Abnormal uterine bleeding Presentation *

Abnormal uterine bleeding

1. AUB
(ABNORMAL UTERINE
BLEEDING)

2. DEFINATION
•Any uterine bleeding outside the normal volume,
dura-tion, regularity or frequency is considered
abnormal uterine bleeding (AUB).
•Nearly 30% of all gynecological outpatient
attendants are for AUB:

3. NORMAL MENSTRUATION PARAMETERS
NORMAL RANGEPARAMETERS
28 DAYSCYCLE INTERVAL
<8 DAYSMENSTRUAL FLOW
35ML(5-80ML)MENSTRUAL BLOOD LOSS

4. Terminologies
•Menorrhagia -Blood loss>80ml(heavy menstrual bleeding).
-Bleeding >8days(prolongedbleeding).
•Polymenorrhea-Menses<24 days.(frequent bleeding)
•Oligomenorrhea -Menses>38 days(infrequent bleeding)
•Amenorrhea -Absence of menses.
•Disfunctionaluterine bleeding (DUB)-Abnormal uterine bleeding
without underlying pathology. Replaced by ovulatory disfunction.
•Metrorrhagia -Pre and post menstrual bleeding Intermenstrual
bleeding
•Breakthroughbleeding–related to harmonaladministration.
•Withdrawalbleeding -Due to abrupt decline in progesterone level.

5. COMMONCAUSESOFAUB

6. FIGOCLASSIFICATIONPALM-COEIN

7. DIFERENTIAL DIAGNOSIS OF AUB
Structural
•Uterine: Leiomyoma, adenomyosis, endometrial hyperplasia or
malignancy, arteriovenous malformatione
•Cervix: Polyp, cancer
•Fallopian tube ,Vagina : Cancer
•Ovarian tumors: Granulosa cell tumor.
•Anovulation -1)Thyroid dysfunction 2)Androgen excess:PCOS
3)Hyperprolactinemia 4)Premature ovarian failure
•Pregnancy complications: Miscarriages, gestational trophoblastic disease
(GTD).
•Iatrogenic: Medications-anticoagulants likeHeparin(LMWH), IUCD,
trauma
•Infections: STIs, endometritis, tuberculosis.

8. CAUSES
•Endometrial polyps (AUB-P) (hyperplasia): Localized outgrowth of
endometrial tissue (with glands,stroma, blood vessels) covered with
endometrial epithelium.TVS-is helpful for detection. Smaller polyps
(<1 cm) regress spontaneously, symptomatic polyps can be resected
hysteroscopically.
•Adenomyosis (AUB-A): Could be focal or diffuse. It is often
observed in multiparous women. MRI is more specific to make the
diagnosis. There is thickening of the junctional zone (JZ) >12 mm.
Caesarean delivery, vigorous curettage dilation, and evacuation are the
risk factors. Abnormal bleeding in adenomyosis is due to altered
uterine contractions.
•Leiomyoma(AUB-L)are benign tumors of the uterine myometrium.
Pathogenesis: myometrial injury leading to cellular proliferation,
decreased apoptosis, increased production of extracellular matrix, and
overexpression of transforming growth factor beta that leads to
fibrosis of these tumors.

9. CONT
.
•Malignancy (AUB-M): This bleeding includes female genital tract
(vulva, vagina, cervix, endometrium, uterus, tubes and ovary) cancers.
•Coagulopathy (AUB-C): Von Willebrand disease, prothrombin
deficiency, disorders of platelets, hemophilias(FVIII/FIX deficiency),
thrombocytopenia, purpura, leukemia, chronic anticoagulation (heparin,
LMWH) can cause menorrhagia. Women on heparin or LMWH may
present with AUB.
•Ovulatory dysfunction (AUB-O) is common during extremes of
reproductive life (postmenarchaland premenopausal) due to anovulation.
Continuous estradiolstimulation (without progesterone) lead to
endometrial proliferation. At one time, breakdown of endometrium starts
due to its outgrowth of blood supply. The cause of anovulatory bleeding
is due to immaturity (adolescent) or dysfunction (perimenopause
women) of HPO axis. The other causes of anovulatory bleeding are:
polycystic ovary syndrome, increased body weight, stress, weight loss,
severe exercise, drug use, endocrine abnormalities (hyperthyroidism,
hyperprolactinemia, hypercortisolism).

10. Cont.
•latrogenic(AUB-1): This may be due to use of medications.
Hormones: Contraceptives (OCs), UCDs including LNG-IUCD may
cause breakthrough bleeding. Medications:Valproate, drugs causing
hyperprolactinemia (ranitidine).
•Endometrial (AUB-E): Physiological mechanism to control bleeding
during menstruation are: (a) Formation of platelet plug, (b) Increased
myometrial contraction stimulated by prostaglandins (PGE2 alpha)
Chronic inflammatory changes of the endometrium may also cause
polyps, hyperplasia, endometritis, atrophy
•Not otherwise specified (AUB-N): Infection, PID, tuberculosis,
cervicitis, Asherman syndrome, foreign bodies, arteriovenous
malformations.

11. INVESTIGATIONS
•Von Willebrand factor: It is responsible for platelet adhesion and
protection against degradation of coagu-lationfactors.
•Family history of bleeding, epistaxis, bruising, gum bleeding, surgical
bleeding or PPH are indications for study of coagulation profile.
•USG for endometrial thickness
•Cervical cytology
•Women >45 years: Endometrial sampling (pipelle) or D&C under
anesthesia (biopsy at the time of bleeding to determine ovulatory
function)
•Saline infusion sonography (SIS), hysteroscopy and endometrial
biopsy (HMB)
•USG, MRI (myoma, adenomyosis)
•Laparoscopy in a selected case

12. Endometrial biopsy (EB)
Diagnostic uterine curettage (D&C) is indicated in AUB:
-To exclude the organic lesions in the endometrium(incomplete abortion,
endometrial polyp, tubercular endometritis or endometrial carcinoma).
-To determine the functional state of the endometrium.Uterinecurettage is the
quickest way to stop acute bleeding for women 235 years.
-D&C is indicated for women with acute bleeding resulting inhypovolemia and for
older women who are at higher risk of endometrial neoplasia.•Laboratoryinvestigationsrequired-
•CBC
•PT/PTT
•BTCT
•TSH

13. MANAGEMENT
MANAGEMENT
General MedicalSurgery
a)General
•Rest is advised during bleeding phase. Assurance and sympathetic handling
are helpful particularly in adolescents.
•Anemia should be corrected appropriately by diet, hematinics, and even by
blood transfusion.
•Any systemic or endocrinal abnormality should be investigated and treated
accordingly.

14. b)Medical management
•Non harmonalmanagement-
1)NSAIDs -prostaglandin synthase inhibitor-all NSAIDsinhibit cyclooxygenase
and thus block the synthesis of both thromboxane and prostacyclin pathway.
•NSAIDs reduce menstrual blood loss in ovulatory DUB by about 25% to 50%.
Mefenamic acid is much effective in women aged more than 35 years and in cases
of ovulatory DUB.
•NSAIDs may be used assecondlineofmedical treatment.
2)Tranexamic acid-Antifibrinolytic agents are potent inhibitors of fibrinolysis. They
reduces menstrual blood loss by 50%.
•It counteracts the endometrial fibrinolytic system.
•It is particularly helpful in IUCD induced menorrhagia.
•Antifibrinolytic agents can be used as a second line therapy.
•History of thromboembolism is a contraindication to its use.

15. •Harmonal
•Orally active progestins, are the mainstay in the management of AUB in
all age groups.
•Progestins (AUB-O):
A. In adolescents: Coagulation disorders are to be ruled out.
Cyclic progesterone: Medroxyprogesterone acetate (MPA) 10 mg once
or twice a day 10 days each month for 6 months is effective. COCs may
be an option if the problem persists beyond 6 months.
B. During reproductive life ovulatory bleeding can be controlled with
COCs. Alternative is to start cyclic progesterone
C. Perimenopausal women can be treated with low dose (20 µg) COCS.

16. Twotherapy-cyclic and continuous
Cyclic therapy
•5th to 25th day course :In ovular bleeding. Any low dose combined oral
pills are effective when given from 5th to 25th day of cycle for 3
consecutive cycles it causes endometrial atrophy.
•It is more effective compared to progesterone therapy as it suppresses the
hypothalamopituitary axis more effectively
•In anovularbleeding: Cyclic progestogen preparation of
medroxyprogesterone acetate (MPA) 10 mg (TTD) or norethisterone 5 mg
(TID) is used from 5th to 25th day of cycle for 3 cycles.
•15th to 25th day course:Inovular bleeding, where the patient wants
pregnancy or in cases of irregular shedding or irregular ripening of the
endometrium, dydrogesterone1 tab (10 mg) daily or twice a day from 15th
to 25th day may cure the state. This regimen is less effective than 5th to
25th day course. However, it does not suppress ovulation.

17. Cont.
Continuous therapy
•Progestins inhibit pituitary gonadotropin secretion and ovarian
hormone production.
•Medroxyprogesterone acetate 10 mg thrice daily is given and
treatment is usually continued for at least 90 days.

18. SURGICAL MANAGMENT
•Surgery:
(1) Uterine curettage (D AND C)
(II) Global endometrial ablation (GEA) techniques
(II) Uterine artery embolization
(iv) Hysterectomy.

19. Cont
.
➤Uterine Curettage-
•predominantly as a diagnostic tool for elderly women.
•Quickest way to stop bleeding in hypovolemic patients
•it has got hemostatic and therapeutic effect by removing the necrosed
and unhealthy endometrium.
➤Endometrial Ablation-
>35 years, completed family, failed medical therapy, small uterine
fibroid<3cm
➤Uterine Artery Embolization -large uterine fibroid>3cm, heavy
bleeding
➤Others include:hysteroscopywith D&C, polypectomy, myomectomy.

20. cont,.
•Hysterectomy in AUB
•Indications-
conservative treatment fails or contraindicated
blood loss impairs the health and quality of life
endometrial hyperplasia and atypia
patient is approaching 40/ completed family
•Types-
1. Total hysterectomy
2. Subtotal hysterectomy
3. Pan-hysterectomy
4. Extended hysterectomy
5. Radical hysterectomy

21. CON
T.
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