ABNORMAL UTERINE
BLEEDING

(AUB)
Redy setyono 07700018
 

DEFINITION
• The evaluation of abnormal uterine bleeding
(AUB) requires characterization and
quantification of the bleeding,specifically the
onset, duration, frequency, amount,and
pattern which is occurring both within and
outside the menstrual cycle.
 

MENSTRUAL DIMENSIONS

Normal  24-35 days

Menstrual Oligomenorrhea > 35 days

Frequency

Polymenorrhea  < 24 days

 

MENSTRUAL DIMENSIONS (2)

 Normal blood loss  5-80 mL

Regular cycles  2-20 days > 12 months

Light cycle  < 5 mL blood loss

The volume of Menorrhagia  > 80 mL blood loss

menstrual blood loss
and cycle regularity
Metrorrhagia  irregular bleeding

Menometrorrhagia

Withdrawal bleeding

Breakthrough bleeding
 

MENSTRUAL DIMENSIONS (3) 

(3) 

Duration of
menstrual bleeding

 Normal Shortened
Prolonged
4 to 6 days < 3 days
> 7 days
 

DIFFERENTIAL DIAGNOSIS OF AUB

• Tabel 1. Differential Diagnosis of AUB by Age Group
Children Adolescent Reproductive Perimenopausal Menopausal
a. Ph
Phys
ysio
iolo
logigicc a. An
Anovu
ovula lato
tory
ry due a. Pr
Preg
egna
nancncyy a. An
Anov
ovul
ulat
ator
oryy a. At
Atro
roph
phyy
b. Vu
Vulvo
lvovag
vaginiinitis
tis to immaturity of related b. End
Endome
ometri trial
al b. End
Endome
ometritrial
al
c. Trau
aum ma hypothalamic- b. Ano
Anovul
vulato
atory
ry hyperplasia carcinoma
d. Ur
Uret
ethr
hral
al pituitary-ovarian c. Va Vagi
gina
nal/
l/pe
pelv
lvic
ic c. En
Endo
dome
metr tria
iall c. En
Endo
dome
metr tria
iall
prolapse axis infection polyps hyperplasia
e. En
Endoc
docririnop
nopat at b. Coa
Coagul
gulopa
opathythy d. Pel
Pelvic
vic tum
tumor or d. Le
Leio
iomy
myom omasas d. End
Endome
ometritrial
al
hies c. Pr
Preg
egnananc ncyy e. End
Endocr
ocrino
inopat
pathie
hie e. Ad
Aden
enom
omyo yosi
siss polyp
f. Pr
Prec
ecococio
ious
us d. Va
Vagin
ginal/
al/pel
pelvic
vic s f. Ge
Geni
nita
tall tract
tract e. Le
Leio
iomy
myomomas as
puberty infection f. Co
Coag
agul
ulop
opatathy
hy neoplasm f. Hormo
monne
g. Ova
Ovaria
rian
n cys
cystt e. Ben
Benign
ign les
lesion
ionss replacement
h. Gen
Genital
ital tra tractct f. Me
Medidica
catition
onss therapy
neoplasm g. Mü
Müllller
eria
iann
anomalies
h. Ge
Gene
netiticc
abnormality

Adapted from Shwayder JM. Pathophysiology of abnormal uterine bleeding. Obstet Gynecol Clin North Am 
 2000;27:219 234, with permission.
 

DIFFERENTIAL DIAGNOSIS OF AUB (2)

• Diagnostic Testing
Order laboratory serum testing for human chorionic
gonadotropin (β-hCG), thyroid stimulating hormone

(TSH), follicle
complete bloodstimulating hormone (FSH), prolactin, and
count (CBC).
In women with risk factors for neoplastic processes a
tissue diagnosis is required.
If anovulatory bleeding and pregnancy have been ruled
rule d
out, evaluate for coagulation disorders.
 

EVAL
EVALUA
UATI
TION
ON OF AUB
ULTRASONOGRAFI

Transvaginal Ultrasonografi (TVUS)

Transvaginal
TVUS is useful to evaluated for the presens of fibroids, intrauterine
 pregnancy and ectopic pregnancy.
pregnancy.
Saline Infusion Sonografi

It is the most sensitive non invasive method of diagnosis for

endometrial polyps and submucous myomata. But, it does not distinguish
 between benign and malignant processes.
HYSTEROSCOPY
•

  The advantage of this procedure is that it provide direct

visualization of the endometrial cavity and can be performed in the
operating room.
MAGNETIC RESONANCE IMAGING (MRI)
•

  Can be useful in the diagnosis adenomiosis and can accurately

localize and measure fibroids, faciltating determination of the best
 treatment.
 

EVALUATION OF AUB (2)

ENDOMETRIAL SAMPLING
Recommended for a women over age 35 years with
anovulatory bleeding and considered in younger women
with a history of chronic anovulatory bleeding or risk
endometrial carcinoma.
The advantage is a rapid, safe, and cost effective.
A potential drawback is that the biopsy does not sample
the entire endometrium and a localized lesion may be
missed. 
DILATION and CURRETAGE
Can be both diagnostic and therapeutic,but incurs the cost of
an operating room and carries the risks of anasthesia.
It’s also can be indicated in women with nondiagnostic
endometrial
endometr ial biopsi.
 

SPECIFIC
CAUSES OF
AUB 

Pregnancy Dysfunctional
Associated uterine

Bleeding  bleeding (DUB)

 

Pregnancy Associated Bleeding

Bleeding  

Pregnancy should be suspected in any woman in her

reproductive years.
β-hCG is positive, a pelvic examination must be
If urine β-hCG
 performed and an ultrasonographic study obtained.
Any patient who is hemodynamically unstable, bleeding
heavily,, or septic
heavily s eptic requires surgical
su rgical intervention.
Women with missed or incomplete abortions who are
stable and not bleeding heavily may be treated
tr eated medically
with misoprostol
 

Dysfunctional uterine bleeding (DUB) 

DEFINITION
Dysfunctional uterine bleeding (DUB) is a diagnosis
dia gnosis of exclusion for AUB
AUB without a
demonstrable pathologic cause and is found in approximately one third of all patients
patie nts
evaluated.
ETIOLOGY
The predominant causes of DUB are anovulation or oligoovulation.
Anovulation is multifactorial and related to alterations of the hypothalamic-pituitary-
ovarian axis.
long-term anovulation estrogen production occurs without the progesterone
 produced from the corpus
corpus luteum thus creating an unopposed
unopposed estrogen state
risk for endometrial hyperplasia
Anovulation is also associated with polycystic ovary syndrome, which also places
women at risk for endometrial hyperplasia.
Morbid obesity
Peripheral conversion of androstenedione to estrone occurs in adipose tissue
 producing elevated estrogen levels
Occasionally,, DUB may be associated with ovulatory cycles.
Occasionally
 

Dysfunctional uterine bleeding (DUB) (2) 

MANAGEMENT

Administration of progestins
The levonorgestrel-releasing intrauterine system (Mirena)
OCPs also regulate menses and often decrease flow.
 Nonsteroidal anti-inflammatory drugs
drugs (NSAIDs)
Danazol
Antifibrinolytic
Gonadotropin-releasing hormone (GnRH) agonists
SURGICAL
SURGICA L TREATMENT
TREATMENT
• Endometrial ablation is designed to ablate the full thickness of the
endometrium.
• Before performing endometrial
endometrial ablation in a woman with anovulatory
 bleedi
 ble eding,
ng, endom
e ndometr
etrial
ial hype
hyperpla
rplasia
sia or
o r carci
ca rcinoma
noma must be rul
ruled
ed out
ou t .
• overall success rate is 80% to 90%, with 30% to 50% of women
reporting amenorrhea 6 months postprocedure. Still, within 5 years,
y ears,
15% will have a second ablation and 20% will have a hysterectomy.
hysterectomy.
• Endometrial ablation is not recommended in women who desire future
 fertility .
 

Pharmacologic Management of Abnormal

Uterine Bleeding
Progestins a. Med
edro
roxy
xyppro
roge
gestster
eron
onee ( Provera) 10 mg 3×/d for 14 d (days
12-25); or for 5-10 d
b. No
Nore
reth
thin
indr
dron
onee ace
aceta
tate
te ( Aygestin) 5 mg 3×/d for 14 d (days
12 and 25) for anovulatory bleeding; or on days 5-25 for
ovulatory bleeding
c. Medr
Medrox
oxyp
yprog
roges
ester
teron
onee aceta
acetate
te inje
inject
ctio
ion
n (Depo Provera)
150 mg IM every 12 wk
d. Lev
Levono
onorge
rgestr
strel-r
el-relea
eleasin
sing
g intrau
intrauter
terine
ine sys
system
tem (Mirena)
Hormonal
Combined a. Oral cont
contrrac
ace
ept
ptiv
ive
es
Management
estrogen and b. Tra
rans
nsde
derm
rmal
al pr
prep
epar
arat
atio
ions
ns
progestins  
progestins c. Vaginal ring
d. Ho
Horm
rmonone
e rep
repla
lace
ceme
ment
nt the
thera
rapy
py
Androgenic Danazol 200 mg/d
steroids  
steroids
GnRH a. Leuprolide (Lupron) 3.75 mg IM/mo or 11.25 mg every 3 mo
agonists  
agonists b. Goserelin (Zoladex) 3.6 mg SQ every 4 wk
 

Pharmacologic Management of Abnormal

Uterine Bleeding (2)
Nonsteroidal Anti-inflammatory Drugs a. Mefena
Mefe namic
mic ac
acid
id 50
500
0 mg
mg 3×/
3×/d
d
(NSAIDs) b. Ibupro
Ibuprofen
fen 600
600-80
-8000 mg
mg ever
everyy 6 hr
c. Mecl
Me clof
ofen
enam
amat
atee sod
sodiu
ium
m 100
100 mg 3×/
3×/d
d
d. Naprox
Nap roxen
en sod
sodium
ium 550 mg × 1, then
then 275
mg every 6 hr
Antifibrinolytic Agents 
Agents  Tranexamic acid 1 g 4×/d on days 1 to 5; or
Tranexamic
1.5 g 3×/d
 

Coagulation Disorders

Menorrhagia during adolescence should be attributed to a

coagulation disorder until proven otherwise.
Bleeding from multiple sites (e.g., nose, gingiva,
intravenous sites, gastrointestinal, and genitourinary tracts)
may suggest coagulopathy.
There is a higher prevalence of bleeding disorders in women
with menorrhagia.
 

Von Willebrand Disease

Von Willebrand disease is the most common inherited bleeding
disorder,
disorder, affecting 1% to 2% of the population
In women with vWD, menorrhagia is the most common
manifestation,
manifestati on, occurring in 60% to 95% beginning at menarche.

Women with vWD

postoperative are also likely to report postpartum or
bleeding.
Other coagulopathies may also cause AUB, including platelet
abnormalities, idiopathic thrombocytopenic purpura, and
hematologic
hematolog ic malignancy (e.g., leukemia).
Testing for vWD should be considered in women with a history of
unexplained menorrhagia beginning at menarche.
Screening for vWD in adolescents with severe menorrhagia
before starting hormonal therapy and in adult women with
significant unexplained menorrhagia.
 

ENDOCRINE DISORDERS
Endocrinopathies can cause anovulation, producing an
estrogen without progesteron.
the endometrium eventually breaks down, which may or
may not lead to the
t he formation of hyperplasia.
 

Hepatic Dysfunction
Decreased metabolism of estrogen and decreased clotting
factor synthesis are common ramifications of liver failure.
Anovulation may also ensue. Menometrorrhagia is common.
Liver function tests are necessary to make the diagnosis,
finding of jaundice, ascites, hepatosplenomegaly, palmar
erythema, pruritus, and spider angioma are suggestive of
liver failure.
 

Medication Side Effects

Psychotropic Medications
a. Certain medications used in the treatment
tr eatment of psychiatric patients
b. Antipsychotic medications (i.e., dopamine antagonists)
Phenothiazines and antidepressants
Hormone Medications
a. Medroxyprogesterone acetate
b. Combination OCPs
c. Progestational agents
Other Medications
a. Anticoagulants
b. Digitalis, phenytoin, and corticosteroids
Intrauterine Devices
a. Copper-containing intrauterine devices, unlike the levonorgestrel-
releasing Mirena intrauterine system
b. Such bleeding is often treated successfully with NSAIDs.
 

Benign Pathology
Leiomyomata
Leiomyomata (fibroids) are the most common uterine
neoplasm, and is the number one indication for
hysterectomy in the United States.

Endometrial Polyps
Generally, benign endometrial lesions tend to be
asymptomatic but may be present in 10% to 33% of women
with complaints of bleeding, typically metrorrhagia.
m etrorrhagia.

Endometrial Hyperplasia
Endometrial hyperplasia, a precursor to endometrial
carcinoma, is classified into simple or complex, based on
architectural features, and typical or atypical, based on cytologic
features.
 

Malignancy
Endometrial Cancer
Endometrial carcinoma is rare in patients younger than age
40. Postmenopausal bleeding, should be assumed to represent
endometrial cancer until proven otherwise.
Cervical Cancer
a. Cervical carcinoma is a disease of both the relatively young
and the old it cause abnormal bleeding.
b. The most common bleeding patterns associated with cervical
carcinoma are intermenstrual and postcoital bleeding
Ovarian Cancer
Estrogen-producing ovarian tumors, such as a granulosa-
theca cell tumor, can produce endometrial hyperplasia and AUB.
 

SUGGESTED READINGS
•
Management of Anovulatory Bleeding. ACOG Practice Bulletin
Number 14. American College of Obstetricians
Obste tricians and
Gynecologists. Int J Gynaecol Obstet 2001;72(3):263-271.
• Von Willebrand Disease in Women. ACOG Committee
Com mittee Opinion
Number 451. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2009;11
2009;114:1439-1443.
4:1439-1443.
• Lacey JV Jr, Chia VM. Endometrial hyperplasia and the risk of
progression to carcinoma. Maturitas 2009;63(1):39-44.
• Casablanca Y. Management of dysfunctional uterine bleeding.
Obstet Gynecol Clin North Am 2008;35(2):219-234, viii.