This document discusses abnormal uterine bleeding (AUB), which refers to menstrual bleeding that differs in quantity, duration, or schedule from normal. AUB is a common gynecological complaint that can be caused by structural issues like fibroids or polyps, hormonal imbalances, or systemic diseases. The document outlines the evaluation, differential diagnosis, and treatment options for AUB, emphasizing history, physical exam, diagnostic testing, and addressing the underlying cause. Treatment involves medication, procedures, or surgery depending on the identified etiology.

1. Abnormal Uterine
Bleeding
Dr.Bülent Urman

2. Definition and Prevalence
• Abnormal uterine bleeding (AUB) refers to
menstrual bleeding of abnormal quantity, duration,
or schedule.
• A common gynecological complaint (1/3 of visits)
• A United States population-based survey of women
ages 18 to 50 years reported an annual prevalence
rate of 53 per 1000 women
• Caused by a wide variety of local and systemic
diseases or related to medications

3. Terminology
• Structural causes
• Hormonal causes-Dysfunctional uterine bleeding
• Systemic diseases that cause abnormal uterine
bleeding

4. Terminology
• A revised terminology system for abnormal uterine
bleeding (AUB) in non-gravid reproductive age
women was introduced in 2011 by the
International Federation of Gynecology and
Obstetrics (FIGO)
• Goal was to avoid poorly defined or confusing
terms used previously (eg, menorrhagia,
menometrorrhagia, oligomenorrhea)

6. Normal Menses
• Frequency: every 21 to 35 days
• Occurs at fairly regular intervals
• Volume of blood ≤80 mL
• Volume of blood is difficult to measure. In clinical
practice, heavy menses are generally defined as:
• soaking a pad or tampon more than every two hours, or
• a volume of bleeding that interferes with daily activities (eg,
wakes patient from sleep, stains clothing or sheets).
• Duration is 2-5 days
• Normal menstrual bleeding is a estrogen-
progesterone withdrawal bleeding

7. Patterns of Abnormal Bleeding
• Hypermenorrhea (menorrhagia): Heavy/prolonged
bleeding
• Hypomenorrhea: light menstrual flow
• Obstruction: cervical or hymenal stenosis
• Oral contraceptives, LNG-IUD
• Uterine synechia (Asherman’s syndrome)
• Polymenorrhea: Periods that occur less than 21
days apart
• Oligomenorrhea: Periods that occur more than 35
days apart

8. Patterns of Abnormal Bleeding
• Metrorrhagia (intermenstrual bleeding): bleeding
that occurs at any time between menstrual periods
• Menometrorrhagia: bleeding that occurs at
irregular intervals. Amount and duration may vary
• Contact bleeding (Postcoital bleeding)

9. Differential diagnosis of AUB

11. Initial Evaluation-History
• Gynecologic and obstetric history
• Menstrual history, LMP
• Sexual intercourse? Trauma? (Bleeding after trauma
usually suggests vaginal or cervical etiology)
• Contraceptive use (IUD, OCP, progestin-only pill use)
• Other medical history
• Systemic diseases (especially endocrine, liver, renal, and
hematological diseases)
• Family history (esp. bleeding disorders)
• Medication use (hormonal, drugs that ↑PRL,
anticoagulants)
• Excessive exercise, eating disorders

12. Initial Evaluation-History
• Is the patient pregnant?
• All patients with AUB should have pregnancy testing
• It should also be performed in women who report no
sexual activity and in those who report use of
contraception.
• Is the patient premenarchal or postmenopausal?
• The differential diagnosis of AUB for reproductive-age
women differs from that of premenarchal or
postmenopausal patients

13. Initial Evaluation-Symptoms
• Are there any associated symptoms?
• Lower abdominal pain, fever, and/or vaginal discharge
could indicate infection (pelvic inflammatory disease
[PID], endometritis)
• Dysmenorrhea, dyspareunia or infertility suggest
endometriosis and possible adenomyosis.
• Changes in bladder or bowel function suggest
extrauterine uterine bleeding or a mass effect from a
neoplasm.
• Galactorrhea, heat or cold intolerance, hirsutism, or hot
flashes suggest an endocrinologic issue.

14. Initial Evaluation-Physical Exam
• Vital signs should be assessed first
• A general examination should be performed to look for
signs of systemic illness, such as
• Anemia
• Fever
• Ecchymoses
• Enlarged thyroid gland
• Evidence of hyperandrogenism (hirsutism, acne,
clitoromegaly, or male pattern balding)
• Acanthosis nigricans may be seen in women with polycystic
ovarian syndrome (PCOS)
• Galactorrhea (bilateral milky nipple discharge) suggests the
presence of hyperprolactinemia

15. Initial Evaluation-Physical Exam
• A complete pelvic examination should be performed
• Abnormal findings along the genital tract (mass, laceration,
ulceration, friable area, vaginal or cervical discharge, foreign
body)
• An enlarged uterus → pregnancy, leiomyoma, adenomyosis,
malignancy
• Limited uterine mobility → pelvic adhesions or a pelvic mass
• Pelvic adhesions → prior infection, surgery, or
endometriosis
• A boggy, globular, tender uterus is typical of adenomyosis.
• Uterine tenderness → pelvic inflammatory disease (PID)
• Presence of an adnexal mass or tenderness

17. Structural causes of AUB

20. Polyps
• Cervical
• Endometrial

21. Adenomyosis

22. Anovulatory uterine bleeding
DUB
• Anovulatory uterine bleeding and DUB are
interchangeable terms
• DUB occurs with the disruption of cyclic hormonal
changes that regulate the normal menstrual cycle
• In up to 90% of cases it is a manifestation of
anovulation leading to estrogen breakthrough
bleeding

23. Causes of DUB
• Polycystic ovary syndrome
• Immaturity of the HPO axis
• Postpubertal adolescents shortly after menarche
• Perimenopausal women
• Dysfunction of the HPO Axis
• Hyperprolactinemia
• Stress and anxiety
• Rapid weight loss
• Anorexia nervosa
• Hypothyroidism
• Perimenopause
• Abnormalities of normal feedback signals
• Liver disease, hypothyroidism
• Obesity
• Estrogen producing ovarian tumors

24. Evaluation of DUB

25. Laboratory Evaluation- Initial Tests
• Pregnancy test
• Repeat if positive
• Blood test if urine is negative
• Repeat in 1 week if negative
• Complete blood count
• Hemoglobin and/or hematocrit for anemia → women
with heavy or prolonged bleeding
• Platelet count → bleeding disorders
• White blood cell count for infection

26. Laboratory Evaluation- Endocrine
• Thyroid function tests -Hypo and hyperthryoidism
• Prolactin
• Androgens levels
• FSH or LH – Poor nutrition, exercise,
perimenopause
• Estrogen levels – estrogen secreting tumor (very
rare)
• Assessment of ovulatory function – Anovulation

27. Diagnostic procedures
• Ultrasound
• Transvaginal examination should be performed, unless there is a
reason to not perform the vaginal study (virginal patient)
• Transabdominal sonography should also be performed if
transvaginal imaging does not allow adequate assessment of the
uterus or adnexa or if a large pelvic mass is present.
• SIS if intracavitary pathology is suspected
• Polyps
• SM fibroids
• Endometrial biopsy
• DC
• Hysteroscopy

28. Endometrial Sampling
• Once pregnancy has been excluded, endometrial
sampling should be performed in women with AUB
if there is:
• increased risk of endometrial hyperplasia or cancer
• Suspicion of endometritis
• Retained products of conception in women with PP
bleeding

30. Saline Infusion Sonography

34. Treatment
• Treatment is planned according to the etiology
• Any medicine that may be responsible for AUB should be
stopped, if possible
• Polyps →polypectomy
• Fibroids and Adenomyosis →
• Medical:
• Tranexamic acid
• Estrogen-progestin pills
• Progestin implants-injections-pills
• Gonadotropin-releasing hormone agonists
• Levonorgestrel-releasing IUD (LNG-IUD)
• Surgical or invasive:
• Myomectomy
• Hysterectomy
• Embolization
• MR guided focused ultrasound

35. Treatment
• Endocrine disorders → Thyroid disease treated as
indicated, cabergoline for hyperprolactinemia
• Von Willebrand Disease and other coagulation
disorders →Desmopressin, tranexamic acid,
estrogen-progestin contraceptives, LNG-IUD
• Infection→Antibiotics according to suspected agent
• Endometrial hyperplasia → High-dose long-term
progestins, LNG-IUD, hysterectomy
• Genital cancer → Treated as indicated

36. Treatment of Acute, Heavy Bleeding in
Dysfunctional Uterine Bleeding
• If endometrium is denuded or attenuated, the best initial
treatment is estrogen therapy. When endometrium is
normal or thickened, high dose estrogen-progestin or
progestin alone may help.
• High-dose IV estrogen(25 mg conjugated E2 every 4 hrs)
gives rapid response
• In hemodynamically stable patients, oral conjugated E2 2.5
mg every 4-6 hrs for 2-3 wks
• Alternatively, OCPs 3-4 times the usual dose may be
preferred and tapered gradually
• Once bleeding has stopped, medroxyprogesterone acetate
5mg once or twice a day for 7-10 days
• Endometrial curettage is warranted when bleeding is acute
or fails to respond promptly to intensive medical therapy

37. Treatment Options for Dysfunctional
Uterine Bleeding
• OCPs regulate menses and decrease flow
• Progestins may be an alternative in patients who
can not use OCPs (eg, smokers over age 35)
• NSAIDs reduce mentstrual volume
• Tranexamic acid
• GnRH agonists + add back therapy with
progesteron+low dose E2 or progestin alone
• Danazol- effective but has side effects
• LNG-IUD