Objectives :

• Overview of the Menstrual Cycle

• Definitions :
Normal Uterine Bleeding
Abnormal Uterine Bleeding
Types of Abnormal Uterine Bleeding
New Terminology of Abnormal Uterine Bleeding
• Etiology of Abnormal Uterine Bleeding : PALM-COEIN Classification developed by the
International Federation of Gynecology and Obstetrics (FIGO)
• History
• Investigations
• Diagnosis
• Treatment :
Medical
Surgical
 The Menstrual Cycle

• The Menstrual Cycle is a series of natural changes in hormone production as well as

structural changes in the ovaries and uterus; specifically, the endometrium of the
female reproductive system which make pregnancy possible.
• The menstrual cycle consists of two interconnected and synchronized processes
namely , the ovarian cycle and the uterine cycle.
• Notably the ovarian cycle centers on the development of the ovarian follicles,
ovulation and the cyclic release of estrogen and progesterone.
• The uterine cycle focuses on the way the functional endometrium thickens and
sheds as a result of ovarian activity
 The Menstrual Cycle

.
Hypothalamic- Pituitary- Ovarian Axis
Endometrial Changes in the Menstrual Cycle
 Uterine Cycle-Proliferative Phase

Early Proliferative Phase Late Proliferative Phase

 Uterine Cycle -Secretory Phase

Late Secretory Phase

Early Secretory Phase
Influence of Progesterone on the
Endometrium
 Normal Uterine Bleeding

• As it relates to frequency, a normal menstrual cycle should be between 21-

35 days in duration
• Normal menstrual bleeding lasts an average of 3-7 days
• The volume of menstrual bleeding peaks on the first or second day of
menstruation with an average blood loss of 30-80mls
 Old Terminology

• Amenorrhea indicates the absence of menstruation

• Oligomenorrhea occurs when there is infrequent and irregularly timed
episodes of bleeding usually occurring at intervals of more than 35 days
• Polymenorrhagia occurs when there is frequent episodes of menstruation;
usually occurring at intervals of 21 days or less
 Old Terminology

• Menorrhagia occurs when there are regularly timed episodes of bleeding

that are excessive in amount (80 mL) and /or duration of flow (5days)
• Hypomenorrhea refers to regularly timed but scanty episodes of bleeding
 Old Terminology

• Metrorrhagia refers to irregularly timed episodes of bleeding superimposed on

normal cyclical bleeding
• Menometrorrhagia means excessive and prolonged bleeding that occurs at
irregular times and frequent intervals
• Postcoital bleeding denotes vaginal bleeding after sexual intercourse
• DUB – abnormal heavy menstrual bleeding when no structural genital tract
abnormality or a general cause was detected in a woman of reproductive age in
the absence of pregnancy
 Discarded Terminology

• Menorrhagia Amenorrhea - Retained

• Hypermenorrhea
• Hypomenorrhea Oligomenorrhea -Retained
• Menometrorrhagia
• Polymenorrhea
• Polymenorrhagia
• Dysfunctional uterine bleeding
• Functional uterine bleeding
• Metropathica Hemorrhagica
 Abnormal Uterine Bleeding

• Abnormal uterine bleeding is defined as menstrual bleeding that is abnormal

and/or irregular in regularity ,frequency, duration and or the volume of blood loss in
women of reproductive age in the absence of pregnancy.
• Heavy Menstrual Bleeding (HMB) – Excessive menstrual blood loss which interferes
with a woman’s physical, social, emotional and /or material quality of life
• Note that blood loss greater than 80mls is considered excessive and therefore
considered abnormal
• However, if the patient is anemic or is experiencing signs and symptoms of
haemodynamic instability with blood less than 80 mls ; it is considered HMB
 New Terminology

• Acute AUB :
This is an episode of bleeding in a woman of reproductive age, who is not pregnant,
that in the opinion of the provider is of sufficient quantity to require immediate
intervention to prevent further blood loss.

• Chronic AUB
Bleeding from the uterine corpus that is abnormal in duration, volume, and or
frequency and has been present for the majority of the last 6 months
 New Terminology

Intermenstrual Bleeding :
• Spontaneous bleeding occurring between Menstrual periods
• Cyclic- early, mid or late cycle (E.g., Mittelschmerz)
• Random
 Frequency

• Absent - Amenorrhea
• Normal -24 -38 days
• Infrequent - > 38 days
• Frequent- < 24
 Duration

• Normal – 7 days is normal

• Prolonged – Greater than 7 days
 Regularity

• Regular – delayed by less than 8 days

• Irregular – delayed greater than 8 to 10 days
 Flow Volume

• Light
• Normal
• Heavy
Causes of Abnormal Uterine Bleeding
Figure 1.0 : Showing the PALM-COEIN CLASSIFICATION of the causes of
Abnormal Uterine Bleeding (structural and nonstructural) developed by FIGO
 Polyps

• These are localized tumours of columnar epithelium arising from either the endocervix or endometrial epithelium
containing both glandular and stromal elements
• The polyps may be round or oval, and range in size from a few millimeters to a few centimeters or larger
• They may be pedunculated or sessile in appearance
• Polyps are very common; they are found in about 50% of patients with AUB and about 35% of those with infertility.
• Up to 80% are asymptomatic.
• Uterine polyps are usually benign
• Malignancy rates correlate with age, with an approximately 1% rate in premenopausal women and up to 9% in
postmenopausal women.
• They may cause problems with menstruation or infertility
 Demographics

• Uterine polyps are more likely to develop in who are in the reproductive age
group and postmenopausal age group
 Risk Factors

Risk factors to developing uterine polyps are :

• Obesity/Overweight
• Hypertension
• Diabetes
• Advancing age
• Hormone Replacement Therapy
• Tamoxifen ( therefore a lot of women who are oestrogen receptor positive will be on
this drug)
 Symptoms of Polyps
• Note that approximately 80% of polyps are asymptomatic
• Irregular menstrual periods
• Unusually heavy and prolonged flow during menstrual periods
• Intermenstrual bleeding or bleeding after menopause
• Bloody discharge
• Post coital bleeding
• infertility
 Diagnosis

• Transvaginal ultrasound:
• Sonohysterography- best way to diagnose polyps is saline infused
ultrasound
• Hysteroscopy
• Endometrial biopsy
• Curettage
Ultrasound
Saline Infusion Sonography
 Saline Infused Sonogram

Ultrasound Saline infusion

Sonography
Polyp on Hysteroscopy
 Treatment

• Medication : Progestins or Gonadotropin-releasing hormone agonists

• Hysteroscopy
• Curettage
• Hysterectomy
Management
 Adenomyosis/ Endometriosis Interna

• Adenomyosis is a benign uterine disease characterized by the presence of ectopic

endometrial glands and stroma within the myometrium as a result of the endometrium
growing into at least 2.5 mm beyond the endo-myometrial junction
• This will cause hyperplasia of the smooth muscle cells referred to as myohyperplasia
• This is estrogen dependent and as there is an abundant expression of the alpha estrogen
receptors.
• Classically; an adenomyotic uterus is termed boggy, globular and symmetrically enlarged
• This extra tissue can cause the uterus to double or triple in size and lead to abnormal
uterine bleeding and painful periods (congestive pain).
 Risk Factors

• Black
• Females between the ages of 35 and 50
• Multiparous
• Endometriosis
• Uterine fibroids
 Symptoms

• Many people with adenomyosis are asymptomatic

Symptoms include :
Painful menstrual cramps (spasmodic dysmenorrhea)
Heavy menstrual bleeding (menorrhagia)

Painful intercourse (dyspareunia)

bloating (enlarged uterus)
Abnormal menstruation
Chronic Pelvic pain
Infertility
 Examination

• Uterus enlarged in the anterior posterior direction generally symmetrical

• Rarely to more than twice its size
• Soft - firm and tender
 Diagnosis

• Ultrasound – first line treatment (cheaper )

• Magnetic resonance imaging (MRI) – (better for diagnosis as it is more

accurate in picking up subtle adenomyosis in comparison to u/s, but u/s
is the first line diagnostic tool used because the sensitivity and specificity
is not far off from that of a MRI, and ultrasounds are cheaper and readily
available)
Characteristics of the uterus in Adenomyosis on Ultrasound
 Medical Management

• Pain medications: Nonsteroidal anti-inflammatory drugs, or NSAIDs, such

as ibuprofen ease cramping.
• Hormonal birth control: Estrogen thickens the uterine wall and can worsen
bleeding and cramping. Certain hormonal contraceptives can stop
menstruation and symptoms. Options include birth control pills, Depo-
Provera injection and hormonal intrauterine device (IUD), such as Mirena.
• Effective agents such as danazol, gestrinone and GnRH-A used in the
treatment of endometriosis may also be beneficial for this condition
 Surgical Management

• Hysterectomy: Hysterectomy remains the only definitive treatment

• Note that where well-localized islands of adenomyosis can be identified
within the myometrium, there is the potential for laparoscopic laser surgery
 Leiomyoma

• The most common pelvic tumour

• Uterine fibroids / leiomyomas are benign , clonal (arise from one cell which is
expanding to become one large tumour cell) fibromuscular tumours arising from
the myometrium
• Fibroids can grow as a single nodule or in a cluster. Fibroid clusters can range in size
from 1 mm to more than 20 cm (8 inches) in diameter or even larger.
• Though mostly benign; note that less than 1% has been reported to be cancerous
 Incidence

• Mostly in women of reproductive age

• Ultrasound studies show a prevalence of greater than 80% in Black women
over 50 and greater than 70% in White women
• 25 – 50% of women are asymptomatic
• Black women develop fibroids at an earlier age, have more and larger
tumors, and have worse symptoms in comparison to Caucasian women
 Types of Fibroids

• Submucosal fibroids
The fibroids are growing inside the uterine space (cavity) where a baby grows during pregnancy. Think of the growths
extending down into the empty space in the middle of the uterus.
• Intramural fibroids:
Embedded into the wall of the uterus itself. Picture the sides of the uterus like walls of a house. The fibroids are growing inside
this muscular wall.
• Subserosal fibroids:
Located on the outside of the uterus this time, these fibroids are connected closely to the outside wall of the uterus.
• Pedunculated fibroids:
• Located on the outside of the uterus. However, pedunculated fibroids are connected to the uterus with a thin stem.
They’re often described as mushroom-like because they have a stalk and then a much wider top.
Classification of Fibroids
Types of fibroids
 Risk Factors for Fibroids

• Black race
• Obesity and a higher body weight (more than 20% over the weight that's
considered healthy for you).
• Family history of fibroids.
• Nulliparous.
• Early onset of menstruation (getting your period at a young age).
• Late age for menopause
 Symptoms of fibroids

• Majority Asymptomatic 50-60%of patients

• Excessive or painful (sharp , stabbing abdominal pain)bleeding during your period (menstruation)
• HMB
• Intermenstrual bleeding
• A feeling of fullness in your lower abdomen/bloating
• Frequent urination (this can happen when a fibroid puts pressure on your bladder)
• Pain during sex
• Low back pain
• Constipation
• Chronic vaginal discharge
• Inability to urinate or completely empty your bladder
• Increased abdominal distention (enlargement), causing your abdomen to look pregnant
• Infertility
 Diagnosis

• Ultrasound

Submucosal Fibroids
• Saline Infusion Sonography
• Hysteroscopy
Intramural
• MRI
Saline Infusion Sonography
 Management

Expectant Management :
Asymptomatic women nearing menopause
• Medical Management :
NSAIDs , Tranexamic acid , OCP, Progestin, UPA
• Surgical :
Myomectomy (young patient)
Hysterectomy ( elderly lady)
 Endometrial Hyperplasia

• Endometrial hyperplasia is a condition of the female reproductive system

where there is an irregular proliferation of the endometrial glands with an
increase in the gland to stroma ratio when compared with proliferative
endometrium and as a result the endometrium becomes unusually thick due
to hyperplasia.
 Incidence

• Endometrial hyperplasia is rare. It affects approximately 133 out of 100,000

women
 Types of Endometrial Hyperplasia

• Simple endometrial hyperplasia (without atypia):

This type of endometrial hyperplasia has normal-looking cells that are not
likely to become cancerous. This condition may improve without treatment.
Hormone therapy helps in some cases.
• Simple or complex atypical endometrial hyperplasia:
An overgrowth of abnormal cells causes this precancerous condition. Without
treatment, the risk of endometrial or uterine cancer increases.
 AUB-M

• Slowly this hyperplasia can change to nuclear atypia and the development
of cancer
• Precursor of type 1 Endometrial Cancer
• Note that the same type of hyperplasia is seen in patients with PCOS or
obese women
 Risk Factors of Endometrial Hyperplasia
• Women who are perimenopausal or menopausal are more likely to have endometrial hyperplasia It
rarely occurs in women younger than 35
• Certain breast cancer treatments (tamoxifen).
• Diabetes
• Early age for menstruation or late onset of menopause.
• Family history of ovarian uterine or colon cancer.
• Gallbladder disease.
• Hormone therapy
• Nulliparous
• Obesity.
• Polycystic ovary syndrome (PCOS).
• Smoking
• Thyroid disease
• White race.
• Long history of irregular or absent menstruation.
 Symptoms of Endometrial Hyperplasia

Women with endometrial hyperplasia may experience:

• Abnormal menstruation, such as short menstrual cycles, unusually long
periods or missed periods.
• Heavy menstrual bleeding.
• Bleeding after menopause (when periods stop).
AUB-M
Classification of AUB-M
 Changes that occur

Normal Simple Complex

Hyperplasia hyperplasia
 DIAGNOSIS

Ultrasound
Histopathology

• Upon ultrasound the endometrium is very thick

• Note in premenopausal women; if in the
thickness is greater than 12 mm or in
postmenopausal women grater than 4mm then
there might be cancer.
• However, note that this could be a polyp or
hyperplasia
• Thereafter Endometrial Aspirate can be taken to
get the diagnosis
Management
 AUB-C (Coagulopathy)

• This is typically seen in the adolescent population ; notably about 20% of adolescents which present with
AUB will be as a result of an underlying coagulopathy
• This is most commonly due to von Willebrand disease or platelet function abnormalities.
• Less frequent causes include idiopathic thrombocytopenia (ITP) and coagulation factor deficiencies.
• About 13% of AUB-C is due to VWD, with mutations in the von Willebrand factor (VWF) gene resulting in 3
types correlating with severity and prevalence (type 1, mildest, 70-80%; type 2, moderate, 20%; type 3,
severe, 5%).
• VWF is responsible for stabilizing factor VIII and promoting platelet binding.
• Type 1 is associated with mildly decreased levels of the protein, type 2 with normal levels but the protein is
dysfunctional, and type 3 with severely decreased levels
AUB-C
 AUB-C Management

• DO NOT GIVE NSAIDS – ANTIPLATELET

• Give Tranexamic Acid
• Gove Desmopressin- Synthetic analogue of vasopressin
• Plasma derived factor VIII
• Recombinant factor rVWF
Ovarian Disorder (AUB-O) –Anovulatory Cycles
• Occur normally in adolescents and perimenopausal women
Causes :
• Imbalances in hormones responsible for ovulation (Gonadotropin-releasing hormone (GnRH),Follicle-stimulating
hormone (FSH) , Luteinizing hormone (LH))
• Polycystic ovary syndrome (PCOS)
• Hypothyroidism
• Hyperprolactinemia
• Obesity.
• Anorexia
• Weight loss
• Mental stress
• Extreme exercise
• R/o Hyperplasia and Malignancy
 Symptoms of Anovulation

• Combination of unpredictable timing of bleeding and variable amount of flow

• Amenorrhea
• Extremely light, infrequent bleeding
• Episodes of unpredictable , extreme heavy menstrual bleeding
• Mostly painless (no structural cause of this bleeding)
• Lack of cervical mucus
• Irregular basal body temperature
Anovulatory Cycle
Ultrasound
 Metropathia Haemorrhagica

• Old term used to describe bleeding in perimenopausal women ages 40-45

• Anovulation would lead to endometrial hyperplasia(usually reveals cystic
hyperplasia –simple hyperplasia without atypia called swiss cheese
appearance), diffuse polyps ( due to increase estrogen) and myometrial
hyperplasia.
 AUB-E (Endometrial Dysfunction)

• Endometrial AUB(referred to as “ovulatory dysfunctional uterine bleeding” in the

past), is a condition where in which women have heavy regular cycles.
• Studies have shown that the perception of the amount of bleeding varies widely
among women, and quantitative analysis shows only approximately 50% of
patients actually exceed 80 mL during menses.
• Heavy menstrual bleeding in the absence of any definable cause with predictable,
cyclic menstrual bleeding typical of ovulatory cycles.
• There is a primary disorder in the endometrium and is a diagnosis of exclusion as
there are no structural causes or anovulation.
 Causes

• Imbalance of prostaglandins leading to increased bleeding

• Infection – Endometritis due to Chlamydia, Gonorrhea, Tuberculosis, or a
mix of normal vaginal bacteria
• Miscarriage , childbirth or having a long labour or C-section.
 Risk Factors

• The risk for endometritis is higher after having a pelvic procedure that is done
through the cervix like :
• D&C
• Endometrial biopsy
• Hysteroscopy
• Placement of an intrauterine device (IUD)
• Childbirth (more common after C-section than vaginal birth)
 AUB-I

• Anticoagulation Therapy - Aspirin, Heparin ,Warfarin

• Contraceptives – OCP and IUDs (Copper, Mirena , Inert)
• Chemotherapy- decreases clotting ability
• Spironolactone
• Drugs related to dopamine metabolism : Antidepressants and
Antipsychotics
 Not Otherwise Classified

• Bleeding abnormalities from etiologies “not otherwise classified” may

include rare conditions or ill-defined conditions.
• Arteriovenous malformation :patients with multiple D&C or multiple
surgeries on the uterus
• Endometrial pseudoaneurysm, which result in unpredictable heavy bleeding
• Symptoms are varied, and likely many cases are asymptomatic.
• Light intermenstrual bleeding may occur in patients with CE.
 History

Menstrual History :
• Age at Menarche and age at Menopause
• Usual duration of each period and length of cycle
• First day of the last menstrual period (exclude the diagnosis of pregnancy)
• Severity of menstrual bleeding : duration of the cycle, amount of blood loss ,the amount of
pads used, the presence of intermenstrual bleeding, clots( if there is heavy bleeding some
blood will not be liquified and you will have clots present) and flooding
• Dysmenorrhea : nature of the pain and relation to period
• Associated local symptoms : pressure symptoms, urinary frequency, constipation
• Vaginal discharge : amount, colour, odour and presence of blood
 History

• Drug History :
Blood thinners
hormone replacement therapy
other hormone treatments
Tamoxifen

• Previous Gynae History : IUD ?

 History
• Previous Obstetric History :
Infertility
On contraceptives – IUD?
PPH ?

• Past Medical History :

Bleeding gums
Epistaxis
Bleeding disorders? Excessive bleeding during childbirth in any surgery; or any dental procedures
PCOS
Hypothyroidism
Prolactinemia
Breast cancer?
 History

• Family History :
Bleeding Disorders

Social History :
Increased stress
Abuse or Trauma
 Examination

• General Examination :
Pallor , increased or decreased BMI , dry cold clammy skin, thinned hair, neck mass?
acanthosis ? Acne? oily skin? Hirsutism? Ecchymosis ?petechiae ?
• Pelvic examination :
External
Speculum with Pap test, if needed
Bimanual Examination – palpate the size of the uterus
Examination
Examination
 Investigations

• Human Chorionic Gonadotrophin (blood and urine)

• CBC
• Pap Smear
• Endometrial Sampling
• Coagulation profile
• Thyroid stimulating hormone level and Prolactin
• Liver Function Test
• Chlamydia Trichomatis
 Hormonal Assays

• TSH
• Prolactin
• Anovulation-LH, FSH, Testosterone levels
• 17 beta estradiol (E2)
 Available Diagnostic and Imaging Test

Modalities :
Transvaginal Ultrasound – cheap and easily available and is helpful as we can measure the size of
the uterus
Saline infusion Sonography – Imaging of choice if you are suspecting that something is protruding
or bulging into the cavity
MRI- if the structural abnormality is in the myometrium ; especially helpful when you have a large
uterus caused my leiomyomas or adenomyosis
Hysteroscopy- small camera inserted into the vagina , through cervix and into the uterus to
visualize any pathology that could be there
 Available tissue sampling methods

Endometrial Biopsy :
• Endometrial sampling via biopsy is recommended for women with a high risk of developing
endometrial cancer like:
Women 45 years and older
BMI >30 kg/m2
past use of unopposed estrogen,
past or current use of tamoxifen
family history of endometrial or colon cancer

• Hysteroscopy directed endometrial sampling (office or operating room)

 Histopathology

• Indications :
Over 40 years old
Risk factors for Endometrial cancer ( Chronic Anovulation, Diabetes Mellitus , HTN)
Failure of medical treatment
Significant intermenstrual bleeding
Consider endometrial biopsy in women with infrequent menses suggestive of anovulatory
cycles)
Reports : Polyp, Proliferative , Secretory or Hyperplasia
 Management

• Eitiology
• Severity (e.g., anemia and interference with daily activities)
• Symptoms and issues (e.g., pelvic pain, infertility)
• Contraception and plan for future pregnancy
• Comorbidities
 Medical Management of Acute AUB

Therapy goals :
Controlling the current bleeding episode
Reducing the potential for future episodes
Decreasing blood loss during subsequent menstrual cycles
 Tx Acute AUB

Pharmacotherapeutic Management :
• Combined oral contraceptives
• Oral progestins
• IV conjugated equine estrogens
• Tranexamic acid
 Medical Management of Chronic AUB

• Goals of Therapy :
Cycle control
Decreased blood loss during menstrual cycles
Prevention of acute AUB episodes.
 Pharmacotherapeutic Management for
Chronic AUB
• Combined hormonal contraceptives (CHCs—pill, patch, vaginal ring),
• oral progestins
• tranexamic acid
• levonorgestrel-releasing intrauterine system (LNG-IUS)
• depot medroxyprogesterone acetate
• leuprolide acetate
• Danazol
• mefenamic acid
• ibuprofen
 Non- hormonal Medical Management

• NSAIDs – COX inhibitor

Decline in the rate of prostaglandin synthesis in the endometrium leading to
vasoconstriction and reduced bleeding
Mefenamic acid (Ponstan) 500 mg TDS
Start on day 1 of bleeding to four or 5 days or until menstruation ceases
 Non- Hormonal Medical Management

Tranexamic acid
Antifibrinolytic agent that competitively blocks the conversion of plasminogen
to plasmin; reducing fibrinolysis.
This is the first line therapy and is generally started on the first day of the
period and given 4 to 5 days.
500 mg TDS ; can go up to 1g TDS-QID
Well tolerated and has a favorable safety profile
 Non-Hormonal Management

Omeloxifen
Selective Estrogen Receptor Modulator
Potent antiestrogenic to endometrium and breast
Weak estrogenic with beneficial effects on bone and CVS
Contraceptive
Dose: 60mg twice weekly for 3 months and weekly for the next 3 months for heavy
menstrual bleeding
 Management – Medical

Hormonal Drugs
Combined Hormonal Contraceptives
Progestin- only pill, Injectable contraceptives, IUD

Effects :
Regular and lighter bleeding
Reduced dysmenorrhea
Provides contraception
 Combined Hormonal Contraceptives

• Monophasic, triphasic, extended, or continuous monophasic Combined Oral

Contraceptives may be used
• A transdermal patch that delivers ethinyl estradiol 35 mcg and norelgestromin 150
mcg daily is available.
• The vaginal ring delivers ethinyl estradiol 15 mcg and etonogestrel 120 mcg daily.
• With the exception of extended or continuous COCs, each option provides active
hormone 21 days per month, with a hormone-free period of 7 days.
• Of the oral COCs, only a four-phase formulation is currently FDA-approved for
treatment of AUB; this product contains synthetic estradiol valerate and dienogest
 CHC

• Regular and lighter bleeding

• Reduce Dysmenorrhea
• Provides contrception
 Progestin

• Patients with AUB trying to conceive or oestrogen contraindicated

• Norethindrone acetate – 5mg BD-TDS
• Medroxyprogesterone acetate- 5 – 30mg TDS daily
• Ovulatory :5-25 days
• Anovulatory : 15-25 days
• Hyperplasia :high dose’ prolonged (LNG preferred and given for 6 months)
 LNG-IUD

• First line in patients not requiring fertility

• Chronic AUB
Mechanism :
• Decidualisation of endometrial stroma
• Atrophy of endometrial glands
• 52 mg LNG / 20 micrograms/ day for 5 years
• Decreased menstruation bleeding loss (94-96%), amenorrhea
• Can be used as a contraceptive
LNG- IUD
 Anovulatory Bleeding and Bleeding Disorders

• Note that rarely ; a young patient with anovulatory bleeding also might
have a bleeding disorder
• Desmopressin, a synthetic analog of arginine vasopressin, has been used to
treat abnormal uterine bleeding in patients with documented coagulation
disorders
• Treatment is followed by a rapid increase in von Willebrand factor and
factor VIII, which lasts about 6 hours.
 Surgical Management

Indications :
• Failure to respond to medical treatment
• Structural causes
Surgical Management
 Surgical Management for Acute and Chronic
AUB

• Dilation and curettage

• Endometrial ablation
• Uterine artery embolization
• Hysterectomy may be indicated
 Surgical Management

• Polypectomy
• Myomectomy
• Adenomyomectomy
• Hysterectomy

Minimally invasive
• Transcervical removal of endometrium
• Uterine Artery Embolisation
 Conservative

• Dilation and Curettage

• Endometrial Ablation
 Dilation and Curettage

• D&C is an appropriate diagnostic step in a patient who fails to respond to

hormonal management. The addition of hysteroscopy will aid in the
treatment of endometrial polyps or the performance of directed uterine
biopsies. As a rule, apply D&C rarely for therapeutic use in AUB because it
has not been shown to be very efficacious and may lead to intrauterine
scarring
 Endometrial Ablation
• Endometrial destruction via the application of various forms of energy
Indications :
Poor surgical candidate
Completed their families
Possibility of uterine or endocrine malignancy ruled out
Active infection ruled out
Endometrial Ablation
 Endometrial Ablation

• Pretreat the patient with an agent, such as leuprolide acetate,

medroxyprogesterone acetate, or danazol, to thin the endometrium
• The ablation procedure is more conservative than hysterectomy and has a
shorter recovery time
• Endometrial ablation is not a form of contraception. Some studies report up
to a 5% pregnancy rate in post-ablation procedures. This is a significant
issue in women who later desire childbearing after an ablation.
 Hysterectomy

A hysterectomy is the surgical removal of the uterus, and most likely, the
cervix.
 Surgery

• Radical
Hysterectomy
• Total hysterectomy
• Supracervical hysterectomy
• Total hysterectomy with bilateral salpingo-oophorectomy
• Radical hysterectomy with bilateral salpingo-oophorectomy
 Surgical

Indications:
1. Failure or decline of medical treatment
2. Family is completed
3. Disruption in the quality of life
Routes:
1. Abdominal
2. Vaginal
3. Laparoscopic
 Hysterectomy

Advantages:
1. Complete cure
2. Avoidance of long term medical treatment
3. Removal of any missed pathology
Disadvantages:
1.Major operation
2.Hospital admission
3.Mortality & morbidity
 References

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https://www.osmosis.org/answers/anovulatory-cycle
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https://www.straighthealthcare.com/hypothalamic-pituitary-ovarian-axis.html
 References

Hysterectomy: Purpose, procedure, benefits, risks & recovery. Cleveland Clinic. (n.d.). Retrieved September 7, 2022, from
https://my.clevelandclinic.org/health/treatments/4852-hysterectomy
Katherine Hale, P. D. (2018, September 14). Abnormal uterine bleeding: A Review. U.S. Pharmacist – The Leading Journal in
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