Abnormal Uterine Bleeding Causes and Treatment

Abnormal Uterine
Bleeding
MOSTAJO, John Adriel T.
OBJECTIVES
- Definition of Abnormal Uterine Bleeding and other terms

- FIGO Classification System
- Causes of AUB
- Management of AUB
Abnormal Uterine Bleeding
Any significant deviation from normal frequency, regularity, heaviness (volume or amount) and
duration of menstrual bleeding
Table 1. NORMAL LIMITS FOR MENSTRUAL PARAMETERS IN THE MID-REPRODUCTIVE YEARS
CLINICAL DIMENSION OF MENSTRUATION NORMAL LIMIT

DESCRIPTION
AND MENSTRUAL CYCLE (5th – 95th Percentile)
Frequent <24 days
Frequency of Menses (based on
Normal 28± 7 days
interval)
Infrequent >38 days
Absent -
Regularity of Menses (cycle to cycle
Regular 2 – 20 days
variation over 1 year)
Irregular >20 days
Prolonged >8
Duration of Flow Normal 4.5 – 8.0
Shortened <4.5
Heavy >80
Volume of Monthly Blood Loss (mL) Normal 5 – 80
Light <5
AUB: Definition of Terms
➔ Menorrhagia (Heavy Menstrual Bleeding)
◆ Prolonged (more than 8 days) or excessive (greater than 80ml) uterine bleeding
occurring at regular intervals
➔ Metrorrhagia
◆ Uterine bleeding of variable amount occuring at irregular but more frequent intervals
➔ Menometrorrhagia
◆ Prolonged uterine bleeding occurring at normal intervals
➔ Oligomenorrhea (Infrequent Uterine Bleeding)

◆ Intervals between episodes vary from 35 days to 6 months
➔ Polymenorrhea (Frequent Uterine Bleeding)

◆ Uterine bleeding at intervals <21 days
Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding; In Comprehensive Gynecology 7th edition, 2017, pp 621-633.
AUB: Definition of Terms
ACUTE AUB CHRONIC AUB

An episode of heavy bleeding Bleeding from uterine corpus
that in the opinion of the that is in abnormal volume,
clinician, that is of sufficient regularity and/or timing. Has
quantity to require immediate been present for the majority
intervention to prevent blood of the last 6 months
loss
FIGO CLASSIFICATION: PALM COEIN
STRUCTURAL ENTITIES (PALM)
1. Polyp
2. Adenomyosis
3. Leiomyoma
4. Malignancy
NON-STRUCTURAL ENTITIES (COIEN)

1. Coagulopathy
2. Ovulatory
3. Endometrial
4. Iatrogenic
5. Not yet Classified
PALM COEIN: POLYP
Definition
➔ Localized overgrowths of endometrial tissue, containing

glands, stroma, and blood vessels, covered with epithelium
➔ Risk factors for malignancy: In symptomatic vaginal bleeding,
postmenopausal status, and Obesity
➔ Symptoms: heavy menstrual, intermenstrual or
postmenopausal bleeding, and dysmenorrhea
Diagnostic
Transvaginal Ultrasound or diagnostic hysteroscopy
Treatment
Symptomatic Polyps are treated via polypectomy under

hysteroscopic guidance
PALM COEIN: Adenomyosis
Definition
Presence of endometrial glands and stroma in the uterine

myometrium. The presence of ectopic endometrial tissue
leads to hypertrophy of the surrounding myometrium.
Risk Factors
➔ Multiparity
➔ Any process that penetrates the endometrial glands
and stroma past the basal layer (e.g dilation and
curretage, cesarean delivery, spontaneous abortion).
Symptoms
Heavy Menstrual bleeding, Dysmenorrhea, Chronic pelvic

pain
PALM COEIN: Adenomyosis
Diagnostic
➔ Histologic diagnosis
➔ Findings include:
◆ Enlarged asymmetric uterus are indicative on
ultrasound and MRI.
◆ Pathognomonic sign: Anechoic avascular cysts
scattered throughout the myometrium on ultrasound
Treatment
➔ Hysterectomy
➔ Medical treatment for symptomatic control
PALM COEIN: Leiomyosis
Definition
➔ a.k.a Uterine Fibroids
➔ Typically presents as heavy menstrual
bleed which may be severe to cause
anemia
PALM COEIN: Malignancy
Definition
Highly considered in post menopausal bleeding
Diagnosis
Thickened endometrium
Management
Endometrial sampling and if + for malignancy, TAHBSO
PALM COEIN: Coagulopathy
Definition
➔ Spectrum of systemic disorders of hemostasis
➔ Disorders on blood coagulation such as Von Willebrand
disease and women on chronic anticoagulant drugs such as
warfarin, and low molecular weight heparin
PALM COEIN: Ovulatory
Definition
➔ Combination of unpredictable bleeding and variable amount
of flow, in some cases resulting to heavy menstrual
menstrual bleeding
➔ Associated with non-secretory endometrium
➔ Most common after menarche or just before the menopause
but may occur at other times
➔ PCOS
PALM COEIN: Endometrial
Definition
Characterized as predictable and cyclic, typical of ovulatory cycles, and

without other identified causes
Factors important for hemostasis during a normal menstruation:
Fibrin clot formation, Stabilization of hemostatic platelet plug & Uterine

Contractility
AUB manifests as prolonged bleeding
Reflect deficiencies in the molecular mechanisms of endometrial repair
PALM COEIN: Iatrogenic
➔ Usually manifest with irregular bleeding or “breakthrough” bleeding
➔ Occur secondary to use of medicated or inert intrauterine device and
pharmacologic agents that has direct impact on the endometrium, interfere
with blood coagulation mechanisms, or influence the system control of
ovulation
➔ E.g. contraceptive pills, IUD, steroids, tranquilizers, digitalis, dilantin,
rifampicin, griseofulvin
PALM COEIN: Not yet classified
➔ Trauma or foreign bodies

➔ Treatment is focused on the specific cause
Diagnosis
1. History and PE
2. Laboratory Exams
Physical
History
Examination
● Detailed focusing on the ● Abdominal palpation

probable causes of abnormal ● Pelvic examination
menstrual bleeding ● Bimanual examination
● Determine type of menstrual
abnormality
● Personal and family history
of bleeding
Laboratory Examination
➔ Indirect assessment by measurement of:
Hemoglobin, Serum Iron levels, Serum Ferritin
levels
➔ Rule out pregnancy in all women in
reproductive age
➔ Coagulation profile
➔ TSH assay, androgen (PCOS)
➔ Ultrasound
➔ Women who are older (≥ 40 years old) and/or
have a long history of excessive bleeding
would benefit from an endometrial biopsy
Treatment
➔ Combined oral contraceptive pills (OCPs) taken continuously

for several months until hemodynamically stable
➔ A definitive diagnosis is required before instituting long-term
treatment, and should be made on the basis of hysteroscopy,
sonohysterography, or directed endometrial biopsies
AUB - OVULATORY DYSFUNCTION
Reproductive-aged
Adolescent Perimenopausal
Woman
➔ cyclic progestogen ➔ Low-dose (20-μg) ➔ Chronic
(medroxyprogesterone combined oral anovulatory
acetate, 10 mg for 10 contraceptives (non bleeding is
days each month for a smoking women). primarily caused by
few months) to produce hypothalamic
➔ Cyclic Progestogens
reliable and controlled dysfunction or
menstrual cycles. PCOS.
➔ oral contraceptive ➔ Combined oral
(OC)may be an option if contraceptives
the problem persist ➔ Cyclic Progestogens
beyond 6 months.
AUB - ENDOMETRIAL
DYSFUNCTION
Antifibronolytic
NSAIDs Agents
GnRH Agonist
➔ Mefenamic acid
(500 mg, three ➔ ε-Aminocaproic ➔ effective means of
acid (EACA) bridging patients to
times daily)
➔ Tranexamic acid surgical treatment,
➔ Ibuprofen (400 mg, allowing for
three times daily) (AMCA)
correction of
➔ Naproxen sodium ➔ Para-aminomethyl anemia.
(275 mg, every 6 benzoic acid ➔ Use of an estrogen
hours after a (PAMBA) or progestogen
together with the
loading dose of
agonist will help
550 mg) prevent bone loss.
MANAGEMENT: ACUTE BLEEDING
ACUTE AUB
● In women who are bleeding heavily and are hemodynamically
unstable, the quickest way to stop acute bleeding is with
curettage.
○ preferred approach for older women and those with medical
risk factors for whom high-dose hormonal therapy may pose
a great risk.
● May also be managed medically (pharmacologic agents)
PHARMACOLOGIC AGENTS FOR ACUTE BLEEDING
Estrogen Progestogen Androgen
➔ Oral conjugated equine ➔ Medroxyprogesterone ➔ Danazol is a
estrogen (CEE)10mg/day, acetate (MPA) at a dose of synthetic androgen
in four divided doses 60 mg daily (20 mg three used in doses of
➔ IV conjugated times daily) for 7 days
estrogen:25mg q4-6h until 200 mg daily for the
followed by 20 mg per day
the bleeding stops.(No for 3 weeks treatment of heavy
more than six doses menstrual bleeding
➔ Depo-MPA 150 mg
should be administered)
intramuscularly followed ➔ Limited use
➔ Combination oral
contraceptive(both by oral MPA 60 mg (20 mg because of the side
estrogen and three times daily) for 3 effects of weight
progestin).Four tablets of days gain and skin
an oral contraceptive ➔ Norethindrone acetate (30
problems
containing 30 to 35 μg of mg per day)
estrogen taken every 24
hours in divided doses. Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding; In Comprehensive Gynecology 7th edition, 2017, pp 621-633.
SURGICAL MANAGEMENT OF ACUTE AUB
Endometrial Biopsy Dilatation and Curettage
● Indications: ● Treatment of choice in
○ Age >40
○ With risk factors for endometrial hypovolemic women
cancer
■ obesity,HPN, DM, PCOS, strong
family history of hereditary
non- polyposis colorectal
cancer
○ Failure of medical management
○ Significant intermenstrual bleeding
○ Infrequent menses suggestive of
anovulatory cycles
SOGC CPG. 2018.
SURGICAL MANAGEMENT OF ACUTE AUB
Endometrial Ablation Hysterectomy
● Alternative to hysterectomy ● Surgical removal of the uterus.
● Used to treat persistent
abnormal uterine bleeding after
all medical therapy has failed, or
medical therapy is
contraindicated.
CHRONIC AUB
Multiple treatment options are available for long-term treatment of
chronic AUB:
➔ levonorgestrel intrauterine system

➔ OCs (monthly or extended cycles)
➔ progestin therapy (oral or intramuscular)
➔ tranexamic acid
➔ NSAIDs
➔ GnRHa
De Silva N. Abnormal uterine bleeding in adolescents: Management. March 2017. www.uptodate.com

SUMMARY OF APPROACHES
TO TREATMENT
➔ Approach the patient according to her acute and chronic needs
or short-term and long-term therapy
➔ Perform curettage if pathology is suspected
➔ Consider the age, medical condition, and reproductive plan of
the patient
➔ Important to rule out pregnancy

Abnormal Uterine Bleeding Causes and Treatment

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Abnormal Uterine

- Deﬁnition of Abnormal Uterine Bleeding and other terms

Table 1. NORMAL LIMITS FOR MENSTRUAL PARAMETERS IN THE MID-REPRODUCTIVE YEARS

CLINICAL DIMENSION OF MENSTRUATION NORMAL LIMIT

➔ Oligomenorrhea (Infrequent Uterine Bleeding)

➔ Polymenorrhea (Frequent Uterine Bleeding)

ACUTE AUB CHRONIC AUB

NON-STRUCTURAL ENTITIES (COIEN)

➔ Localized overgrowths of endometrial tissue, containing

Transvaginal Ultrasound or diagnostic hysteroscopy

Symptomatic Polyps are treated via polypectomy under

Presence of endometrial glands and stroma in the uterine

Heavy Menstrual bleeding, Dysmenorrhea, Chronic pelvic

Highly considered in post menopausal bleeding

Endometrial sampling and if + for malignancy, TAHBSO

Characterized as predictable and cyclic, typical of ovulatory cycles, and

Factors important for hemostasis during a normal menstruation:

Fibrin clot formation, Stabilization of hemostatic platelet plug & Uterine

AUB manifests as prolonged bleeding

Reﬂect deﬁciencies in the molecular mechanisms of endometrial repair

➔ Trauma or foreign bodies

● Detailed focusing on the ● Abdominal palpation

➔ Combined oral contraceptive pills (OCPs) taken continuously

➔ levonorgestrel intrauterine system

De Silva N. Abnormal uterine bleeding in adolescents: Management. March 2017. www.uptodate.com

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