Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB) is bleeding from the uterus that is longer than usual or that occurs at an irregular time. Bleeding may be heavier or lighter than usual and occur often or randomly. AUB can occur: As spotting or bleeding between your periods.

1. PALESTINE POLYTECHNIC UNIVERSITY
Faculty of Medicine and Health Sciences
MohmmadRjab Seder

2. oDefineAUB.
oGetabriefoverviewofnormaluterinebleeding(menstruation).
oDistinguishtheAUBfromothersimilarterms.
oDescribeetiologiesofAUB.
oClassificationofAUB.
oPatternsofAUB.
oAssessingAUB?
oDiagnosis(Examination+Labtests)
oManagement.
Learning Objectives

3. oTheperiodicbloodthatflowsasadischargefromthewoman’s
uterus.
oNormaluterinebleedingisalsocalledmenorrhea.
oTheprocessbywhichmenorrheaoccursiscalledmenstruation.
oThetimeofthecycleduringwhichmenstruationoccursisreferredto
asmenses.
What is Normal Uterine Bleeding?

4. oFemalesofreproductiveage.
oShadingoftheendometrium.
oControlledbytheendocrinesystem(HPOAxis).
Menstruation –Brief Overview

5. Menstruation –Brief Overview
Normal
Menses
Frequency
24-35 days
Duration
2-8 days
Avg blood
loss
(30-40 ml)
Pad count
not reliable
to quantify
blood loss
Symptoms
associated
with
menstrual
cycle
Heavy
blood loss
is >80
ml/cycle
↑ Cervical mucus secretions at
mid-cycle
Premenstrual symptoms (cramps,
breast tenderness, bloating,
appetite/mood changes)

6. oAbnormal uterine bleeding (AUB):variation in normal bleeding
patterns.
oFrequency
oRegularity
oDuration
oVolume
oFrequent condition in Gynecology.
oThe commonest menstrual problem during perimenopause.
oAUB may be acuteor chronic(> 6months).
oAcute??
What is AUB?

7. oMenorrhagia:prolongedorheavymenstrualbleedingatregular
intervals.
oMetrorrhagia:bleedingbetweennormalmenses(irregularintervals).
oMenometrorrhagia=Menorrhagia+Metrorrhagia
=Heavybleedingbetweennormalmenses
oPolymenorrhea:frequentmenstrualbleeding.
oOligomenorrhea:uterinebleedingatintervals>35days.
oHypomenorrhea:abnormallylowbleeding(<30mL/menstrualcycle).
Related Terms

8. Age group:
oPremenarchal
oPostmenopausal
oReproductive
oPregnant
oNon-pregnant
oAbnormal Uterine Bleeding (AUB)
oDysfunctional Uterine Bleeding (DUB)
Vaginal Bleeding

9. Effects of AUB on different aspects

10. How to Measure Blood Loss?
Tocalculateactualmenstrualbloodloss,multiply
thenumberofhygieneproductsusedduring
periodby5ml(incaseofregularsizeproducts)or
10ml(forextra-absorbentproducts).Multiplythis
numberby0.36(WHY?)togettheapproximate
amountofbloodyoulostduringyourperiod.

11. oAwomanused9extra-absorbentpadsduringher
period.Whatistheaveragebloodlossduringa
typicalmenstrualcycle?
A.90mL
B.66mL
C.40mL
D.33mL
Question
✔

12. Advantages and disadvantages of
methods to measure menstrual
blood loss
Click Here

13. Etiologies | PALM-COEIN Scheme

14. PALM-COEINScheme
Each letter indicates
one of the etiologies of
bleeding:
PALM
Assessed by inspection,
imaging and histopathology.
COEIN
Needs further workup
PALM-COEIN Classification System

15. Distribution of Cases as Per Clinical
Diagnosis
Chinese women aged 15 to 55 yearsIndian women aged 40 years till menopause

16. Usual Causes of AUB Vary by
Female Age

17. Patterns of AUB

18. oEndometrialpolyps.
oUsuallyBENIGN.
oCharacteristics:
oUsuallylight.
oIntermenstrual.
oDiagnosis:
oTransvaginalultrasonography(TVUS)
oHysteroscopy
oHistologicexamination(WHY??)
oManagement:
oHysteroscopy
PALM-COEIN | Polyps

19. oEndometrialtissuegrowsintothemuscularwalloftheuterus.
(tissuedevelopsectopically)
oBENIGN.
oCharacteristics:
oDysmenorrhea.
oHeavymenstrualbleeding.
oChronicpain.
oEnlargeduterus.
oRespondtohormonalchangesthroughoutthecycle.
oDiagnosis:
oHysterectomy(histopathologicalanalysisofuterus)
oManagement:
oHysterectomy
oContraceptives.
PALM-COEIN |Adenomyosis

20. oUterinefibroids
oBENIGH growths oftheuterus
(myometrium)thatoftenappearduring
childbearingyears.
oMostcommonpelvictumor(Repr.AgeF.)
oCharacteristics:
oDiagnosis:
oManagement:
PALM-COEIN |Leiomyoma

21. oMalignancyandHyperplasia
oCharacteristics:
oDiagnosis:
PALM-COEIN |Malignancy

22. o15%ofAUBcaseshavecoagulopathies.
ovonwillebranddiseaseisthemostcommon
hereditarycoagulationabnormality.
oFamilyhistory.
oLabs:
oCBC
oPT
oPTT
ovWFantigen.
PALM-COEIN |Coagulopathy
If 1, 2 or 3 is ascertained, it indicates
positive screen, and further referral
for appropriate investigation should
be considered.

23. oExcessivelyheavy,prolonged,orfrequentbleeding.
oAnovulatoryAUB
ounpredictabletimes
ounpredictablepatterns
oOvulatoryAUB
oexcessivebleedingduringregularmenstrualcycles
oDiagnosis:
oExclusionofotherpotentialcauses
oCBC,pregnancytest,andhormonemeasurement(eg,TSH,prolactin)
otransvaginalultrasonography.
ohysteroscopy
oManagement:
oHormonaltherapy:e.g.OCTs,GnRHagonists
oNSAIDs
oTranexamicacid
PALM-COEIN |Ovulatory disorder

25. oEndometrialdysfunction.
oAUBthatoccursinthecontextofastructurallynormaluteruswith
regularmenstrualcycleswithoutevidenceofcoagulopathyislikely
tohaveanunderlyingendometrialcause.
oLackofclinicallyavailablespecifictestsorbiomarkersmeans.
oDiagnosis:
ocarefulhistorytakingandexclusionofothercontributors.
PALM-COEIN |Endometrial

26. oExogenoustherapythanmayleadtounscheduledendometrial
bleeding
oTypicallyassociatedwithcontinuousoestrogenorprogestintherapy.
oIUD→low-gradeendometritis→AUB.
PALM-COEIN |Iatrogenic

27. oRareorpoorlydefinedpathologiesthatdonoteasilyfitwithinthe
othercategories.
oExamples:
oarteriovenousmalformations.
oendometrialpseudoaneurysms.
omyometrialhypertrophy.
ochronicendometritis.
PALM-COEIN|Not yet classified

28. oInitialassessment–Historyandphysicalexamination.
oLaboratorytests–pregnancytest,testsforinfections,bloodtests.
oTeststodetermineovulatorystatus–ovulation?
oEndometrialassessment.
oEndometrialbiopsy.
oTransvaginalultrasound.
oHysteroscopy.
oSalineinfusionsonography(sonohysterography).
AUB Evaluation

29. SpecifictreatmentoptionsforindividualPALM-COEINcausesofAUB.
Management

30. The medical management of abnormal uterine bleeding in
reproductive-aged women
Click Here
Management –Further Reading

31. oBenetti-Pinto,C.,Rosa-e-Silva,A.,Yela,D.,&SoaresJúnior,J.(2017).AbnormalUterineBleeding.InRevista
BrasileiradeGinecologiaeObstetrícia/RBGOGynecologyandObstetrics(Vol.39,Issue07,pp.358–368).
GeorgThiemeVerlagKG.https://doi.org/10.1055/s-0037-1603807
oMishra,D.,&Sultan,S.(2016).FIGO’sPALM–COEINClassificationofAbnormalUterineBleeding:AClinico-
histopathologicalCorrelationinIndianSetting.InTheJournalofObstetricsandGynecologyofIndia(Vol.67,
Issue2,pp.119–125).SpringerScienceandBusinessMediaLLC.https://doi.org/10.1007/s13224-016-0925-8
oWhitaker,L.,&Critchley,H.O.D.(2016).Abnormaluterinebleeding.InBestPractice&amp;ResearchClinical
Obstetrics &amp; Gynaecology (Vol. 34, pp. 54–65). Elsevier BV.
https://doi.org/10.1016/j.bpobgyn.2015.11.012
oKaplanMedical.(2018).USMLEStep2CKLectureNotes2019:5-bookset.KaplanPublishing.
oKenny,L.,&Bickerstaff,H.(Eds.).(2017).Gynaecologybytenteachers,20thedition(20thed.).CRCPress.
oOsmosis
oUptodate
References

32. Thank You