“bleed

me up,
buttercup don’t
break my heart”

PGI MRAB
Objectives
• Define Abnormal Uterine Bleeding and Heavy
Menstrual Bleeding
• Differentiate Acute Abnormal Uterine Bleeding
from Chronic Abnormal Uterine Bleeding
• Provide brief overview on the classification of
Abnormal Uterine bleeding, its diagnosis and
management
Abnormal Uterine Bleeding
• Encompasses any significant deviation from normal
frequency, regularity, heaviness (volume or
amount) and duration of menstrual bleeding.
Clinical Dimension of Normal Menstruation and Normal Menstrual Cycle
Menstruation and Normal 24-38 days
Frequency of Cycle
(Frequency of menses)

Duration of flow Normal 4.5 -8 days

Volume of monthly blood Normal 5-80 ml
loss
Fraser IS1 , Critchley HO, Broder M, Munro M. The FIGO recommendations on terminologies and definitions for normal and
abnormal uterine bleeding. Semin Reprod Med. 2011 Sep;29(5):383-90. doi: 10.1055/s-0031-1287662. Epub 2011 Nov 7
 Abnormal Uterine Bleeding
Symptoms (FIGO, 2018)

Munro MG, Critchley HOD, Fraser IS; FIGO Menstrual Disorders Committee. The twoFIGO systems for normal and abnormal uterine
bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018
Dec;143(3):393-408. doi: 10.1002/ijgo.12666. Epub 2018 Oct 10
 Abnormal Uterine Bleeding
Symptoms (FIGO, 2018)

Munro MG, Critchley HOD, Fraser IS; FIGO Menstrual Disorders Committee. The twoFIGO systems for normal and abnormal uterine
bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018
Dec;143(3):393-408. doi: 10.1002/ijgo.12666. Epub 2018 Oct 10
Heavy Menstrual Bleeding (HMB)
• Excessive menstrual blood loss which interferes
with a woman’s physical, emotional, social and
material quality of life, and which can occur alone
or in combination with other symptoms
• Replaces the term “menorrhagia”

Philippine Obstetrical and Gynecological Society (POGS) Clinical Practice Guidelines on Abnormal Uterine
Bleeding 2017.
Acute vs Chronic AUB

Acute AUB Chronic AUB

• An episode in bleeding in a woman of • Bleeding from the uterine corpus that
reproductive age who is not pregnant is abnormal in duration, volume,
• Sufficient quantity to require and/or frequency and has been
immediate intervention to prevent present for the majority of 6 months
blood loss

Fraser IS1 , Critchley HO, Broder M, Munro M. The FIGO recommendations on terminologies and definitions
for normal and abnormal uterine bleeding. Semin Reprod Med. 2011 Sep;29(5):383-90. doi: 10.1055/s-0031-
1287662. Epub 2011 Nov 7
 CAUSES of Abnormal Uterine
Bleeding

Munro MG 1, Critchley HO, Fraser IS; FIGO Menstrual Disorders Working Group. The FIGO classification of causes of abnormal uterine
bleeding in the reproductive years. Fertil Steril. 2011 Jun;95(7):2204-8, 2208.e1-3. doi: 10.1016/j.fertnstert.2011.03.079. Epub 2011 Apr 15
 CAUSES of Abnormal Uterine
Bleeding

Munro MG 1, Critchley HO, Fraser IS; FIGO Menstrual Disorders Working Group. The FIGO classification of causes of abnormal uterine
bleeding in the reproductive years. Fertil Steril. 2011 Jun;95(7):2204-8, 2208.e1-3. doi: 10.1016/j.fertnstert.2011.03.079. Epub 2011 Apr 15
 CAUSES of Abnormal Uterine
Bleeding

Munro MG 1, Critchley HO, Fraser IS; FIGO Menstrual Disorders Working Group. The FIGO classification of causes of abnormal uterine
bleeding in the reproductive years. Fertil Steril. 2011 Jun;95(7):2204-8, 2208.e1-3. doi: 10.1016/j.fertnstert.2011.03.079. Epub 2011 Apr 15
AUB- E
• Women who present with heavy menstrual bleeding in the
absence of other abnormalities are thought to have
underlying disorders of the endometrium (AUB-E)
• primary line of defense to excessive bleeding during normal
menses is the formation of the platelet plug->uterine
contractility (mediated by PGF2α)
• prolonged and heavy bleeding can occur with abnormalities
of the platelet plug or inadequate uterine levels of PGF2α.

Lobo, R. A., Gershenson, D. M, Lentz, G. M., & Valea, F. A. Comprehensive gynecology. 7th edition
AUB-E
• excessive uterine production of prostacyclin, a
vasodilatory prostaglandin that opposes platelet
adhesion and may also interfere with uterine
contractility
• uterine factors affecting blood flow, such as the
endothelins and vascular endothelial growth factor,
which controls blood vessel formation, may be
abnormal in some women with heavy menstrual
bleeding

Lobo, R. A., Gershenson, D. M, Lentz, G. M., & Valea, F. A. Comprehensive gynecology. 7th edition
Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Committee Opinion No.
557. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013; 121:891–6.
Management
 Diagnosis
• History and PE
• A thorough and methodical history is necessary in the
diagnosis of AUB
• Complete physical examination strongly advised on all
patients to identify any structural pathology or systemic
disease as the etiology for AUB

Philippine Obstetrical and Gynecological Society (POGS) Clinical Practice Guidelines on Abnormal Uterine Bleeding 2017.
Diagnosis
• 1. Pregnancy should be excluded in women of
reproductive age
• 2. An initial CBC with platelet count, PT, PTT are
indicated for all adolescents with acute heavy
menstrual bleeding (HMB) including adult patients
with positive screening history for bleeding
disorder

Philippine Obstetrical and Gynecological Society (POGS) Clinical Practice Guidelines on Abnormal Uterine Bleeding 2017.
3. Coagulation tests should be considered in women
with HMB since menarche, and/or have personal or
family history suggestive of coagulopathy a disorder
of hemostasis in pxs with HMB may be diagnosed in
90% of cases based on the ff circumstances:

Philippine Obstetrical and Gynecological Society (POGS) Clinical Practice Guidelines on Abnormal Uterine Bleeding 2017.
Lobo, R. A., Gershenson, D. M, Lentz, G. M., & Valea, F. A. Comprehensive gynecology. 7th edition
4. Female hormone testing (E2, progesterone, LH,
FSH, ) should not be routinely done on women with
HMB
5. Thyroid screening should only be obtained in the
presence of signs and/or symptoms of thyroid
disease.

Philippine Obstetrical and Gynecological Society (POGS) Clinical Practice Guidelines on Abnormal Uterine Bleeding 2017.
Imaging
• Ultrasound is the first line diagnostic tool for identifying
structural abnormalities
• Saline infusion sonography (SIS) is a useful tool in
providing a more accurate evaluation of the uterus with
intracavitary lesions
• Hysteroscopy should be performed when the
ultrasound results are inconclusive (eg to determine
the exact location of a fibroid or the exact nature of an
abnormality), or when focal lesions are seen within the
endometrium2. Outpatient endometrial biopsy should
be the first line diagnostic tool to use when assessing
women with HMB
Philippine Obstetrical and Gynecological Society (POGS) Clinical Practice Guidelines on Abnormal Uterine Bleeding 2017.
 The following are
indications for
endometrial biopsy:
• Age > 40
• Risk factors for
endometrial cancer
• Failure of medical
treatment
• Breast cancer
patients on
tamoxifen with AUB

Philippine Obstetrical and Gynecological Society (POGS) Clinical Practice Guidelines on Abnormal Uterine Bleeding 2017.
 Medical Management
• Hormonal:
• Levonorgestrel-releasing intrauterine system (LNG-IUS)
• Combined oral contraceptives (COCs)
• Progestins
• Danazol and GnRH
• Non-hormonal:
• Anti-fibrinolytic agents
• Nonsteroidal anti-inflammatory drugs (NSAIDs)

Philippine Obstetrical and Gynecological Society (POGS) Clinical Practice Guidelines on Abnormal Uterine Bleeding 2017.
Surgical Management
• The performance of a D&C can be diagnostic and is
therapeutic for the immediate management of severe
bleeding.
• D&C is the treatment of choice in women who suffer
from hypovolemia
• A D&C may be preferred as an approach to stop an
acute bleeding episode in women older than 35 when
the incidence of pathologic findings increases.
• Hysterectomy should only be used to treat persistent
abnormal uterine bleeding after all medical therapy has
failed, medical therapy is contraindicated, and the
amount of MBL has been documented to be excessive
by direct measurement.

Lobo, R. A., Gershenson, D. M, Lentz, G. M., & Valea, F. A. Comprehensive gynecology. 7th edition