this about uterine bleeding

1. College of Public Health & Medical Sciences
Department of Nursing and Midwifery
Presentation on: AUB
By Tigist Teklu
compiled by Tigist 1

2. Abnormal Uterine Bleeding
(AUB)
2
compiled by Tigist

3. Presentation Outline
 Objectives
 Introduction
 Incidence
 Spectrum of AUB
 Etiology of AUB
 Diagnostic approach of AUB
 Management of AUB
 Summary
 Acknowledgement
 References
3
compiled by tigist

4. Objective of presentation
After the presentation the students will able to:
o Define AUB
o Describe incidence
o Describe spectrum of AUB
o Discuss etiology of AUB
o Explain diagnostic approach of AUB
o Describe management of AUB
4
compiled by tigist

5. Brain storming
• What is AUB?
• What is the difference between AUB and DUB?
compiled by tigist 5

6. Abnormal Uterine Bleeding (AUB)
Introduction
 AUB Is excessive, irregular, prolonged , slight, absence of
menstrual flow and/or bleeding..
 20% of 1st Gynecological Visit (AJOG 2001)
 90% an ovulatory and 10% ovulatory.
 Occurs at any of phases of menstrual life:
Adolescence: puberty till 20 year old.
Reproductive: 20-45 year old
Peri-menopause: 45 year old to established menopause
6
compiled by tigist

7. Spectrum of AUB
 Menorrhagia
 Metrorrhagia
 Menometrorrhagia
 Polymenorrhea
 Midcycle spotting
 Oligomenorrhea
 Amenorrhea
 Premenstrual spotting
 Postmenopausal bleeding:
 Intermenstrual Bleeding
 Post-coital Bleeding
7
compiled by tigist

8. Spectrum of AUB cont…
1) Hyper menorrhea/menorrhagia:
Cyclic menstrual bleeding occurring at regular intervals but excessive in
amount (> 80 mL daily) or greater than 7days in duration.
2.Metrorrhagia(Intermenstrual bleeding):
• Uterine bleeding of variable amounts occurring between regular menstrual
periods or
• Irregular uterine bleeding esp. between menstrual periods.
3) Menometrorrhagia:
• A combination of menorrhagia and metrorrhagia
• Prolonged or heavy uterine bleeding occurring at irregular and more
frequent than normal intervals
8
compiled by tigist

9. Spectrum of AUB cont…
4.Midcycle spotting :
• Spotting occurring just before ovulation, typically from declining
estrogen levels
5) Hypomenorrhea :
• Is slight menstrual flow, sometimes spotting
• Decreased menstrual flow
6) Polymenorrhea:
• Bleeding occur too frequent less than 21 days apart.
7) Oligomenorrhea: bleeding with interval > 35 days
8) Amenorrhea: absence of bleeding for ≥ 3 months or longer
9
compiled by tigist

10. Spectrum of AUB cont…
9. Premenstrual spotting: Light bleeding preceding menses
10. Postmenopausal bleeding: Recurrence of bleeding in a
menopausal woman at least for 6 months to 1 year after
cessation of cycles
11. Post coital spotting: vaginal bleeding within 24h of
intercourse that is not menstrual loss.
10
compiled by tigist

11. Etiology of AUB
 Organic causes: anatomic/systemic disease:
Reproductive tract disease
Systemic disease
Iatrogenic
 Dysfunctional uterine bleeding(DUB)
11
compiled by tigist

12. Reproductive tract disease
 Pregnancy Complications:
• Abortion
• Ectopic pregnancy
• Trophoblastic disease
• Placental polyp
• Subinovlution of placental site
• Placental previa
• Abruptio placenta
 Upper Genital Tract Infection/ Puerperal complications
• Endomyometritis
• Endometritis
• Salpingitis
12
compiled by tigist

13. Reproductive tract disease cont..
 Benign pelvic lesions
• Traumatic lesions
• Vaginal lesion
• Foreign bodies
• Cervical polyps/ erosions/ cervicitis
• Submucous myomas
• Adenomyosis
• Endometriosis
• Endometrial polyp
 Malignancy
• Cervical CA
• Endometrial CA ( should primarily be ruled out in a
postmenopausal bleeding unless proven otherwise)
13
compiled by tigist

14. Systemic cause
Thyroid disease
 Hypothyroidism: > 20% experience Menorrhagia
Polycystic ovary disease
Hepatic disease :sex steroids metabolized in the liver, liver disease:
 Diminished conjugation of estrogen  Elevated Estrogen  Hyper
stimulation of endometrium  Hypo prothrombinemia  Bleeding
Adrenal hyperplasia
R/ted to ACTH  Adrenal  cortisol contraction
14
compiled by tigist

15. Systemic cause
Pituitary adenoma or hyper prolactinemia
Hypothalamic suppression (from stress, wt loss, excessive
exercise)
Coagulation disorders: platelet or clotting factors deficiency
(seen in 20% of adolescence)
15
compiled by tigist

16.  Oral/ Sub-dermal/ Injectable steroids
 IUD’s
 Corticosteroids
 Tranquilizers, anti-depressants, psychotropic medications
 Anti-coagulants
 Herbal substances, i.e., ginseng, ginkgo, soy supplements
16
compiled by tigist

17. 2.DUB
Is abnormal bleeding with not attributable to organic
(anatomic/systemic) disease
Is defined as AUB in the absence of:
 Organic disease or
 Clinical or U/S evidence of structural abnormalities, inflammation,
or pregnancy
 Anovulation – no anatomical or systemic disease – by exclusion
Is particularly common at the extremes of the reproductive years
(perimenarcheal and perimenopausal)
17
compiled by tigist

18. Symptoms of DUB
• Bleeding or spotting from the vagina between periods
• Periods that occur less than 28 days apart (more common) or more than 35 days
apart
• Time between periods changes each month
• Heavier bleeding
• Bleeding lasts for more days than normal or for more than 7 days
• Other symptom
• Excessive growth of body hair in a male pattern (hirsutism)
• Hot flashes
• Mood swings
• Tenderness and dryness of the vagina
18
compiled by tigist

19. Diagnostic Approach to AUB
Diagnosis of excluding other cause of bleeding.
1. History
2. Physical Examination
3. Laboratory Exams
4. Imaging Procedures
5. Endometrial Assessment
DDx: PHIMIC
19
compiled by tigist

20. 1. History
Medical history
 Always R/O pregnancy !– check Sx and Sx of pregnancy
 Previous pregnancies and outcomes
 Present sexual activity
 Menstrual history
 Is it ovulatory or anovulatory AUB?
 Episode of vaginal bleeding
 Last known normal menstrual cycle
 Previous episodes of abnormal bleeding
 Medications (ASA, anticoagulants)
 Past medical history (Genital Infections, Surgeries or gynecological
procedure)
 Contraceptive methods (IUCD’s, Hormonal)
20
compiled by tigist

21. 2. Physical Examination
 Evidences of anemia
 BMI (obese patients are prone to unopposed estrogen due to
peripheral conversion of fats to androstenedione)
 Acne
 Evidence of thyroid disorders
 Abdominal exam
 Inspection of external genitalia
 Speculum
 Bimanual exam
Pelvic exam (speculum & bimanual)
21
compiled by tigist

22. 3. Laboratory Exams
(should be done on a case to case basis)
 Pregnancy test (Urine or Serum B-HCG)
 CBC + Ferritin Levels (Platelet count)
 TSH (if with symptoms of thyroid dysfunction)
 Day 21-23 progesterone to verify ovulatory status
 FSH, LH - to support PCOS or verify menopausal status
 Coagulation Profile: clinical suspicion of coagulopathy
 Prothrombin time (PT) and an activated partial thromboplastin time
(PTT)
 Pap Smear
22
compiled by tigist

23. 4. Imaging Procedures
23
compiled by tigist

24. 4A. Transvaginal Sonogram (TVS)
 Basic procedure to rule in or out
anatomic causes of AUB
 Provides information of
 Tumors: size, shape, location
 Thickness of endometrium
 Lesions with in endometrial cavity
24
compiled by tigist

25. 4C. Hysteroscopy
 Direct visualization of
endometrial cavity to
diagnose cavitary defects
25
compiled by tigist

26. Diagnostic Studies of AUB; Pros and Cons
26
compiled by tigist

27. Treatment of AUB
• Depends on the Identified Etiology
Factors in the treatment of AUB includes;
 Age
 Fertility preservation
 Coexisting medical conditions
 Patient preference
27
compiled by tigist

28. Treatment cont…
Self-Care at Home
• Rest in bed
• Keep track of the number of pads to determine the amount
• Avoid taking aspirin
 Medical Treatment includes;
NSAID
Antifibrinolytic
Danazol
Progestins
Combined OCP
Estrogen
Progestin Intrauterine System (IUS)
GnRH Agonist
28
compiled by tigist

29. 1. NSAID
 Increase endometrial PG in menorrhagia
 NSAIDs Inhibits cyclooxygenase  Diminished PG
 Start on day1 - 5 days or till menses ceases
29
compiled by tigist

30. 2. Antifibrinolytic
Tranexamic acid;
 An antifibrinolytic drug (C8H15NO2)
 Synthetic derivative of A.A. Lysine
 Has antifibrinolytic effect through reversible blockade of plasminogen
 No effect on coagulation parameters or dysmenorrhea
 1 gram q 6 hours from 1 to 4days
30
compiled by tigist

31. 3. Danazol
 Synthetic steroid
 Androgenic properties
 Inhibits steroidgenesis
 Lowers blood loss by 80%
 200-400 mgs/ day X 3 months
20% amenorrhea
70% oligomenorrhea
 Weight gain: most common side effect
31
compiled by tigist

32. 4. Progestin
 For anovulatory AUB which is not profuse/ prolonged
 Anti-mitotic activity causing endometrial atrophy
 Patients with a thin endometrium with denuded endometrium occur
after several days of bleeding will need induction of endometrium
with estrogen 1st
 Medroxyprogesterone Acetate ( Provera) 10 mgs OD from Day 16-
25, second half of cycle to simulate normal cycle
 RCTs show cyclic progestin not effective in controlling regular,
heavy, menstrual bleeding compared to NSAIDs & Tranexamic acid
32
compiled by tigist

33. 5. Combined OCP
 Induces endometrial atrophy
 RCT :30 ugs EE/ day – 43% reduction
 Suppresses endometrial development reestablish predictable
bleeding patterns
 Blood flow
Iron deficiency anemia
 Bleeding controlled within 1st 24 hours as endometrium is
psuedo decidualized
 Alternate treatment sought if it fails to abate in 24 hours
33
compiled by tigist

34. 6. Estrogen
 Effective in controlling acute phase
 Vasospastic action on capillary bleeding (fibrinogen, factor IV,
factor X, platelet aggregation, capillary permeability)
 Does not treat underlying cause
34
compiled by tigist

35. 7. Progestin IUS
 Levonorgestrel IUS (Mirena) (Intrauterine system)
 Provides a steady amount of Levonorgestriel (20 ugs in 24 hours) for a steroid
reservoir
 Device good for 5 years
35
compiled by tigist

36. 8. GnRH Agonist
 Reversible hypo estrogen
 Blood loss in peri-menopausal
36
compiled by tigist

37. Surgical Treatment:
1. D and C
2. Hysteroscopy (Dx and Operative)
3. Endometrial destruction
4. Hysterectomy
37
compiled by tigist

38. 38
Summary of Dx and mgt
compiled by tigist

39. summary
• What is AUB?
• What are the spectrums of AUB?
• What are the possible causes of AUB?
• What are the diagnostic methods of AUB?
• What are the managements of AUB?
compiled by tigist 39

40. Acknowledgement
compiled by Tigist 40
My deeper gratitude goes to our instructor Mr.Bekana F.(Bsc.mw,
Msc)for giving me this chance and Jimma University for free
internet and library service and my class mates for your attention
and constructive comments.

41. References
1.Current Diagnosis & Treatment Obstetrics & Gynecology,
Tenth Edition (2007)
2.William obstetrics, twenty second edition
3.Human reproduction update vol.2 living stone,2002
4.Management of Abnormal Uterine Bleeding SLCOG National
Guidelines
compiled by tigist 41

42. 42
compiled by Tigist