TOPIC: AUB

Abnormal uterine bleeding or AUB is defined as any deviation from the normal
menstrual pattern. On the other hand, Heavy menstrual bleeding (HMB) is defined as
xcessive menstrual blood loss which interferes with the woman’s physical, emotional,
social and material quality of life, and which can occur alone or in combination with other
symptoms. Another form of AUB is intermenstrual bleeding which is defined as Bleeding that
occurs between clearly defined cyclic and predictable menses, which may occur randomly, or
predictably on the same day in each cycle. In order for us to identify which is abnormal, we
have to know first the normal menstrual pattern (See table below).
Parameter Normal Abnormal
Frequency Normal (>24 to <38 days) Absent (no bleeding)
Infrequent (>38 days)
Frequent <24 days
Duration Normal (<8days) Prolonged (>8 days)
Regularity Normal or “Regular” (shortest to Irregular (shortest to longest cycle
longest cycle variation <7-9 days)* variation >8-10 days)
Flor Volume Normal Light
(patient
determined) Heavy

In every case of AUB, the goals of management are the following: 1) Assess
hemodynamic status, 2) Stop acute bleeding, and 3) Identify an treat the cause. Based on
POGS CPG on AUB, 2017, pregnancy is the primary consideration as the cause of AUB
among childbearing women and that the diagnostics include bimanual exam, βhCG tests,
pelvic ultrasound.
Acute AUB is defined as an episode of heavy bleeding that, in the opinion of clinical, is
of sufficient quantity to require immediate intervention to minimize or prevent further blood loss
while Chronic AUB is defined as bleeding from the uterine corpus that is abnormal in duration,
volume, frequency, and/or regularity, and has been present for the majority of the preceding 6
months. Based on the POGS CPG on AUB 2011, several medical management can be
given to stop acute AUB. Below is a table showing the different management with
corresponding percentage of effectiveness.

Placebo 38%
High dose CEE (25mg IV q4h) 72%
 Tranexamic acid (1 gm q6H) 54%
Progestins 25%
Combined OC’s ????

One of the most effective management of AUB is Estrogen. It is said that the bleeding
that results from most causes of AUB will respond to estrogen because a rapid growth of
endometrial tissue occurs over the denuded and raw epithelial surfaces. Conjugated equine
estrogens may be given orally, 10mg/day in four divided doses or intravenously, 25mg every 2-
4 hours for 24 hours. This should be followed by CEE oral 10mg/day for 21-25 days and
Progestins for last 7-10 days or CEE oral in decreasing dose for 3 weeks and Progestins for
last 7-10 days. In addition, estrogen therapy is said to be more effective in the setting of thin
endometrium (<5mm stripe). However if endometrium is thick or if an anatomic finding is
suspected, curettage should be considered. If curettage is not performed, at least an
endometrial biopsy should be obtained. However, high dose estrogen may be contraindicated
for some women such as those with history of thrombosis, certain rheumatologic diseases, and
estrogen responsive cancer. In this case, progrestogen is an alternative as well as a curettage.
Curettage is the fastest way to stop acute bleeding and should be used in women who are
volume-depletes and severely anemic. Progestrogen however do not stop bleeding but may
slow it down as organization of tissue occurs. Based on POGS CPG 2011, Management of
HMB is as follows: 30 ug EE/0.3mg Norgestrel 1 tab 4x a day for 4 days, 1 tab 3x a day for 3
days, 1 tab 2x a day for 2 days and 1 tab a day for 3 weeks.
The basic work-up for AUB is as follows: CBC with QPC, urinalysis with pregnancy test,
coagulation tests (Platelets, prothrombin, PTT, aPTT, fibrinogen), and hormones such as E2,
P4, LH, FSH, TSH, FT3, FT4. In addition, FIGO recommends screening for systemic disorders
of hemostatis on the following patients: those with HMB sine menarche, one of the ff:
postpartum hemorrhage, surgical related bleeding, bleeding associated with dental work, and
two or more of the following symptoms: bruising 1-2 times per month, epistaxis 1-2 times per
month, frequent gum bleeding, and family history of bleeding symptoms. Furthermore, based
on POBS CPG 2017 on AUB, female hormone tesing (E2, P4, L, FSH) should not be routinely
done on women with HMB, while thyroid screening should only be obtained in the presence of
signs and symptoms of thyroid disease. As for imaging, ultrasound still is the first line
diagnostic tool for identifying structural abnormalities with sensitivity as high as 96% for
endometrial carcinoma and 92% for other endometrial abnormality. In requesting for
ultrasound, schedule between Day 4 – 6 of the menstrual cycle. The cut off for endometrial
lining for menopause is less than 5mm while for secretory phase 8-14 mm.
Another management of AUB is doing endometrial biopsy esp in cases wherein patiet is
more than 40 years old, has risk factors for endometrial Ca, with failed medical management
and those breast cancer patients on tamoxifen complaining of vaginal bleeding.
 Aside from TVS, SIS may also aid in diagnosing etiology of AUB. It is a useful tool
which can provide more accurate evaluation of the uterus with intracavitary lesions. Aside from
SIS, hysteroscopy may also be used for visualization of endometrial cavity esp if ultrasound
results are inconclusive and focal lesions are seen within the endometrium.
A systematic way devised in diagnosing AUB is the PALM-COEIN system. The first 4
letters: P for polyp, A for Adenomyosis, L for Leiomyoma and M for malignancy refers to
structural abnormalities. On the other hand, C stands for coagulopathy problems, O for
ovulatoru, E for endometrial, I for Iatrogenic and N for not otherwise specified.