormality that occurs slowly
over a period of 6 months.

8.  10-20% of OPD patients

9.  Adolescents – 20 %
 Age between 40-50 years – 50 %
 Reproductive age 30 %

10.  1. Pelvic pathology – PCOS
 2. Pregnancy related conditions – abortions,
ectopic, GTD [ Gestational trophoblastic
diseases]
 3. Coagulation & Haematological problems
 4. Medical problems – Thyroid, Liver, Hepatic
 5. Iatrogenic
 6. Dysfunctional Uterine Bleeding [DUB]

12.  1. Menorrhagia or Heavy Menstrual Bleeding
[HMB]:
 Bleeding more than 80 ml and duration more
than 7 days with normal frequency of 21 -35
days
 2. Metrorrhagia or Irregular Menstrual
Bleeding [IMB]:
 Inter menstrual bleeding
 3. Mid cycle spotting:
 Bleeding occurring before ovulation due to
low levels of estrogen.

13.  4. Meno-metrorrhagia:
 Irregular heavy bleeding
 5. Polymenorrhoea:
 Bleeding occurring less than 21 days may be
due to a luteal phase defect.
 6. Oligomenorrhoea:
 Bleeding occurring beyond 35 days due to
prolonged follicular phase.
 7. Acyclic bleeding:
 Irregularly irregular excessive bleeding

14.  8. Threshold bleeding:
 Bleeding occurring due to low levels of estrogens
due to poor follicles and due to atrophic
endometrium.
 9. Postmenopausal bleeding:
 Bleeding occurring after one year of menopause
from the previous episode of bleeding.
 10. Secondary amenorrhea:
 Cessation of menses of 3 of her normal cycles or
6 months in absence of pregnancy or lactation.

18.  A group of menstrual disorders following the
exclusion of pregnancy or pregnancy related
disorders, systemic disorders, hematological,
pelvic pathologies and iatrogenic causes.
 The term was coined by Sutherland.
 AUB in the absence of palpable pelvic
pathology – Kistner
 AUB devoid of tumour, pregnancy,
inflammation – Novak.

19.  Anovulatory DUB:[80%]
 Metropathia hemorrhagica or Schroeder’s
disease – variable period of amenorrhea
followed by prolonged heavy bleeding due to
cystic glandular hyperplasia.
 Seen in extreme ends of reproductive ages
due to anovulation or luteal phase
insufficiency.

20.  Ovulatory DUB:[20%]
 It is more common in reproductive life.
 Irregular ripening of premenstrual spotting
is due to short luteal phase with insufficient
corpus luteum.
 Irregular shedding of postmenstrual spotting
is due to long luteal phase with persistent
corpus luteum.

30.  1. Detailed History
 2. General examination:
 Anaemia, Goiter
 3. Per Speculum Examination:
 Polyps, growths
 4. Bimanual pelvic examination:
to exclude any palpable pelvic pathology
 5. Rectal examination:
to exclude any palpable pelvic pathology

31.  CBC
 Pap Smear
 Ultrasonography – Pelvis
 Hysteroscopy
 Saline infusion Sonography
 Endometrial Biopsy/ Fractional curettage
 Pregnancy Test
 Hormonal tests – TSH, Serum Prolactin
 Coagulation profile – CT, BT, PPT, aPTT, vW factor
assay, Factor VIII, Ristocetin cofactor assay
 LFT
 [ Preoperative investigations]

33.  Depends upon
 1. Age
 2. Fertility desire
 3. Coexisting morbid conditions

34.  Explanation and reassurance
 Maintain Menstrual calendar
 Life style modification
 Weight reduction
 Treatment of Anaemia with Iron and Folic
acid and rarely blood transfusion
 This type of treatment is applicable to
Puberty AUB

35.  Admission
 IV fluids
 Blood transfusion
 Inj. Premarin or conjugate estrogens 25mg iv
every 4 hrs till bleeding is subsided for 12 to 24
hr.
 Followed by oral conjugate estrogens 1.25 or2.5
mg cyclically with progesterone [ Medroxy
progesterone acetate] 10 mg supplementation
for later 12 days
 If no response in 24 hr D&C +_ Hysteroscopy is
needed.

36.  Medical management:
 It can be Hormonal or Non Hormonal

37.  Mafenamic Acid:
 Prostaglandin synthetase inhibitor
 Tab.500 mg three times a day, started from
1st day of period for 3-5 day
 Useful for puberty AUB and reproductory AUB
 Efficacy – 25% reduction in bleeding

38.  Tranaxamic acid:
 Antifibrinolytic agent
 Tab. 1-2 gm four times a day for 3-5 days
 Useful in Puberty and reproductory AUB
 Efficacy – 50 % reduction in bleeding
 It is also used in IUCD induced menorrhagia

39.  Ethamsylate:
 Increases capillary integrity
 Anti hyaluronidase activity
 Prostaglandin synthesis inhibitor
 Tab.500 mg four times a day
 Started before anticipated menses and
continued for 10 days
 Efficacy – 20 % reduction in bleeding

40.  Cyclical Progestins:
 It has antimitotic and anti growth effect on
endometrium.
 First line treatment for Anovulatory AUB of
perimenopausal age.
 Endometrial biopsy should exclude
Endometrial malignancy.
 19 Nortestosterone derivative like
Norethisterone acetate,
Medroxyprogesterone acetate or Natural
progetsin like Dirogestrone are used.

41.  Tab.Norethisterone 10mg from 16th day to
25th day for 6-9 months – For Anovulatory
DUB
 For Endometrial hyperplasia –it can be
started from 5th day of period till 25th day
for 6-9 months – For Ovulatory DUB
 Micronized progesterone 200 mg per day for
12 days in a cycle for 6-9 month
 Useful also for Premenstrual spotting also.

42.  First line treatment for ovulatory DUB
 It makes endometrium atrophic.
 Estrogen and Progesterone combination pill
used for 4-6 time a day followed by a single
tablet per day for 21 day for 6-9 month
 Efficacy – 50 % reduction in bleeding.

43.  It stabilizes endometrium
 Forms clot formation in capillary bed and
vasoconstriction in spiral arterioles.
 25 mg intravenously four hourly in 12 to 24
hrs till bleeding stops
 Followed by 1.25 to 2.5 mg tab for 21 days
along with Tab. Medroxy progesetrone
acetate 10 mg for last 10 days.

44.  Acts by down regulating pituitary
 Decapeptyl or Luprolide given
subcutaneously or intramuscularly monthly
for 3-6 months.
 Used in women who are at perimenopausal
age, preoperatively, young patient with
medical disorder, anaemia or
immunosuppressoin.
 Estrogen ‘ Add Back’ supplementation is used
to prevent osteoporosis.

45.  Ormeloxifene:
 Weak estrogenic and good antietrogenic
action
 60mg twice daily for 12 weeks.
 60 mg weekly for 3-6 months
 Useful in perimenopausal women with
hormonal deficiency
 Efficacy – 60 % reduction in bleeding.

46.  A Synthetic androgen, antiestrogenic and
antiprogestogenic action.
 Acts by competitive inhibition at
pituitaryreceptor sites decreasing gonadotropins.
 Makes endometrium atrophic.
 Tab. 200 -400 mg per day for 3-6 months
 Useful in Young adolescent women
 Efficacy - 60 % reduction in bleeding
 Side effects - weight gain, acne, menopausal
symptoms, Hirsutism, Jaundice
 Used for short course, before surgery.

47.  Useful in Anovualtory DUB in omen who want
or desire to conceive.
 Tab.50-150 mg from day to 5 day of period
for 3 -6 months.

48.  Atrophies endometrium.
 It will release 20 micrograms of
Levonorgestrel per day used for 5 years.
 Efficacy -80-98 % reduction in bleeding
 20 % will become amenorrheic
 Alternative to surgery
 Other IUDs:
 1. Metraplant IUCD
 2. Azzam IUCD

50.  Two types:
 Conservative Surgical:
 Endometrial Ablation techniques
 Radical treatment:
 Myomectomy
 Hyterectomy

51.  Minimally invasive surgical technique to treat
heavy menstrual bleeding.
 Indication:
 1. Failure of medical treatment
 2. Women who have completed child bearing
 3. Women who are not candidates for surgery

52.  Hysteroscopic:
TCRE – Tran Cervical Resection of
Endometrium
Roller Ball coagulation
LASER ablation
 Non Hysteroscopic:
 Thermal balloon therapy [ Therma choice]
 Microwave endometrial ablation
 Heated free fluid – HydroThemAblator [HTA]
 Cryoablation
 Radiofrequency ablation

55.  It should be last resort
 Definitive treatment
 High rate of patient satisfaction
 Not a choice in young reproductive age group
women.

56.  Perimenopausal age [ >40 yrs]
 Women who have completed child bearing
 Failed medical treatment, medical treatment
contraindicated, not tolerated.
 Failed ablative therapy
 Endometrial hyperplasia with atypia.
 Other pelvic pathology that needs treatment

57.  1. NDVH - Non Descent Vaginal hysterectomy
 2. LAVH – Laparoscopic assisted vaginal
hysterectomy
 3. TLH – Total laparoscopic hysterectomy
 4. TAH &BO – Total abdominal hysterectomy
and bilateral salpingo-oopherectomy
 5. Subtotal Hysterectomy -rarely

58.  Each completely soaked pad or Tampon holds
about 5-15 ml of blood.
 Normal age of Menarche starts from 9 yrs.
 Menopause starts from 48 yrs onwards
 Reproductive age means from age of
menarche to menopause. [ 15 to 49 yrs]
 Early menopause starts from 40 yrs.
 Adolescent is between 10 and 19 yrs
 Puberty means starts from 8-14 yrs
 Youth – 15 to 24 years
 Young - 10-24 yrs

59.  Local growth factors play a very important
role in regeneration of endometrium.
 They are
 1. Epidermal Growth Factor
 2. Insulin like Growth Factor I and II
 3. Platelet Derived growth Factor
 4. Transforming Growth factor Alfa and
Beta
 Analogue of thee factor may be a ne
therapeutic tool for DUB treatment

60. Thank You All