F.

05 APPROACH TO MENSTRUAL ABNORMALITIES  Copper IUD

AND MENSTRUAL PAIN o Increases menstrual flow
Dr. Lucas | April 29, 2019 o Increases incidence of intermenstrual bleeding, reasons
why this is not really used
 Levonorgestrel IUD
OUTLINE
o Typically cause an initial period of irregular spotting or
I. History
bleeding, followed by a gradual decrease in menstrual
II. Physical Examination
flow and possible amenorrhea.
III. FIGO Classification of AUB
2. RISK FACTORS FOR ENDOMETRIAL CANCER
I. HISTORY  Any agent/factor that rises the level or time of
 The relevant medical history in non-pregnant reproductive- exposure to estrogen is a risk factor
age women with abnormal uterine bleeding (AUB) includes  One of the most common symptom of endometrial cancer
the following: is Abnormal uterine bleeding
o Older age - >35 years old
A. GENERAL HISTORY o Early menarche – average menarche in the Philippines is
1. GYNECOLOGIC AND OBSTETRIC HISTORY around 10 years old, if she has menarche earlier that
a. MENSTRUAL HISTORY that then it is a risk factor
 Ask for the patient’s age at menarche (first menstruation) o Late menopause – Average is 49 years old
 Ask the patient to describe her first menses as to how many o Nulliparity – never been pregnant
days? How many pads did she use? Were there any associated o Unopposed estrogen (Obesity, PCOS, HRT)
signs and symptoms? o Chronic Tamoxifen use – Tamoxifen is stimulatory to the
 Also ask the patient to describe the subsequent menses endometrial lining though inhibitory to the breast that’s
 The menarche could be the basis of how the patient’s menses why it is a treatment for breast cancer.
would be, the regularity of the menses afterwards.  If a patient with breast cancer that is on tamoxifen
 Subsequent menses: suddenly develops abnormal uterine bleeding it is
o Interval then an indication for diagnostic curettage
 Ask if the patient’s menses is monthly or regular, if o Previous pelvic irradiation
irregular, ask why o Hypertension, Diabetes mellitus
 More often than not patients would say it’s  What do they have in common? They are all exposed to
irregular because it does not fall on the same day estrogen for a longer period
every month o If a patient can’t get pregnant she is exposed to
 If for example, her last menses was January 1 st and unopposed estrogen
her next is February 8, it is still considered regular
because there is a normal interval for the interval B. OTHER MEDICAL HISTORY
 It is then your responsibility to educate your 1. BLEEDING DISORDERS
patient  Symptoms, risk factors (anticoagulant therapy,
o LMP thrombocytopenia, liver or renal disease), or a family history
 1st day of the patient’s last menses of a bleeding disorder.
 Women with a hematologic malignancy may present with AUB
b. SEXUAL HISTORY especially with the adolescent age group
 This information may help determine the patient's risk for o 3.6 per 1000 in one study
pregnancy and STI. o Associated symptoms include fatigue, dyspnea or SOB,
o Could present as abnormal vaginal bleeding bruising or petechiae, fever
c. HISTORY OF OBSTETRIC OR GYNECOLOGIC SURGERY
2. THYROID DISEASE
 A prior cesarean delivery, particularly multiple prior
 Symptoms or family history of thyroid disease
abdominal deliveries, raises the possibility that cesarean
 Associated with heavy menstrual bleeding or oligomenorrhea
scar defect may be responsible for AUB.
 Hypothyroidism causes heavy menstrual bleeding because of
 A prior myomectomy raises the possibility that uterine
an increase TSH
fibroids are responsible for AUB.
 READING ASSIGNMENT: In hypothyroidism, gonadotropin
o The risk of recurrence from uterine fibroids are quite
levels are usually normal. TSH, which is markedly increased
high
in hypothyroidism, has a small FSH- and LH-like effect
d. CONTRACEPTIVE HISTORY because of the shared alpha subunit. The mid-cycle FSH and
 Estrogen-progestin LH surge may thus be blunted or absent. Menorrhagia is a
o May develop unscheduled bleeding frequent complaint and is probably due to estrogen
o Used in the management of AUB but misuse of this could breakthrough bleeding secondary to anovulation, which is
also lead to AUB so it is important to ask how does she frequent in severe hypothyroidism
take the pills  Hyperthyroidism causes oligomenorrhea or amenorrhea
 Progestin only
o Irregular uterine bleeding or amenorrhea CELIAC DISEASE
o Known for spotting, minimal vaginal bleeding  May develop secondary amenorrhea.

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MEDICATIONS
 Anticoagulants - heavy or prolonged uterine bleeding
 A variety of medications can cause hyperprolactinemia
resulting in oligomenorrhea or amenorrhea
C. ADDITIONAL QUESTIONS
 Were there precipitating factors, such as trauma (such as
post-coital lacerations)
o Suggests a vaginal or cervical, rather than uterine
source of bleeding.
 Are there any associated symptoms?
o Lower abdominal pain
o Fever
o Vaginal discharge
 Could indicate infection such as pelvic
inflammatory disease and endometritis
o Dysmenorrhea, dyspareunia, or infertility suggests
endometriosis and/or adenomyosis
 Endometriosis manifests as increasing severity of
dysmenorrhea
o Changes in bladder or bowel function suggest
extrauterine bleeding or a mass effect from an enlarged
fibroid uterus or a neoplasm.
o Galactorrhea, heat or cold intolerance, hirsutism, or hot
flashes suggest an endocrinologic issue.
 Has there been a recent illness, stress, excessive exercise, or
possible eating disorder?
o Suggests hypothalamic dysfunction
II. PHYSICAL EXAMINATION
A. VITAL SIGNS
 Should be assessed and a complete pelvic exam should be
performed with a particular focus on:
o Potential sites of bleeding from the vulva, vagina,
cervix, urethra, anus, or perineum.
o Any abnormal findings along the genital tract (eg.
Mass, laceration, ulceration, friable area, vaginal or
cervical discharge, foreign body).
 Initially the foreign body would be the cause of
infection and abnormal discharge but later on
because of necrosis at the tissue surrounding the
foreign body would then result to vaginal bleeding.
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B. CURRENT UTERINE BLEEDING
 The presence and volume of bleeding from the cervical
os should be noted.
 Blood or blood clots in the vaginal vault should be noted.
 Patients who present with a complaint of heavy vaginal
bleeding should be assessed for acute bleeding.
 Patients who are hemodynamically unstable or who have
copious, ongoing blood flow form the uterus or other genital
tract site should be evaluated and managed in an
urgent care facility.
Upper picture: Endocervical Polyp that causes bleeding
Lower picture: Post-coital bleeding; the cervix is edematous and
friable; it easily bleeds after coitus
C. SIZE AND CONTOUR OF THE UTERUS
 An enlarged uterus may be due to pregnancy, uterine
leiomyomas, adenomyosis, or uterine malignancy.
 Limited uterine mobility (difficulty in moving the uterus)
should be noted, if present, this finding suggests that pelvic
adhesions (especially if the patient has undergone recent
pelvic surgery or previous infection or PID) or a pelvic mass
is present.
 Pelvic adhesions may be due to prior infections, surgery, or
endometriosis, and also may impact surgical planning if
surgical treatment is indicated.
 A boggy, globular, tender uterus is typical of
adenomyosis.
 Uterine tenderness (pain illicited when the uterus is
palpated) is present in women with pelvic inflammatory
disease (PID), but is not consistently found in those with
chronic endometritis.
Bimanual Examination: To examine the uterus and adnexa (ovary
and fallopian tubes)
BOLEYLEY, CAI, ROBANCHO
D. GENERAL EXAMINATION
 Should be performed to look for signs of systemic illness,
such as fever, ecchymoses, an enlarged thyroid gland, or
evidence of hyperandrogenism which is seen in Polycystic
ovarian syndrome (PCOS) (hirsutism, acne, clitoromegaly, or
male pattern balding).
 Acanthosis nigricans may be seen in women with PCOS
o Also seen in diabetics
 Galactorrhea (bilateral milky nipple discharge) suggests the
presence of hyperprolactinemia.
Upper picture (left): Hyperthyroidism usually coupled with a
complaint of oligomenorrhea
Upper picture (right): Galactorrhea
Lower picture: Hirsutism and acne associated with Polycystic
ovarian syndrome
 NOTE: Refer to table at the end for evaluation of abnormal
uterine bleeding in non-pregnant reproductive-age women.
III. FIGO CLASSIFICATION OF AUB
 Based on concerns about the confusing nature of AUB
terminology raised by a multinational group of experts in
gynecology, an international workshop was convened in
Washington, DC in 2005.
 The workshop addressed the most obvious and confusing
issues regarding AUB terminology, definitions, and
classifications.
 As a result of this workshop, an international working group
was set up with oversight from the International Federation
of Gynecology and obstetrics via a Menstrual Disorders
Working Group (FIGO MDWG), and since 2012, this working
group has become a standing committee of FIGO, the FIGO
Menstrual Disorders Committee (MDC).
 The process of developing new definitions and
terminology has included:
o Identifying terms describing AUB symptoms that should
no longer be used because they are confusing and
poorly defined
o Among the most commonly used terms were
menorrhagia and metrorrhagia.
MENORRHAGIA METRORRHAGIA
Heavy menstrual bleeding at REGULAR heavy menstrual
IRREGULAR intervals bleeding
o The experts group also recommended abandonment
of the term dysfunctional uterine bleeding (DUB),
which is another poorly defined term.
 This term has been used with variability as both
a vague symptom and/or a poorly defined
diagnosis.
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 Mainly, the term DUB has been used as a
diagnosis of exclusion in women with AUB in
whom the structural pathology has not been
identified.
A. NORMAL MENSES
 NOTE: Refer to table at the end for summary
1. FREQUENCY
 Interval
 24-38 days
 Oligomenorrhea – more than 38 days
 Regularity - variation ≤ 7 to 9 days
 NMT (mean variation) 7-9 days difference between the
shortest to longest cycles; cycle length is the number of days
from the 1st day of one menstrual cycle to the 1st day of the
next.
 For some young girls who have occasional or frequent long
cycles, typically, but not always, the cycle length evolves
spontaneously to fit norms. For others, such an evolution may
not occur.
2. DURATION
 ≤ 8 days
 Number of days of bleeding in a single menstrual period.
 There are no specific clinical entities that are associated with
reduced duration below 4 days, with the exception of
amenorrhea.
3. QUANTITY
 Volume
o Clinical definition is subjective and defined as a volume
that does not interfere with a woman's physical, social,
emotional, and/or material quality of life.
 Research definition is ≤ 80 ml vaginal “blood” loss per
cycle.
 Normal amount of blood is just 35mL.
 If greater than 80mL = heavy
 1 regular pad is about 60mL if fully soaked
 Light if she is only able to use 1 pad for the entire day
B. ABNORMAL UTERINE BLEEDING
 AUB is the overarching term used to describe any
symptomatic variation from normal menstruation and
also includes intermenstrual bleeding.
 This term covers the full range of symptoms of abnormal
bleeding.
BOLEYLEY, CAI, ROBANCHO
1. ACUTE AUB 1. AUB-P (ENDOMETRIAL POLYPS)
 An episode of uterine bleeding in a woman of reproductive  Polyps are localized epithelial tumors that include those in
age, who is not pregnant, that is of sufficient quantity to the endometrial cavity and the cervical canal.
require immediate intervention to prevent further  Overgrowth of endometrial tissue, containing glands, stroma
blood loss. and blood vessels, covered with epithelium.
 Difference between acute and chronic would be the urgency  Most commonly found in reproductive age women, rare
of the situation before menarche.
 Estrogen stimulation is thought to play a key role in its
2. CHRONIC AUB
development.
 Bleeding from the uterine body present for at least the
 Increases overall surface area of the endometrium leading to
majority of the past 6 months.
heavier blood loss
 Does not need urgent intervention
 More friable and edematous compared to leiomyomas
C. PALM-COIEN CLASSIFICATION
2. AUB-A (ADENOMYOSIS)
 Adenomyosis is the presence of endometrial-type glands
and stroma within the myometrium, a diagnosis that
traditionally requires a histopathologic diagnosis.
 However, it is now apparent that transvaginal ultrasound
or MRI may be used to make a clinical diagnosis of
adenomyosis.
 The presence of ectopic endometrial tissue leads to
hypertrophy of surrounding epithelium.
 Endometriosis if the ectopic endometrial tissue is seen outside
of the uterus (ovary, fallopian tube, posterior cul de sac)
 If ectopic tissue seen inside the myometrial tissue –
adenomyosis
 If localized at one area it is called adenomyoma
 Peak incidence in the 5th decade.
 Multiparity: most significant risk factor, but any process
that allows penetration of endometrial glands and stroma past
the basalis layer is thought to contribute (dilatation and
curettage, cesarean delivery, abortion).
 It is a result of altered uterine contractility and
associated with profound dysmenorrhea.
PALM COEIN  The ectopic endometrial tissue is interspersed between the
Non-Structural causes of muscle fibers allowing it to contract leading to more blood loss
Structural causes of AUB
AUB
Measurable visually using 3. AUB-L (LEIOMYOMAS)
 AKA myomas or uterine fibroids are benign neoplasms of
imaging techniques Not defined by imaging or
and/or with histopathology smooth muscle
histopathology  Leiomyomas vs Adenomyosis:
o Leiomyomas – smooth muscle within the myometrium
o Adenomyosis – endometrial-type glands and stroma
within the myometrium
 While the diagnosis of leiomyomas can be suggested by pelvic
exam, pelvic imaging is necessary for a more accurate
diagnosis.
 Pathogenesis is thought to initiate from myometrial injury
leading to cellular proliferation, decreased apoptosis and
increased production of extracellular matrix.
 Causes AUB by: Intracavitary, submucous increase of overall
surface area of endometrium, altering uterine contractility.
 Locations: (nice to know only)
o Submucous – most associated with heavier menstrual
bleeding
o Intramural and subserous, “other” or outside the
endometrial cavity
o Hybrid (transmural)
 Like polyps, increases overall surface area of the
endometrium and since myometrium is involved then it alters
contractility leading to bleeding

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 FIGO LEIOMYOMA CLASSIFICATION (BASED ON 5. AUB-C (COAGULOPATHY)
LOCATION)  Coagulopathy encompass the spectrum of systemic disorders
0 Pedunculated Intracavity of hemostasis.
Submucosal:  Such disorders are identifiable in up to 24% of women with
1 <50% intramural
Primary Type the symptom of heavy menstrual bleeding, most
2 >50% Intramural
Contacts endometrium, 100% commonly mild Von Willebrand disease.
3  The approach to identifying these patients starts with
intramural
Other: 4 Intramural structured history to assess symptoms or risk factors for
Secondary 5 Subserosal, >50% intramural coagulation disorders.
Type 6 Subserosal, <50% intramural  Confirmation requires lab testing.
7 Subserosal pedunculated  Platelet disorders, hemophilia, leukemia, severe
sepsis, ITP, hypersplenism.
8 Others (Specify if cervical, parasitic)
 Routine screening indicated for:
 Two numbers are listed separated
o Adolescent with prolonged menses beginning at
by hyphen
menarche.
Hybrid  By convention, the first refers to
o Adults with heavy menstrual bleeding with clinical signs
Leiomyomas the relationship with
such as bleeding gums, epistaxis or ecchymosis.
(impacts endometrium while 2nd refers to
2-5
both the relationship with serosa,
endometrium submuscosal, and serosal, each
and Serosa) less than half the diameter in the
endometrium and peritoneal
cavities
 NOTE: No need to Memorize! Just know the hierarchy


6. AUB-O (OVULATORY DYSFUNCTION)

 Occurs when a woman is not ovulating, has infrequent
ovulation, or especially in the late reproductive years (when
 Written as: E.g. AUB-Lsm-1 – Submucosal under 1 wherein it patient transitions from reproductive age to menopause),
is <50% intramural experiences luteal out-of-phase events.
 Alterations in neuroendocrine function.
4. AUB-M (MALIGNANCY AND HYPERPLASIA)
 A luteal out-of-phase event occurs when there is early,
 Endometrial hyperplasia with cytological atypia and
luteal phase recruitment of a follicle that then matures
carcinoma, including endometrial stromal sarcomas, are
precociously, resulting in high circulating levels of estradiol
epithelial neoplasms of the endometrium that are usually
making the endometrium thick leading to heavy menses and
diagnosed with transcervical endometrial sampling.
associated increased menstrual volume.
 Diagnosed after a diagnostic curettage
 Proliferating endometrium may outgrow its blood supply
 Endometrial hyperplasia has a risk of turning into a
leading to various degrees of necrosis.
malignancy
o Pattern is irregular heavy bleeding; heavy-spotting-
 Unopposed estrogen stimulation of the endometrium:
heavy again
o Obesity - increased estrone levels due to peripheral
o There is no normal uniform sloughing off of the
conversion by aromatase in adipose tissue.
endometrium
o Impaired ovulation, absence of progesterone withdrawal
 Occurs in extremes of reproductive life (1st few years after
- sustained estrogen production and endometrial
menarche, perimenopause).
stimulation.
 Adolescent - cause of anovulation is immaturity of HPO axis,
o Lynch syndrome (hereditary non-polyposis colorectal
failure of positive feedback of estradiol to cause LH surge.
cancer) - 40-50% risk for endometrial cancer;
o Allows 2-3 years of adjustment for the HPO axis to
therefore, immediately referred
mature
o Estrogen producing ovarian tumors (granulosa cell
o If still irregular or oligomenorrhea has become heavy
tumors).

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 menstrual bleeding after 2-3 years, patient should seek  PGF2 alpha
for further consultation o Promotes uterine contractility.
o Anovulation is caused by immaturity of HPO axis which o Together with formation of the platelet plug are the
causes failure of positive feedback of estradiol to cause primary line of defense to excessive bleeding during
LH surge which is an important prerequisite to ovulation normal menses.
o No ovulation = no production of progesterone  Excessive production of prostacyclin - Vasodilatory
 Perimenopausal - lack of synchronization between prostaglandin, opposes platelet adhesion.
components of the HPO axis as the woman approaches
9. AUB-N (NOT OTHERWISE CLASSIFIED)
ovarian decline.
 These have been poorly defined, inadequately
 Other causes of anovulation:
examined, and/or are extremely rare.
o PCOS because of the hyperandrogenism
 Wastebasket
o Hypothalamic dysfunction – may be caused by Bulimic,
 E.g. - arteriovenous malformation and AUB in the context of
anorexic, extreme exercise, stress
a uterine isthmocele (there would be necrosis surrounding the
o Abnormalities in other hormones like TSH, prolactin,
isthmocele that would affect the shedding of the endometrium
cortisol
lining producing heavy menstrual bleeding) secondary to a
7. AUB-I (IATROGENIC) lower segment cesarean section.
 AUB due to medical devices, mainly intrauterine  Foreign body
contraception systems, or pharmaceutical therapy.  Trauma
 Medications that can cause AUB include:
D. DOCUMENTATION
o Gonadal steroids (estrogen, progestins, androgens)
 Following appropriate investigation, a woman with AUB
o Gonadal steroid-related therapy (GnRH analogues,
symptoms may be found to have 1 or multiple potential
aromatase inhibitors, selective estrogen receptor
causes or contributors. The FIGO systems have been
modulators, selective progesterone receptor
designed to allow both categorization and
modulators)
documentation.
 Usually given to patients with adenomyosis,
 The full documentation might be considered to be
endometriosis to preserve their fertility
cumbersome, abbreviating the notation to only the positive
 They do not have menses while on these
findings can be considered.
medications
o For example, a patient with adenomyosis, irregular
o Anticoagulants
bleeding, and a type 6 leiomyoma could be recorded as
o Systemic agents that can contribute to disorders of
AUB-A1, -Lo1, -O
ovulation, for example, those that interfere with
o First write the OB score then the day of cycle
dopamine metabolism or cause hyperprolactinemia
o The 0 subscript would mean she does not have that
(Refer to Table 2 on Page 1 for drugs that cause
pathology
Hyperprolactinemia)
o 1 would mean that it is the culprit
o IUD devices, such may be inert, are frequently
o It is written this way because a patient could have
composites of copper and plastic, or take the form of a
multiple pathologies
local progesterone-releasing system.
o Alternative way of writing it would be if multiple
o OCP WITH antibiotics and anticonvulsants
pathologies: AUB-P, AUB-M
Cephalosporins, chloramphenicol, macrolide,
o Although the right way of documenting would be the
barbiturates.
image below
 Some drugs react with OCP leading to decreased
efficacy of the OCP even if she takes the OCP
religiously leading to abnormal uterine bleeding
 Alter circulating levels of steroids
 increased endogenous levels of estrogen
 Common cause of irregular bleeding in
contraceptive users.
8. AUB-E (ENDOMETRIAL)
 In women with predictable and cyclic menses suggestive of
normal ovulation who have AUB, particularly the symptom of
heavy menstrual bleeding (HMB) compared to previous ones
but can also include intermenstrual bleeding, and absent
other definable causes, the patient is classified having AUB-E.
 Most often, the cause of such bleeding is a primary
disorder of the endometrium.
 If the symptom is HMB, the patient may have a primary
disorder of mechanism regulating local endometrial
hemostasis (Prostaglandin producing function of the
endometrium) (A) Single entity
 At the present time, there are no available tests for these (B) Multiple entity
disorders, so AUB-E is assigned after excluding other  NOTE: Please focus on HISTORY AND PHYSICAL
etiologies of AUB in women of reproductive years. EXAMINATION for the quiz

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ADDENDUM
EVALUATION OF ABNORMAL UTERINE BLEEDING IN NONPREGNANT REPRODUCTIVE-AGE WOMEN

COMMENTS: (AUDIO)
 Missed Period/Amenorrhea – ALWAYS CONSIDER PREGNANCY! Even if the patient denies contact.
 Do not limit yourself to just obstetrics or gynecologic causes

NORMAL MENSTRUATION PARAMETERS

CLINICAL DIMENSIONS OF
NORMAL LIMITS (5TH TO 95TH
MENSTRUATION AND MENSTRUAL DESCRIPTIVE TERMS
CENTILES)
CYCLE
Absent
Infrequent >38
Frequency of Menses (Days)
Normal 24-38
Frequent <24
Regularity of menses (variation Regular Variation 7 to 9 days*
defined as shortest to longest cycle
Irregular Variation >7 to 9 days*
length, in days)
Normal  8 days
Duration of flow (days)
Prolonged >8 days
Heavy >80
Volume of monthly blood loss
Normal 5 to 80
(objective)
Light <5
Clinical Definition of heavy menstrual
bleeding (HMB): based on the patient’s
Volume of monthly blood loss
Heavy, Normal, and Light perception of volume (refer to UpToDate
(subjective)
topic on Abnormal Uterine Bleeding in
reproductive-age women)
*Normal variation depends on age; these data are calculated excluding short and long outliers
NOTE: THIS WILL COME OUT IN THE QUIZ/EXAM!

END

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