Normal & Abnormal 


Uterine Bleeding

Syamel Muhammad
 Curriculum Vitae
Nama : Dr. Syamel Muhammad, SpOG K.Onk

Nip : 198320112008121001
E-Mail : Syamelmuhammad@yahoo.com
Kantor : Bagian/SMF Obstetri dan Ginekologi Fakultas Kedokteran Universitas Andalas
Status : Menikah
Riwayat Pendidikan : Pendidikan Dokter Fakultas Kedokteran Univ. Andalas (2001-2007)
PPDS Obstetri dan Ginekologi Fak.Kedokteran Univ. Andalas (2008- 2013)
PPDS 2 Onkologi Ginekologi Fak. Kedokteran Univ. Padjajaran
Riwayat Pekerjaan : Staf Pengajar Fak. Kedokteran Univ. Andalas (2008-sekarang)
Pelatihan :
1. Advanced Ultrasound in Obstetri and Gynecology
2. Tutor Training
3. TOT Evidence Based Medicine
4. Workshop How to set Up Clinical Trial
5.Pembicara pada: Applied Surgical Anatomy in Obstetrics and Gynecology Surgery Workshop
6.The 3rd Basic Laparoscopic Surgical Skill Training Program in Gynecologic Oncology
7.Laparoscopy training in 7th INASGO Bineal meeting
8.Gynecology Cancer Screening and Management
9.XVIII World Congress on Gestational Trophoblastic Diseases
Makalah :
• Simple Hysterectomy in Cervical Cancer (PIT POGI 19)
• The Deference of Uterine Artery Resistence Index (RI) and Pulsatility Index (PI) between Early Onset Severe Preeclampsia and Late
Onset Severe Preeclampsia. (Tesis)
Pengabdian Masyarakat :
1. Tenaga Kesehatan pada World Cancer Day event di Bandung
2. Tenaga kesehatan pada Bakti Sosial Pemeriksaan Kesehatan dan pengobatan gratis di Kota Bandung
3. Pembicara pada Pelatihan deteksi dini kanker leher rahim dan kanker payudara di kabupaten Indramayu Jawabarat
4. Pembicara pada Pelatihan deteksi dini kanker leher rahim dan kanker payudara di kabupaten Pangandaran Jawabarat
Objectives
! Recognize the characteristics of Normal
Menstrual Bleeding (The LMP as the fourth vital
sign!)
! Describe the etiologies of Abnormal Uterine
Bleeding (AUB.)
! Understand etiologies of AUB with respect to
the life stages of women.
! Understand the diagnostic tools to identify the
etiology of the AUB.
! State the medical & surgical options available
in primary care and gynecology settings.
Normal Menstruation

! The Menstrual Cycle

In the normal menstrual cycle, orderly cyclic
hormone production and parallel proliferation of
the uterine lining prepare for implantation of the
embryo.

Berek & Novak’s Gynecology, 2012, p.145

 Normal Menstruation

! “The menstrual cycle starts with the first day of

bleeding of one period and ends with the first
day of the next. In most women, the cycle last
about 28 days. Cycles that are shorter or longer
by 7 days are normal.”
ACOG Website: FAQ095
The Normal Menstrual Period

! Blood loss < 80 ml (average 30-35 ml)

! Duration of flow 2-7 days (average 4 days)
! Cycle length 21 - 35 days (average 29 days)
(28 days +/- 7 days}
Phases of the Menstrual Cycle

Reproductive Cycle
! Follicular
! Begins with Menses ends with luteinizing (LH) hormone
surge
! Ovulation (30-36 hours)
! Begins with LH surge and ends with ovulation
! Luteal (14 days)
! Begins with the end of the LH surge and ends with
onset of menses
The Normal Menstrual Cycle

Another Way of looking at it

M. Manting; DUB LECTURE 2008

Phases of the Menstrual Cycle

Endometrium
! Proliferative
! Begins with menses and ends at ovulation

! Secretory
! Begins at ovulation and ends with menses
The Normal Menstrual Cycle

Another Way of looking at it

M. Manting; DUB LECTURE 2008

Regulation:

Hypothalamic Pituitary Axis
! Hypothalamus is the
pulse generator
mediated through
GnRH

! GnRH cannot be
directly measured

! Negative Feedback
Abnormal Uterine Bleeding (AUB)
! Definition: ! Prevalence:
! Any change in ! 20 million office
menstrual period
! Flow visits/year
! Duration ! 25% of visits to
! Frequency
gynecologists
! Bleeding
between
cycles
 Old Terminology

! Menorrhagia ! Dysmenorrhea
! Metrorrhagia ! Amenorrhea
! Menometrorrhagia ! Oligomenorrhea
! Polymenorrhea ! Hypomenorrhea
New Terminology
! Heavy Menstrual Bleeding
! Acute
! Chronic

! Intermenstrual Bleeding
History for AUB
!Onset

!Quantity :
!Spotting or heavy
!daily or intermittent

!Duration
History for AUB
! Associated
Symptoms
! Pain ! Fever/chills
! Dysmenorrhea ! Changes in hair/
! Menstrual body
Changes ! Bruising/bleeding
! Timing
! Rectal/urethral
! Flow (clots)
bleeding
! Frequency
! Nausea/vomiting
Gender Specific History

! Menstrual
! Contraception
! Gynecologic
! Obstetric
! Sexual
! Genital Infections
Other Important Details
! Family History ! Chronic conditions
! Anyone else? ! Liver disease
! Von Willebrand's ! Kidney disease
! PCOS
! Anemia
! Drugs /medications
! Psychiatric
! Nutrition and exercise
medications
! Weight changes ! Thyroid Disorders
! Exercise habits
! Blood thinners
! diet


Differential Diagnosis Of AUB
!Structural: PALM-COEIN
(Non Gravid Women)

!Life Cycles: Pre-menarche

Menarche
Reproductive
Post-Menopause

!Anatomic: “Bottoms Up”

P
Pregnancy

Never
Age is Not Forget
An Issue! Pregnancy

PROVE IT!

Assumptions can
lead to death
PALM-COEIN
! FIGO Classification System (PALM-COEIN)
for causes of AUB in non gravid women of
reproductive age

! Structural vs. Non-Structural

! Developed to create a universally

accepted nomenclature
PALM

Structural Causes


P- Polyp (AUB-P)

A- Adenomyosis (AUB-A)

L- Leiomyoma (AUB-L)

Submucosal myoma (AUB-LSM)

Other myoma (AUB-LO)

M- Malignancy & hyperplasia (AUB-M)
COEIN

Non-Structural Causes

C- Coagulopathy (AUB-C)

O-Ovulatory dysfunction (AUB-O)

E- Endometrial (AUB-E)

I- Iatrogenic (AUB-I)

N- Not yet classified (AUB-N
AUB-O
! Abnormal Uterine Bleeding with ovulatory
dysfunction
! Heavy, irregular bleeding
Causes of Anovulation:


Physiologic

! Adolescence
! Menopause Transition
! Lactation
! Pregnancy
Causes of Anovulation



Pathologic
❑ Hyperandrogenic ! Thyroid disease
anovulation (e.g., ! Pituitary disease
PCOS, CAH, or ! Premature ovarian
androgen- failure
producing tumors)
! Iatrogenic (Chemo)
❑ Hypothalamic
! Medications
dysfunction
❑ Hyperprolactinemia
Liver Disease
! Patients known to have liver disease
manifest additional symptomatology
because of abnormal hepatic function.

! Evaluate patients for spider angioma,

palmar erythema, splenomegaly, ascites,
jaundice, and asterixis.
 C Coagulation Disorders
Rule out
von Willebrand's
in any girl who
requires
transfusion for excessive
Coagulation Disorders bleeding
when first
starting periods

Inherited Acquired Drug Induced

von Willibrand's ITP coumadin/heparin
hemophilia leukemia aspirin
 O
Bleeding from ther Sites
! GI
! Neoplasia or hemorrhoids
! GU
! Urethral caruncle or diverticulum
! Renal lithiasis or hemorrhagic cystitis
! GYN
! Labia, cervix, or vagina
! Trauma, infection, or
Remember
neoplasia Hemoccult
& Urinalysis
Differential Diagnosis

of AUB: Life Cycles
! Pre-Menarche

! Menarche

! Reproductive

! Postmenopausal
 Etiology
of AUB
Life Cycles
Approach

Menarche Reproductive Post-

Premenarchal
Menopausal

• Coagulation
• E2 withdrawal • Pregnancy
Defects • Carcinoma
@birth • Anovulation
• Hypothalamic • Vaginal Atrophy
• Foreign Body • Endogenous
Immaturity • E2 Replacement
• Sarcoma • Exogenous
• Psychogenic • Anatomic
• Ovarian Tumor • Anatomic
• Trauma
Differential Diagnosis of AUB:
Structural
! “Bottoms Up” ! Contiguous
! Vulva Anatomy
! Vagina ! GU
! Cervix ! GI
! Ovary
! Brain ! Non-Pelvic Etiology
! Endogenous
! Iatrogenic
Vulvar
! Infections
! HPV
! Atrophy
! Benign Lesions
! Cancerous lesions
! Dermatologic Causes

PHYSICAL EXAM: INSPECTION IS IMPORTANT

Vagina
! Malignancy :
! Carcinoma ! Laceration/trauma
! Sarcoma

! Atrophic changes
! Infections

! Foreign bodies ! Granulomatous

! Diaphragm, Pessary tissue
! Tampon ! formed after surgery
! other ! post hysterectomy
Physical Exam: Inspection is important
Cervix
! Neoplasia
! Cancer
! Polyps
! Myomas
! Cervical Eversion (Ectropion)
! Infection
! Cervicitis
! Condyloma Acuminata

IMPORTANT:
Visualize the Cervix!
 Postmenopausal
Bleeding

Uterus is considered
endometrial cancer
until proven otherwise
! Myomas
! Polyps
! Endometrial Hyperplasia
! Endometrial Carcinoma Postmenopausal
bleeding
! Atrophy is evaluated
by an
Endometrial
biopsy
Most PMB
PHYSICAL EXAM: Bimanual Exam checks Is due to
enlargement Atrophy
Ovary
! Anovulation
! PCOS
! Menopause Transition
Pathophysiology

Etiologies Of AUB
! Estrogen Withdrawal

! Estrogen Breakthrough

! Progesterone Withdrawal

Clinical Management of Abnormal Uterine Bleeding:

APGO Educational Series, May 2002, p. 8.
Initial Assessment of AUB
!Acute

!Sub-Acute

!Chronic
Initial Assessment of AUB

! History & Physical

! Vital Signs
! Shock Signs

! Laboratory
! Pregnancy Test
! Complete Blood Count
EVALUATION OF AUB

! Pregnant?

YES NO
! Evaluate for ! Structural (PALM)
complications ! VS.
! IUP, SAB, Ectopic ! Non-Structural
(COEIN)
Evaluation of AUB
! Evaluation of the Endometrium
! Pregnancy test
! Endometrial Biopsy
! Transvaginal &/or abdominal Ultrasound (TVS/AUS)
! Saline Sono-hysterocopy (SIS)
! Hysteroscopy
! Evaluation of the Uterus
! TVS
! SIS
! Hysteroscopy
Endometrial Biopsy (EMB)
! Evaluation of the
Endometrium
! Pipelle
Transvaginal Ultrasound
! To assess for thickened endometrium
! In 92% of abnormal endometrial biopsies,
ultrasound showed >5mm endometrium
! In 96% of endometrial cancer by biopsy result,
ultrasound showed >5mm endometrium
! Therefore, ultrasound measured endometrium
<5mm is likely benign uterine condition
TVS & SIS

TVS

SIS
Hysteroscopy
MRI
! Precisely localizes sub-mucosal fibroids

! MRI is not superior to TVS & SIS in overall

diagnostic potential

Dueholm M, et al. Fertil Steril. 2001;76(2):350357

Treatment of AUB
! Observation
! Medical
! Minimally invasive surgery
! Major surgery
Medical Management
! Iron ! Parenteral estrogens
! Anti-fibrinolytics ! Androgens
! Progestins ! GnRH agonists
! Estrogen + progestins ! Anti-progestational
(OCP) agents
 Minimally Invasive Surgery

! Intrauterine Device (IUD) with progesterone

! Dilation & Curettage

! Endometrial Ablation
Major Surgery
! Myomectomy
! Total Abdominal Hysterectomy (TAH)
! Total Vaginal Hysterectomy (TVH)
! Laparoscopic Hysterectomy
! LSH (laparoscopic supra-cervical)
! TLH (total laparoscopic)
! LAVH (laparoscopically assisted vaginal
hysterectomy)
! Robotic (TLH or LSH)
Management of Acute AUB
! Can be a life-threatening emergency
! Monitor Vital signs, Start oxygen
! IV fluids (wide bore IV catheter)
! Type and Cross 2-4 units of blood
! IV Estrogen
! IM Progesterone
! NSAIDS (Anti-prostaglandins vs. Anti-
fibrinolytics)
! Emergency Dilatation and Curettage (D&C)
Treatment in Chronic, 

Stable AUB

! High dose OCP’s to slow the bleeding

! Anovulatory Bleeding can be treated with
progesterone alone
! Endometrial sampling is indicated prior to
starting hormones in older women
Clinical Pearls

Never
Forget
Pregnancy! PROVE IT!
Age is
Not an Issue!

Assumptions Can
Lead to Death!
References
! ACOG Practice Bulletin No. 136, July 2013
! Beckmann, et al., Obstetrics & Gynecology, 7th ed.,
Chapters 37, 39
! Clinical Management of Abnormal Uterine
Bleeding: APGO Educational Series, May 2002
! Dueholm M, et al. Fertil Steril. 2001;76(2):350357
! Fritz, MA, Speroff et al, Clinical and Gynecologic
Endocrinology and Infertility,
8th ed. 2011.
! Manting M., AUB Lecture 2008
! Munro, MG, et al, FIGO Classification System
(PALM-COEIN) for causes of AUB in non gravid
women of reproductive age. Int J Gynaecol Obstet
2011; 113:3-13