Abnormal uterine bleeding includes heavy, prolonged, irregular or abnormal menstrual bleeding that can be caused by various gynecological or systemic conditions. A thorough history, physical exam, blood tests and diagnostic imaging are used to evaluate the bleeding and identify potential causes. Dysfunctional uterine bleeding, one of the most common causes, is attributed to anovulation and unopposed estrogen levels resulting in irregular bleeding. Treatment involves hormonal regimens or surgical procedures if hormones do not control the bleeding.

1. Lecture on
Abnormal uterine
bleeding

2. Abnormal Uterine Bleeding
 Includes abnormal menstrual bleeding
and bleeding due to other causes
such as pregnancy, systemic disease,
or cancer.
 The diagnosis and management of
abnormal uterine bleeding present
some of the most difficult problems in
gynecology.

3. Patterns of Abnormal Uterine
Bleeding
 Menorrhagia (hypermenorrhea)
 Hypomenorrhea (cryptomenorrhea)
 Metrorrhagia (intermenstrual bleeding)
 Polymenorrhea
 Menometrorrhagia
 Oligomenorrhea
 Contact bleeding (postcoital bleeding)

4. 1) Menorrhagia (hypermenorrhea)
 Is heavy(>80ml) or prolonged(>7days) menstrual
flow.
"Gushing" or "open-faucet" bleeding is always
abnormal.
Causes include:
- Submucous myomas
- Complications of pregnancy
- Adenomyosis
- IUDs
- Endometrial hyperplasias
- Malignant tumors, and
- Dysfunctional uterine bleeding

5. 2) Hypomenorrhea
(cryptomenorrhea)
 Is unusually light menstrual flow,
sometimes only spotting.
Causes include:
- Hymenal or cervical stenosis
- Uterine synechiae
(Asherman's syndrome)
- oral contraceptives

6. 3) Metrorrhagia
(intermenstrual bleeding)
 Is bleeding that occurs at any time between
menstrual periods(irregular acyclic bleeding
from the uterus).
Causes include:
- Endometrial polyps
- Endometrial ca
- Cervical carcinomas
- Exogenous estrogen
administration(break through bleeding in pill
use)
- Dysfunctional uterine bleeding

7. 4) Polymenorrhea
 Describes periods that occur too
frequently(cyclic bleeding which occurs
every 21days or less).
Causes include:
- anovulation( DUB)
- a shortened luteal phase in the
menstrual cycle.
- ovarian endometriosis

8. 5) Menometrorrhagia
 Is bleeding that occurs at irregular
intervals. The amount and duration of
bleeding also vary(Irregular, prolonged
and excessive bleeding).
 Any condition that causes
intermenstrual bleeding can eventually
lead to menometrorrhagia.
 Sudden onset of irregular
bleeding episodes may be an indication
of malignant tumors or complications of
pregnancy.

9. 6) Oligomenorrhea
 Describes menstrual periods that occur more
than 35 days apart.
 Amenorrhea is diagnosed if no menstrual period
occurs for more than 6 months.
 Bleeding usually is decreased in amount and
associated with anovulation, either from:
- Endocrine causes (e.g., pregnancy,
pituitary-hypothalamic causes, menopause) or
- Systemic causes (e.g., excessive weight
loss).
Estrogen-secreting tumors produce
oligomenorrhea prior to other patterns of
abnormal bleeding.

10. 7) Contact bleeding (postcoital
bleeding)
 Is self-explanatory but must be considered a
sign of cervical cancer until proved otherwise.
Causes include:
- cervical eversion,
- cervical polyps,
- cervical or vaginal infection (e.g.,
Trichomonas,
chlamydia or tuberculosis ), or
- atrophic vaginitis.
 A negative cytologic smear does not rule out
invasive cervical cancer, and colposcopy,
biopsy, or both may be necessary.

11. Summary of AUB
 Abnormal Menses—Terminology
Term Interval Duration Amount
Menorrhagia Regular Prolonged
Excessive
Metrorrhagia Irregular ±Prolonged Normal
Menometrorrhagia Irregular Prolonged Excessive
Hypermenorrhea Regular Normal Excessive
Hypomenorrhea Regular Normal or less Less
Oligomenorrhea Infrequent or irregular Variable Scanty
Amenorrhea Absent No menses for 90 d Absent

12. Evaluation of Abnormal Uterine Bleeding
 Detailed history, physical examination,
cytologic examination, pelvic ultrasound,
and blood tests are the first steps in the
evaluation of abnormal uterine bleeding.
 The main aim of the blood tests is to
exclude a systemic disease, pregnancy,
or a trophoblastic disease.
 The blood tests usually include complete
blood count, assay of the β subunit of
human chorionic gonadotropin (hCG),
and thyroid stimulating hormone (TSH).

13. History
 Many causes of bleeding are strongly suggested
by the history alone.
 Note the amount of menstrual flow, the length of
the menstrual cycle and menstrual period, the
length and amount of episodes of intermenstrual
bleeding, and any episodes of contact bleeding.
 Note also the last menstrual period, the last
normal menstrual period, age at menarche and
menopause, and any changes in general health.
 The patient must keep a record of bleeding
patterns to determine whether bleeding is
abnormal or only a variation of normal.
 Depending on the patient's age and the pattern of
the bleeding, observation may be all that is
necessary.

14. Physical Examination
 Abdominal masses and an enlarged, irregular
uterus suggest myoma.
 A symmetrically enlarged uterus is more
typical of adenomyosis or endometrial
carcinoma.
 Atrophic and inflammatory vulvar and vaginal
lesions can be visualized, and cervical polyps
and invasive lesions of cervical carcinoma
can be seen.
 Rectovaginal examination is especially
important to identify lateral and posterior
spread or the presence of a barrel-shaped
cervix.

15. Laboratory Evaluation
• Complete blood count
 Serum iron and iron-binding globulin
 Coagulation studies (prothrombin
time(PT) and partial thromboplastin
time(PTT))
 Bleeding time
 Urinary hCG assay
 Thyroid function studies
 Serum progesterone
 Liver function studies
 Renal function tests
 Prolactin levels
 Serum FSH levels

16. Diagnostic procedures
 Cervical cytology (Papanicolaou smear)
 Endometrial biopsy
 Pelvic ultrasonic imaging
 Hysteroscopy
 Hysterosonogram, and/or
 D&C

17. Causes of AUB
1. IATROGENIC
- Exogenous estrogen (e.g., oral contraceptives)
- Aspirin
- Heparin/ coumadin
- Tamoxifen
- Intrauterine device
2. DYSCRASIAS
- Thrombocytopenia
- Increased fibrinolysins
- Autoimmune disease
- Leukemia
- Von Willebrand's disease
3. SYSTEMIC DISORDERS
- Hepatic disease (impaired metabolism of estrogens)
- Renal disease (hyperprolactinemia)
- Thyroid disease

18. Causes of AUB…
4. TRAUMA
- Laceration
- Abrasion
- Foreign body
5. ORGANIC CONDITIONS
- Complications of pregnancy
- Uterine leiomyomas
- Malignancies of cervix or uterine corpus
- Endometrial polyp
- Adenomyosis
- Endometritis
- Endometrial hyperplasia

19. General principles of mgt of AUB
 Algorithm
Pelvic ultrasound
Endometrial sampling(Hysteroscopy, D
& C)
Gynecologic problem
Non gynecologic
problem
Operative
hysteroscopy,
Hysterectomy
Thyroid disease,
coagulopathy ,
rectal bleeding,
urologic bleeding Medical
therapy,
IUS- LNG
ablation
Dysfunctional
uterine bleeding
Pelvic pathology
Hx, P/E & Ix
AUB

20. Postmenopausal bleeding
 Defined as bleeding that occurs after
12 months of amenorrhea in a middle-
aged woman.
 Gynecologic causes include:
1. Exogenous Hormones
2. Vaginal Atrophy and Vaginal and
Vulvar Lesions
3. Tumors of the Reproductive Tract

21. Postmenopausal bleeding…
Tumors of the Reproductive Tract
causing postmenopausal bleeding
include:
 endometrial hyperplasias
 endometrial polyps
 endometrial carcinoma
 cervical carcinoma
 uterine sarcomas
 uterine tube cancer, and
 estrogen-secreting ovarian tumors also

22. Dysfunctional Uterine Bleeding
 Is defined as abnormal uterine bleeding (AUB) in
women between menarche and menopause that
cannot be attributed to medications, blood
dyscrasias, systemic diseases, trauma, uterine
neoplasms, or pregnancy.
 This form of AUB is almost always caused by
abnormalities in the hypothalamic-pituitary-ovarian
hormonal axis resulting in anovulation.
 Usually, a diagnosis of DUB is made by excluding
other treatable causes of AUB.
 In most cases, it is associated with anovulatory
or oligo-ovulatory ovarian cycles, and estrogen
levels are frequently unopposed by progesterone.

23. Dysfunctional uterine bleeding…
 It is one of the most common problems dealt
with in the gynecologic clinics.
 Most DUB occur during the years around the
menarche (11 to 14 years of age), 20% of
cases or menopause (45 to 50 years of age),
40% of cases.
 During the perimenopausal years, the
anovulatory bleeding is mainly caused by the
declining functional capacity of the ovary.
 In adolescence, the anovulatory bleeding may be
caused by a failure of the hypothalamic-
pituitary system to respond to the positive
feedback effect of estrogen.

24. Dysfunctional uterine bleeding…
 The diagnosis is made by:
- history
- absence of ovulatory temperature
changes
- low serum progesterone level, and
- results of endometrial sampling in
the
older woman.

25. Management of DUB
1. Hormonal Rx
- Is the main stay of treatment.
 Numerous regimens are available, including
estrogens followed by progesterone, progesterone
alone, or combination oral contraceptives.
 Oral contraceptives, 3–4 times the usual dose, are
effective and may be simpler to use. Then the dose
is lowered after a few days and the lower dose is
continued for the next few cycles, particularly to raise
the hemoglobin levels in an anemic patient.
 In adolescents in whom the bleeding is not severe,
oral contraceptives can be used as normally
prescribed(one pill per day).

26. Management of DUB…
2. Surgical Measures
 For patients whose bleeding cannot be controlled
with hormones, who are symptomatically anemic,
and whose lifestyle is compromised by persistence
of irregular bleeding, D&C may temporarily stop
bleeding.
 If bleeding persists, levonorgestrel-releasing
IUDs or a minimal invasive procedure such as
endometrial ablation may be done.
 However, if these minimally invasive procedures
fail or if the patient prefers a definitive solution,
hysterectomy may be necessary.

27. Thanks
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The end !