Abnormal uterine bleeding is a deviation from the normal menstrual pattern. This presentation deals with causes, investigations and treatment.

1. Dr.Suresh Babu Chaduvula
Professor
Department of Obstetrics & Gynaecology
GIMSR
Visakhapatnam
Andhra Pradesh, India

2. 1.What is the importance of learning
AUB?
2. What is normal menstruation?
3. What is Abnormal menstruation?
4. FIGO classification
5. Diagnosis
6. ACOG/ RCOG guidelines for the
treatment

3.  1-2 % untreated anovulatory AUB may
develop endometrial cancer.
 Unnecessary curettages.
 Unnecessary Hysterectomies.
 Proper work up and Medical management is
most appropriate in majority.

6.  Any deviation from normal frequency [21-35
days], amount of bleeding [30-80 ml],
duration [3-7 days] in women of reproductive
age.
 Menstrual bleeding that is unpredictable,
abnormally heavy or abnormal in timing.

7.  1. Acute Emergent:
 Bleeding is characterised by a significant loss
that results in hypovolemia or shock
 2. Chronic:
 Menstrual abnormality that occurs slowly
over a period of 6 months.

8.  10-20% of OPD patients

9.  Adolescents – 20 %
 Age between 40-50 years – 50 %
 Reproductive age 30 %

10.  1. Pelvic pathology – PCOS
 2. Pregnancy related conditions – abortions,
ectopic, GTD [ Gestational trophoblastic
diseases]
 3. Coagulation & Haematological problems
 4. Medical problems – Thyroid, Liver, Hepatic
 5. Iatrogenic
 6. Dysfunctional Uterine Bleeding [DUB]

12.  1. Menorrhagia or Heavy Menstrual Bleeding
[HMB]:
 Bleeding more than 80 ml and duration more
than 7 days with normal frequency of 21 -35
days
 2. Metrorrhagia or Irregular Menstrual
Bleeding [IMB]:
 Inter menstrual bleeding
 3. Mid cycle spotting:
 Bleeding occurring before ovulation due to
low levels of estrogen.

13.  4. Meno-metrorrhagia:
 Irregular heavy bleeding
 5. Polymenorrhoea:
 Bleeding occurring less than 21 days may be
due to a luteal phase defect.
 6. Oligomenorrhoea:
 Bleeding occurring beyond 35 days due to
prolonged follicular phase.
 7. Acyclic bleeding:
 Irregularly irregular excessive bleeding

14.  8. Threshold bleeding:
 Bleeding occurring due to low levels of estrogens
due to poor follicles and due to atrophic
endometrium.
 9. Postmenopausal bleeding:
 Bleeding occurring after one year of menopause
from the previous episode of bleeding.
 10. Secondary amenorrhea:
 Cessation of menses of 3 of her normal cycles or
6 months in absence of pregnancy or lactation.

18.  A group of menstrual disorders following the
exclusion of pregnancy or pregnancy related
disorders, systemic disorders, hematological,
pelvic pathologies and iatrogenic causes.
 The term was coined by Sutherland.
 AUB in the absence of palpable pelvic
pathology – Kistner
 AUB devoid of tumour, pregnancy,
inflammation – Novak.

19.  Anovulatory DUB:[80%]
 Metropathia hemorrhagica or Schroeder’s
disease – variable period of amenorrhea
followed by prolonged heavy bleeding due to
cystic glandular hyperplasia.
 Seen in extreme ends of reproductive ages
due to anovulation or luteal phase
insufficiency.

20.  Ovulatory DUB:[20%]
 It is more common in reproductive life.
 Irregular ripening of premenstrual spotting
is due to short luteal phase with insufficient
corpus luteum.
 Irregular shedding of postmenstrual spotting
is due to long luteal phase with persistent
corpus luteum.

30.  1. Detailed History
 2. General examination:
 Anaemia, Goiter
 3. Per Speculum Examination:
 Polyps, growths
 4. Bimanual pelvic examination:
to exclude any palpable pelvic pathology
 5. Rectal examination:
to exclude any palpable pelvic pathology

31.  CBC
 Pap Smear
 Ultrasonography – Pelvis
 Hysteroscopy
 Saline infusion Sonography
 Endometrial Biopsy/ Fractional curettage
 Pregnancy Test
 Hormonal tests – TSH, Serum Prolactin
 Coagulation profile – CT, BT, PPT, aPTT, vW factor
assay, Factor VIII, Ristocetin cofactor assay
 LFT
 [ Preoperative investigations]

33.  Depends upon
 1. Age
 2. Fertility desire
 3. Coexisting morbid conditions

34.  Explanation and reassurance
 Maintain Menstrual calendar
 Life style modification
 Weight reduction
 Treatment of Anaemia with Iron and Folic
acid and rarely blood transfusion
 This type of treatment is applicable to
Puberty AUB

35.  Admission
 IV fluids
 Blood transfusion
 Inj. Premarin or conjugate estrogens 25mg iv
every 4 hrs till bleeding is subsided for 12 to 24
hr.
 Followed by oral conjugate estrogens 1.25 or2.5
mg cyclically with progesterone [ Medroxy
progesterone acetate] 10 mg supplementation
for later 12 days
 If no response in 24 hr D&C +_ Hysteroscopy is
needed.

36.  Medical management:
 It can be Hormonal or Non Hormonal

37.  Mafenamic Acid:
 Prostaglandin synthetase inhibitor
 Tab.500 mg three times a day, started from
1st day of period for 3-5 day
 Useful for puberty AUB and reproductory AUB
 Efficacy – 25% reduction in bleeding

38.  Tranaxamic acid:
 Antifibrinolytic agent
 Tab. 1-2 gm four times a day for 3-5 days
 Useful in Puberty and reproductory AUB
 Efficacy – 50 % reduction in bleeding
 It is also used in IUCD induced menorrhagia

39.  Ethamsylate:
 Increases capillary integrity
 Anti hyaluronidase activity
 Prostaglandin synthesis inhibitor
 Tab.500 mg four times a day
 Started before anticipated menses and
continued for 10 days
 Efficacy – 20 % reduction in bleeding

40.  Cyclical Progestins:
 It has antimitotic and anti growth effect on
endometrium.
 First line treatment for Anovulatory AUB of
perimenopausal age.
 Endometrial biopsy should exclude
Endometrial malignancy.
 19 Nortestosterone derivative like
Norethisterone acetate,
Medroxyprogesterone acetate or Natural
progetsin like Dirogestrone are used.

41.  Tab.Norethisterone 10mg from 16th day to
25th day for 6-9 months – For Anovulatory
DUB
 For Endometrial hyperplasia –it can be
started from 5th day of period till 25th day
for 6-9 months – For Ovulatory DUB
 Micronized progesterone 200 mg per day for
12 days in a cycle for 6-9 month
 Useful also for Premenstrual spotting also.

42.  First line treatment for ovulatory DUB
 It makes endometrium atrophic.
 Estrogen and Progesterone combination pill
used for 4-6 time a day followed by a single
tablet per day for 21 day for 6-9 month
 Efficacy – 50 % reduction in bleeding.

43.  It stabilizes endometrium
 Forms clot formation in capillary bed and
vasoconstriction in spiral arterioles.
 25 mg intravenously four hourly in 12 to 24
hrs till bleeding stops
 Followed by 1.25 to 2.5 mg tab for 21 days
along with Tab. Medroxy progesetrone
acetate 10 mg for last 10 days.

44.  Acts by down regulating pituitary
 Decapeptyl or Luprolide given
subcutaneously or intramuscularly monthly
for 3-6 months.
 Used in women who are at perimenopausal
age, preoperatively, young patient with
medical disorder, anaemia or
immunosuppressoin.
 Estrogen ‘ Add Back’ supplementation is used
to prevent osteoporosis.

45.  Ormeloxifene:
 Weak estrogenic and good antietrogenic
action
 60mg twice daily for 12 weeks.
 60 mg weekly for 3-6 months
 Useful in perimenopausal women with
hormonal deficiency
 Efficacy – 60 % reduction in bleeding.

46.  A Synthetic androgen, antiestrogenic and
antiprogestogenic action.
 Acts by competitive inhibition at
pituitaryreceptor sites decreasing gonadotropins.
 Makes endometrium atrophic.
 Tab. 200 -400 mg per day for 3-6 months
 Useful in Young adolescent women
 Efficacy - 60 % reduction in bleeding
 Side effects - weight gain, acne, menopausal
symptoms, Hirsutism, Jaundice
 Used for short course, before surgery.

47.  Useful in Anovualtory DUB in omen who want
or desire to conceive.
 Tab.50-150 mg from day to 5 day of period
for 3 -6 months.

48.  Atrophies endometrium.
 It will release 20 micrograms of
Levonorgestrel per day used for 5 years.
 Efficacy -80-98 % reduction in bleeding
 20 % will become amenorrheic
 Alternative to surgery
 Other IUDs:
 1. Metraplant IUCD
 2. Azzam IUCD

50.  Two types:
 Conservative Surgical:
 Endometrial Ablation techniques
 Radical treatment:
 Myomectomy
 Hyterectomy

51.  Minimally invasive surgical technique to treat
heavy menstrual bleeding.
 Indication:
 1. Failure of medical treatment
 2. Women who have completed child bearing
 3. Women who are not candidates for surgery

52.  Hysteroscopic:
TCRE – Tran Cervical Resection of
Endometrium
Roller Ball coagulation
LASER ablation
 Non Hysteroscopic:
 Thermal balloon therapy [ Therma choice]
 Microwave endometrial ablation
 Heated free fluid – HydroThemAblator [HTA]
 Cryoablation
 Radiofrequency ablation

55.  It should be last resort
 Definitive treatment
 High rate of patient satisfaction
 Not a choice in young reproductive age group
women.

56.  Perimenopausal age [ >40 yrs]
 Women who have completed child bearing
 Failed medical treatment, medical treatment
contraindicated, not tolerated.
 Failed ablative therapy
 Endometrial hyperplasia with atypia.
 Other pelvic pathology that needs treatment

57.  1. NDVH - Non Descent Vaginal hysterectomy
 2. LAVH – Laparoscopic assisted vaginal
hysterectomy
 3. TLH – Total laparoscopic hysterectomy
 4. TAH &BO – Total abdominal hysterectomy
and bilateral salpingo-oopherectomy
 5. Subtotal Hysterectomy -rarely

58.  Each completely soaked pad or Tampon holds
about 5-15 ml of blood.
 Normal age of Menarche starts from 9 yrs.
 Menopause starts from 48 yrs onwards
 Reproductive age means from age of
menarche to menopause. [ 15 to 49 yrs]
 Early menopause starts from 40 yrs.
 Adolescent is between 10 and 19 yrs
 Puberty means starts from 8-14 yrs
 Youth – 15 to 24 years
 Young - 10-24 yrs

59.  Local growth factors play a very important
role in regeneration of endometrium.
 They are
 1. Epidermal Growth Factor
 2. Insulin like Growth Factor I and II
 3. Platelet Derived growth Factor
 4. Transforming Growth factor Alfa and
Beta
 Analogue of thee factor may be a ne
therapeutic tool for DUB treatment

60. Thank You All