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1. Abnormal Uterine Bleeding By Dr. Abel(Assistant Prof. of Ob-Gyn) Date:-May 28/2018

2. Abnormal Uterine Bleeding(AUB) FIGO system Recommended descriptive nomenclature for symptoms of AUB Frequency –Frequent <24 days - Normal 24-38 days -Infrequent <24 days Regularity- Absent -Regular Variation +/- 4days -Irregular Variation >4days Duration- Prolonged >8days -Normal 4.5-8 days -shortened <4.5 days Volume –Heavy >80ml -Normal 5-80ml -Light <5ml

3. Acute Versus Chronic AUB Acute AUB is ab episode of bleeding that is of sufficient quantity to require immediate intervention to prevent further blood loss. Chronic AUB is bleeding from uterus that is abnormal in duration, volume, regularity and or frequency that has been present for the majority of the last 6 months Abnormal Uterine Bleeding(AUB)

4. FIGO classification for causes of AUB in non pregnant reproductive years Structural Abnormality P olyp A denomyosis L eiomyoma M alignancy&hyperplasia No structural Abnormality C oagulopathy O vulatory dysfunction E ndometrial I atrogenic N ot yet classified

5. Normal Menstrual cycle Endometrial Ovarian

6. Local endometrial requirements for menstrual hemostasis High levels Vasoconstrictors PGF2 alpha Endothelin-1 Cloting mechanisms Tissue factor pathway Contact activation Low levels Vasodilators PGI2 PGE2 Fibrinolytic activity Plasminogen activator

7. Causes of ovulatory dysfunction Obesity Low BMI Weight change Psychological stress Elite Athlet Endocrinopathy (Thyroid dysfunction,polycystic ovarian syndrome(PCOS) and hyperandrogenism,hyperprolactinemia and Idiopathic)

8. Mechanism of AUB Endometrial(Disturbance in function) Decreased vasoconstrictors: Increased vasodilators PGF2 alpha/PGE ratio Increased prostacyclin(Vasodilator) Increased plasminogen activator

9. Iatrogenic AUB (AUB-I) Systemic pharmacotherapy Gonadal steroids Other( Phenothazines , Tricyclic antidepressants) Medical devices(Intrauterine device) Mechanism of AUB

10. AUB Not yet classified(AUB-N) includes Arteriovenous malformation Myometrial hypertrophy Association with systemic disease Mechanism of AUB

11. Patient evaluation Structural Polyp Adenomyosis Leiomyoma Malignancy Test SIS, Hysteroscopy TVUS,MRI TVUS, Hysteroscopy Endometrial sampling(Biopsy)

12. Patient evaluation Non structural Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Test Lab testing Structured history, timed lab testing No available test Structured history

13. Treatment Acute AUB Combined oral contraceptive pills 1 tab po TID for one week then 1 tab po daily for 3 weeks Projestins Iron therapy if there is Iro deficiency anemia

14. Treatment of chronic AUB-O Medical or Surgical decision is based on patient need for fertility Medical Treat the cause if identified Combined oral contraceptive pills Cyclic progestins GnRH (Agonist, Antagonist) Surgical Endometrial ablation Hysterectomy

15. Treatment of chronic AUB-E &AUB-C Medical NSAIDS Antifibrinolytics COCPs Danazol Progestin IUD Surgical Endometrial ablation Hysterectomy

16. Treatment of AUB due to structural cause AUB-P - Hysteroscopic polypectomy AUB-L(Medical or surgical) Medical COCPs Progesterone GnRH agonist or antagonist Progesterone receptor modulators Antifibrinolytics Aromatase inhibitors Surgical Hysteroscopic myomectomy Laparoscopic myomectomy Uterine artery embolization Focused ultrasound myolysis Endometrial ablation Hysterectomy

17. AUB-A Medical( Levonorgestrel IUD system) Surgical-endometrial ablation -uterine artery embolization -Hysterectomy Treatment of AUB due to structural cause

18. THANK YOU