It's from Williams 26th latest edition

1. Abnormal Uterine bleeding
Dr Abenezer G.(R-II)
Moderator: Dr Amenu(Urogynecology and pelvic reconstructive
surgeon)
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2. OUTLINE
• DEFINITIONS
• ETIOLOGY
• PATHOPHYSIOLOGY
• DIAGNOSIS
• ENDOMETRIAL ABNORMALITIES
• STRUCTURAL ABNORMALITIES
• EXTERNAL SOURCES and SYSTEMIC CAUSES
• OVULATORY DISORDERS
• PRIMARY ENDOMETRIAL DYSFUNCTION
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3. Introduction
• Menses that deviates from
normal cycle.
• Four qualities- volume, duration,
frequency, and regularity.
• Can be Acute or Chronic.
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4. QUALITY NORMAL ABNORMAL
Volume 5- 80 ml Light (<5 ml) Heavy (>80 ml)
Duration </=8d Prolonged (>8 d)
Frequency 24- 38 d Frequent (< 24 d) Infrequent
(>38 d) ; Amenorrhea (>90 d)
Regularity </= 7- 9d Irregular >/= 10 d
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5. Terminology
•Reproductive years.
• Menstrual - Heavy menstrual bleeding (HMB),
- Prolonged menstrual bleeding.
- Infrequent bleeding
• Non-menstrual - Intermenstrual bleeding;postcoital bleeding
- Pre- and postmemtrual spotting
- Breakthrough bleeding & unscheduled bleeding
- Withdrawal bleeding
• Non reproductive yrs - Precocious mensturation
- Postmenopausal bleeding
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6. Objective Ass’t of bleeding
• Sanitary napkins
/spectrophotometrically
• Hbg and Hct evaluation.
• Pictorial blood assessment chart
(PBAC).
• Menstrual Cup
• Menstrual calendars(Clue and
iPeriod apps)
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7. Incidence
• True rates varies due to ass’t & Definition.
• Commonly cited; 10 to 30 percent.
• 15 to 20 percent of pregnancies
• Directly releated with age.
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8. ETIOLOGY
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9. PATHOPHYSIOLOGY
• Progesterone plays a critical role.
• Two progesterone receptors (PR) are found in the endometrium, PRA and
PRB.
• Mzm of bleeding in progestrone withdrawal
 Raises cytokine-> influx of leukocytes,-> lytic enzymes(MMP)->
break down stroma and vascular architecture of functionalis layer.
 Raises cyclooxygenase-2-> prostaglandin F2a (PGF2a) rise -> intense
spiral arteriole constriction.
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10. • Hemostasis and cessation of menstruation depend on
coagulation system.
 Platelets aggregation
 Endometrial arterioles constriction.
• During menses, augmented endometrial glucocorticoid production
helps to control blood loss.
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11. DIAGNOSIS
• History & Physical Examination
• Laboratory Evaluation - Hematologic Testing
- B-human Chorionic Gonadotropin
- Cervicitis evaluation(cytology/biopsy)
- Endometrial evaluation(Biopsy)
• Imaging: SonographyTransvaginal Sonography , Saline-Infusion
Sonography, Other Sonographic Techniques
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12. Hx
• Age of menarche or menopause
• Menstrual bleeding patterns
• Timing & Severity of bleedings(clots)
• Medical conditions
• Surgical history
• Use of medications
• Sign and symptoms of possible hemostatic disorders
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13. P/E
• General P/E
• Pelvic examinations -External
- Speculum with pap test.
- Bimanual
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14. lab.
• Pregnancy tests
• CBC- Anemia,
- Degree of blood loss,
- Platelet count extremes
• TFT
• Cervicitis Evaluation
Histo-pathology
Cervical Cytology or Biopsy
Endometrial Biopsy- Indications
- Sampling methods
Imaging
• SIS
• TVS
• MRI
• Hystrescopy
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15. Cervical/Endometrial Biopsy
• Pap testing & abnormal cytologic testing.
• Endometrial pathology entities includes focal lesion and
diffuse conditions.
• Woman older than 45 years with AUB.
• Sanpling methods: Dilation and curettage (D & C )
- Office techniques(metal & plastic )
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17. • Pipelle device- Insufficient or scant sample.
- Inability to access cavity from stenosis.
- Imperfect negative predictive value.
- Greater False-negative results with focal pathology.
• Sonography/hysteroscopy used to replace or complement it.
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18. Transvaginal Sonography
• Becomes primary diagnostic modality tool.
• Offers anatomic informations about myometrium, uterine
surfaces, and adnexa.
• Most helpful and sensitive to define endometrial thickness.
• Obesity and other uterine pathology limit visualization.
• Poor in differentiating global & focal lesion, but SIS or hysteroscopy.
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19. • Postmenopausal women without bleeding, > 11 mm.
• Sonographic feautures of Malignancy
- Intermingled hypo- and hyperechoic areas.
- Irregular endometrial-myometrial junction.
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20. SIS/Sonohysterography/Hysterosonography
• Allows identification of common masses associated with AUB.
• Includes polyps, submucous leiomyomas, and intracavitary
blood clots.
• Many focal lesions needs biopsy or excision due to malignant
potential.
• Best performed in proliferative phase of the menstrual cycle.
• Contraindications include pregnancy, active pelvic infection,
or stenosis.
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21. Other Sonographic Techniques
• Doppler technology is applied to assess vascularity.
(feeding vessel --> endometrial polyp).
(multiple irregularly branching vessels--> malignant.
• 3-D sonography and 3-D SIS are most helpful to clarify focal lesions.
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22. Hysteroscopy
• Small-diameter endoscope is inserted into cavity and distended with
saline or another medium for visualization.
• Used to take hysteroscopic biopsy, resection & detection of focal
lesions.
• Accurate for identifying endometrial cancer, but not for hyperplasia
or intraepithelial neoplasia.
• Can be combined with EMB or endometrial curettage.
• Limitation include cervical stenosis, heavy bleeding
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23. Summary of Diagnostic Procedures
• No clear sequence of EMB, TVS, SIS, and hysteroscopy
• TVS is a first step for several reasons.
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24. ENDOMETRIAL ABNORMALITIES
• Include Hyperplasia, lEN ,Metaplasia and Structural abnormalities
like Uterine Enlargement ,polyp, Arteriovenous Malformation.
• Can also be External source(IUD, Hormonal Therapy, Anticoagulants
and Systemic causes( Kidney, Liver, and Thyroid Disease, Coagulopathy
(Von Willebrand Disease))
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27. STRUCTURAL ABNORMALITIES
• Include endometrial and endocervical structural abnormalities.
• Uterine Enlargement include Myomas, adenomyosis, polyp.
• Polyp: soft, fleshy IU growths are composed of endometrial glands,
fibrous stroma, and surface epithelium.
• Intact polyps may be single or multiple, can also be sessile or
pedunculated.
• Prevalence in general population 9 percent, in those with AUB, rates
range from 10 to 30 percent.
• Risk factors include advanced age, obesity, and tamoxifen use.
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28. • Management is directed by symptoms and malignancy risk.
• Risks for transformation are postmenopausal status, age older than
60, and abnormal bleeding, larger polyp (> 1.5 cm), tamoxifen use,
diabetes, and obesity.
• Operative hysteroscopic polypectomy is most effective.
• Conservative managment is indicated for asymptomatic women
and no malignant risk factors.
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29. Endocervical Polyp
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30. Arteriovenous Malformation
• Contain a mixture of arterial, venous, and small capillary-like channels
with fistulous connections.
• May be congenital or acquired(vessels that develop after myometrial
or intracavitary uterine surgery).
• Mostly found on uterine corpus, but may also be in cervix.
• Pt can be presented with HMB and perhaps intermenstrual bleeding
triggered by miscarriage, curettage, or intracavitary uterine surgery.
• Rx: hysterectomy, Arterial embolization.
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31. EXTERNAL SOURCES
• Include IUD, Hormonal Therapy and Anticoagulants.
• Cu-IUD (ParaGard), alone cause HMB or intermenstrual bleeding, but
concurrent pregnancy, infection, or malpositioned device.
Rx: Empiric trial of NSAIDs, Tranexamic acid.
• Intermenstrual bleeding typically occurs with COC use during early
use, and reassurance alone is suitable.
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32. • Anticoagulants includes vitamin K antagonists(warfarin & heparin)
and direct oral anticoagulants(DOACs) include apixaban, rivaroxaban,
dabigatran, and edoxaban.
• Rx: If anticoagulant levels lie in therapeutic range, LNG-IUS, DMPA,
or an oral daily progestin.
• TXA is contraindicated due to risks of venous thromboembolism.
• Foley balloon is inserted for acute severe HMB in urgent surgery.
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33. SYSTEMIC CAUSES
• Include disease of Kidney, Liver, and Thyroid Disease.
• Other causes include Coagulopathy, Von Willebrand Disease.
• COCs are contraindicated in patients with renal disease
having HTN/SLE.
• NSAIDs cause renal artery vasoconstriction to diminish GFR.
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34. OVULATORY DISORDERS(AUB-O)
• Are at risk for developing endometrial hyperplasia, EIN, or
endometrial cancer.
• Characterized by several months of amenorrhea followed by HMB.
• Rx directed as acute or chronic(progestrone: requiring contraception
or not)
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35. General Principles of Management
• Address the underline cause
• Rule out unsuspected pregnancies
• Treat complication
• Treat concomitant conditions
 Acute Hemorrhage Management
 Chronic mediacl managment: LNG-IUS, COC, TXA, NSAID
& Others
 Uterine Procedures

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37. Uterine Procedures
• Indications: unsuccessful or associated significant side effects.
• Directed to destroy endometrium or remove uterus.
• Include D & C, Endometrial resection/ablation & hysterectomy.
• After ablation, 70 to 80% significantly decreased flow, and
15 to 35 percent of these develop amenorrhea.
• About 25% required additional surgery by 5 years after ablation
due to endometrial regeneration.
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Endometrial Ablation

39. • Distorted cavity anatomy.
• Intracavitary synechiae.
• Cyclic pain.
• Postablation tubal sterilization syndrome (PATSS).
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Cont...long-term problems

40. Reference
• Ti Linde 13th edition.
• Gynecology 4th edition
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41. Thank you
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