This document provides guidelines for evaluating and managing abnormal uterine bleeding (AUB). It outlines the history and examination findings that should be obtained. It recommends laboratory tests, imaging studies, and procedures like endometrial biopsy that can help determine the cause of AUB. The document then describes the general management approaches for different causes of AUB, including non-hormonal and hormonal medical treatments as well as surgical options. It provides specific treatment guidelines for different AUB types based on patient factors like desire for fertility preservation or contraception.

1. ABNORMAL
UTERINE BLEEDING

2. History and initial examination
• DETAILED HISTORY
• Frequency of menses
• Duration of flow
• Regularity of flow
• Volume of blood loss
• USE OF MEDICATIONS LIKELY TO CAUSE AUB .
• POSITIVE SCREEN FOR COAGULOPATHIES
• HISTORY OF HEAVY BLEEDING STARTING AT MENARCHE
• ONE OF THE FOLLOWING:
• AT LEAST ONE EPISODE OF BRUISING PER MONTH
• ..,
• AT LEAST ONE EPISODE OF EPISTAXIS PER MONTH
• FREQUENT GUM BLEEDING
• FAMILY HISTORY OF BLEEDING SYMPTOMS
•
• EXAMINATION:
• WEIGHT
• PALLOR
• THYROID
• BREASTS
• ACNE
• HIRSUTISM SCORING (IF PRESENT)
• ABDOMINAL
• P/S
• P/V EXAMINATION

5. Laboratory testing Imaging HPE
 CBC
 UPT
 BT,CT,aPTT,PT, INR
 TSH
 Coagulation profile
 Serum ferritin
 USG Abdomen
 SIS
 Doppler USG
 3D-USG
 Hysteroscopy
 MRI
 Endometrial HPE
 Cervical biopsy
 biopsy

6. • ENDOMETRIAL HPE:
• IN WOMEN > 40 YEARS
• IN WOMEN < 40 YEARS
• WHO HAVE HIGH RISK FACTORS FOR
CARCINOMA ENDOMETRIUM SUCH AS
IRREGULAR BLEEDING,
• OBESITY ASSOCIATED WITH
HYPERTENSION,PCOS, DIABETES
• ENDOMETRIAL THICKNESS > 12 MM
• , FAMILY HISTORY OF MALIGNANCY OF
OVARY/BREAST/ENDOMETRIUM/COLON
• , USE OF TAMOXIFEN FOR HRT OR
BREAST CANCER, LATE MENOPAUSE,
• AUB UNRESPONSIVE TO MEDICAL
TREATMENT

7. GENERAL MANAGEMENT
•TRANEXAMIC ACID IS FIRST-LINE
THERAPY. OTHER NON-HORMONAL-
NSAIDS
• LNG-IUD
•COCS -SECOND LINE THERAPY IN
PATIENTS DESIRING EFFECTIVE
CONTRACEPTION, BUT UNWILLING OR
UNSUITABLE FOR LNG-IUD
•CYCLIC ORAL PROGESTINS (FROM DAY
5 TO 26), ARE RECOMMENDED IF COCS
ARE CONTRAINDICATED
.
•CENTCHROMAN -WHEN STEROIDAL
HORMONES AND OTHER MEDICAL
OPTIONS ARE NOT SUITABLE
•GNRH AGONISTS - WHEN MEDICAL OR
SURGICAL TREATMENTS FOR AUB HAVE
FAILED OR ARE CONTRAINDICATED

8. MANAGEMENT OF PATIENTS WITH AUB AUB-P (POLYPS)
1.- .
• LITY- HYSTEROSCOPIC
• POLYP SHOULD BE SENT FOR HISTOPATHOLOGY. IF
HISTOPATHOLOGY SUGGESTS MALIGNANCY,
FURTHER MANAGEMENT SHOULD BE AS AUB-M.
TO PRESERVE FERTILITY HYSTEROSCOPIC POLYPECTOMY
MULTIPLE ENDOMETRIAL POLYPS AND NOT DESIROUS
OF CONTINUED FERTILITY
HYSTEROSCOPIC POLYPECTOMY FOLLOWED BY LNG-
IUS INSERTION AFTER CONFIRMATION OF BENIGN
LESION ON HISTOPATHOLOGY.

9. HISTORY
36yr old P2 irregular uterine bleeding not associated with periods of
amennorhea
Examination
Abdominal examination – normal.
Per speculam – 4 × 4 cm polyp coming out of cervix, surface inflamed but smooth,
vagina
healthy.
Per-vaginum- cervical rim felt all around the
polyp, seems to be originating from the uterine cavity, firm in consistency with a
smooth surface. Uterus 8 weeks in size, mobile, ante- verted, firm, nontender, no
adnexal mass.
Questions
1.D/D
2.Treatment options

10. • Answers
1.A. Uterine fibroid polyp.
B. Chronic uterine inversion
2.D&C , Operative hysteroscopy, polypectomy, hysterectomy.

11. •ADENOMYOSIS-A
1.IN WOMEN , PROGESTOGENS ESPECIALLY IS
RECOMMENDED AS FIRST-LINE THERAPY .
2.IN PATIENTS WITH AUB-A, , IS
RECOMMENDED AS SECOND-LINE THERAPY
3.IN PATIENTS WITH AUB-A, AND MEDICAL
MANAGEMENT USING
CAN BE INITIATED.
•
DESIROUS OF PRESERVING FERTILITY BUT UNWILLING FOR
IMMEDIATE CONCEPTION,
LNG-IUS
DESIROUS OF PRESERVING FERTILITY AND RESISTANT TO
LNG-IUS/ UNWILLING TO USE LNG-IUS
GONADOTROPIN RELEASING HORMONE (GNRH) AGONISTS
NOT DESIROUS OF PRESERVING FERTILITY, LONG-TERM GNRH AGONISTS
FAILURE/REFUSAL FOR MEDICAL MANAGEMENT VAGINAL OR LAPAROSCOPIC HYSTERECTOMY
COMBINED ORAL CONTRACEPTIVES, DANAZOL, NSAIDS, AND PROGESTOGEN OFFERED FOR
SYMPTOMATIC RELIEF WHERE LNG-IUS AND GNRH AGONISTS CANNOT BE INDICATED

12. 45-year-old parous sterilised woman complains of cycles once in 20 days lasting for 6-8 days, passing clots since last
8 months, and gives history of painful periods. Her prior cycles were regular. She is anemic. Her vitals are normal; per
abdominal examination shows no mass, and there is no organomegaly. S/E cervix is normal. On pelvic examination
uterus enlarged to 12 weeks size; fornices are free.
a. What is the probable clinical diagnosis?
b. What investigations will you order?
C. TVS showed adenomyosis. How will you perform endometrial biopsy?
d. Endometrial biopsy was proliferative phase. What management will you offer her?

13. Answers-
A. AUB-L-may be fibroid or AUB A- adenomyosis.
B. Routine investigation and specific investigation-_TVS and endometrial biopsy.
C. Endometrial biopsy by Pipelle curette or hysteroscopic guided biopsy or fractional curettage.
D. The option for medical management and LNG-IUS and surgery were offered to her.
As she has completed family and did not want to have menstrual cycles, she opted for total
abdominal hysterectomy.

14. AUB-L
• Watchful waiting
• Medical therapy-
• tranexamic acid-1.3g ytds for 3-5 days during menstrual bleeds
• GNRH agonists
• Gonadotropin releasing hormone agonist-late perimenopausal wonmen
• Gonadotropin releasing hormone antagonist-ganirelix
• Progesterone mediated medical treatment-mifepristone
• Ulipristal acetate 5mg or 10mg
• Progesterone releasing iud-levonorgesteral intrauterine system

15. AUB-L
1. INTRAMURAL OR SUBSEROSAL MYOMAS, DESIROUS OF PRESERVING FERTILITY- MANAGED WITH TRANEXAMIC ACID OR COMBINED ORAL
CONTRACEPTIVES (COCS) OR NSAIDS
2. INTRAMURAL OR SUBSEROSAL MYOMAS AND DESIROUS OF PRESERVING FERTILITY CAN BE MEDICALLY MANAGED WITH LNG-IUS IF OTHER
MEDICAL TREATMENT FAILS AND PATIENT IS NOT TRYING TO CONCEIVE FOR AT LEAST 1 YEAR.
3.IF TREATMENT FAILS, OR IF MYOMA IS CAUSING INFERTILITY, MYOMECTOMY IS RECOMMENDED BY ABDOMINAL (OPEN OR LAPAROSCOPIC)/
HYSTEROSCOPIC ROUTE
4. SUB-MUCOSAL MYOMAS -HYSTEROSCOPIC RESECTION (FOR <4 CM DIAMETER) OR ABDOMINAL MYOMECTOMY (FOR >4 CM DIAMETER)
• >40 YEARS OF AGE, NOT DESIROUS OF CONTINUED FERTILITY, HYSTERECTOMY .
•
• SHORT-TERM MANAGEMENT (UP TO 6 MONTHS), GNRH AGONISTS - PERI-MENOPAUSAL WOMEN, PRIOR TO MYOMECTOMY OR FOR IMPROVING
GENERAL CONDITION.
1.FOR LONG-TERM MANAGEMENT OF LEIYOMYOMAS, IT IS RECOMMENDED TO USE LNG-IUS (EXCEPT IN AUB-L 0 , PROGESTERONE RECEPTOR
MODULATORS SUCH AS ULIPRISTAL ACETATE AND LOW DOSE MIFEPRISTONE. - NOT AVAILABLE IN INDIA.

16. 45-YEAR-OLD MULTIPAROUS WOMAN, STERILISED, PRESENTS TO OUTPATIENT CLINIC WITH HEAVY MENSTRUAL BLEEDING
WITH PAIN ABDOMEN SINCE LAST 6 MONTHS. ON EVALUATION, IT IS FOUND THAT UTERUS IS IRREGULARLY ENLARGED TO 20
WEEKS. S/E CERVIX NORMAL; PELVIC EXAMINATION SHOWS UTERUS IRREGULARLY ENLARGED TO 20 WEEKS.
A. WHAT INVESTIGATION WILL YOU ORDER?
B. ENDOMETRIAL BIOPSY-_PROLIFERATIVE PHASE; USG- FIBROID UTERUS, KIDNEYS NORMAL
HOW WILL YOU MANAGE HER?

17. AUB-L
ANSWER
A.HB. USG - TAS, ENDOMETRIAL BIOPSY.
B. CORRECTION OF ANEMIA SHOULD BE DONE. BECAUSE SHE HAS COMPLETED HER FAMILY, TOTAL
ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPINGECTOMY EITHER BY LAPAROTOMY OR
LAPAROSCOPICALLY SHOULD BE PERFORMED. OVARIES SHOULD BE RETAINED.

18. AUB-M
1.
ENDOMETRIAL HYPERPLASIA WITH ATYPIA, HYSTERECTOMY
1.ENDOMETRIAL HYPERPLASIA WITHOUT ATYPIA, 1. LNG-IUS
2.ORAL PROGESTINS

19. 60 years old postmenopausal lady complains of bleeding per vaginum off and on for one month.
Mrs X had menopause at 50 years, is obese, hypertensive Para1+0 and has no other positive history or findings on general examination.
On P/S, cervix is healthy, flushed with vagina, os stenotic, upper vagina narrow with difficulty in exposing cervix.
On P/V, bleeding through os is present, and on P/V/R, uterus is anteverted, normal size, mobile, adnexae free, parametrium and POD free.
What would be your most probable diagnosis?

20. AUB-C
AUB-C • NON-HORMONAL TREATMENT - TRANEXAMIC ACID
• HORMONAL TREATMENT WITH COCS/LNG-IUS
REFRACTORY CASES FACTOR REPLACEMENT OR DESMOPRESSIN
SURGICAL INTERVENTION

21. AUB-O
1.IN WOMEN NOT DESIRING CONCEPTION PRESENTLY, COCS CAN BE USED AS FIRST-LINE THERAPY FOR 6-12 MONTHS
2.CYCLIC LUTEAL-PHASE PROGESTINS SHOULD NOT BE USED AS A SPECIFIC TREATMENT IN WOME
3.NORETHISTERONE CYCLICALLY (FOR 21 DAYS) IS GIVEN AS INITIAL THERAPY IN ACUTE EPISODES OF BLEEDING FOR
SHORT-TERM MANAGEMENT OF 3 MONTHS
4.IT IS SUGGESTED RESPONSE AFTER 1 YEAR OF MEDICAL MANAGEMENT AND JUDGE TO CONTINUE/DISCONTINUE
EXISTING THERAPY
5.SURGICAL INTERVENTION IS NOT RECOMMENDED UNLESS, THERE IS EVIDENCE OF PERSISTENT AUB OR FAILURE OF
MEDICAL MANAGEMENT TO ALLEVIATE THE CONDITION (GRADE A; LEVEL 4).
6.IF COCS ARE CONTRAINDICATED OR PATIENT IS UNWILLING FOR COCS, LNG-IUS IS RECOMMENDED IF SHE WISHES TO
USE IT FOR ATLEAST 1 YEAR (GRADE A; LEVEL 1).
7.IN ADOLESCENTS WITH AUB-O, BOTH HORMONAL AND NON-HORMONAL THERAPIES CAN BE PRESCRIBED,

22. 14-year-old girl complaining of fatigue and weakness gives history of bleeding per vaginum
for 20 days once in 4 months for the past 1 year. She attained menarche at the age of 12 years.
The girl is pale. There is no significant medical/family history.
a. What is the diagnosis?
b. How will you investigate her?
C. What is the management for her?

23. Answers:
A .Puberty Menorrhagia - Adolescent anovulatory AUB (AUB-O) with anaemia
B. Perform complete haemogram including platelet count, total count (rarely leukaemia may be
the cause of AUB), bleeding time, clotting time, coagulation profile and Thyroid function test.
C. After ruling out thyroid dysfunction, bleeding diathesis or coagulation disorder, because she
is anaemic, packed red blood cell (PRBC) transfusion given if haemoglobin is very low. She is
started on haematinics. To regularise the menstrual cycle, ostrogen-progesterone combination
pill can be given for six cycles.

24. AUB-E (Endometrial)
1. Management of AUB-E can be similar to the management of AUB-O
(Grade
AUB-I (Iatrogenic causes)
1. Whenever possible, medications causing AUB should be changed to
other alternatives, if no alternatives are available, LNG-IUS is recommended

25. AUB-N
In patients with idiopathic AUB and
desire effective contraception, LNG-
IUS is recommended as first-line
therapy to reduce menstrual bleeding
(Grade A; Level 1).
In patients with AUB-N desirous of
continued fertility, in whom, LNG-IUS
are contraindicated, use of COCs are
recommended as second line therapy
(Grade A).
For the management of abnormal
uterine bleeding that are mainly cyclic
or predictable in timing, non-hormonal
options such as NSAIDs and
tranexamic acid are recommended
When medical or conservative surgical
treatments (such as ablation) have
failed or are contraindicated, and
GnRH agonists along with add-back
hormone therapy are recommended to
reduce idiopathic AUB, while
hysterectomy is suggested as last
resort (Grade B; Level 4).
Uterine Artery embolization is
recommended for A-V malformations

26. GENERAL MANAGEMENT GUIDELINES

30. •Thank you