Abnormal uterine bleeding

Syeda Rabia
Associate Professor
 Abnormal Uterine bleeding
• . Abnormal uterine bleeding is a common
condition affecting women of reproductive
age that has significant social and economic
impact.
 PALM-COEIN Classification of AUB

Structural cause Non structural

polyp coagulopathy
adenomyosis Ovulatory dysfunction
Leomyoma
Endometrial.(primary disorder of
mechanisms regulating local
endometrial.hemostasis
malignancy Iatrogenic
hyperplasia Not yet specified
 History

• Nature of the bleeding

• related symptoms, such as persistent intermenstrual
bleeding, pelvic pain and/or pressure symptoms, that
might suggest uterine cavity abnormality, histological
abnormality, adenomyosis or fibroids
• impact on her quality of life
• factors that may affect treatment options (such as
comorbidities or previous treatment for HMB)
• Family history
 Physical examination
• Vital signs
• Weight/BMI
• Thyroid
• Skin(pallor, bruising, striae, hirsutism, petechiae)
• Abdominal examination.(mass,
hepatosplenomegaly)
• Testing: Pap smear, cervical cultures if risk for
sexually transmitted infection
 Pelvic examination
• Inspection:.
vulva,vagina,cervix,anus,and urethra
• Bimanual examination
uterus and adnexa

• Rectal examination-
if bleeding from rectum suspected or risk
of concomitant pathology
 Risk factors for endometrial cancer

• Age
• Obesity(BMI.>.30.kg/m2)
• Nulliparity
• PCOS
• Diabetes
• HNPCC
 Investigations
Consider starting pharmacological treatment
for HMB without investigating the cause if the
woman's history and/or examination suggests
a low risk of
fibroids,
uterine cavity abnormality,
histological abnormality or adenomyosis.
 INVESTIGATION
Blood CP
Coagulation screening if needed
S TSH if needed
Pregnancy test
 Investigation
• U/S
• Hysteroscopy
• Endometrial sampling for women at high risk of endometrial
pathology, such as women with
persistent intermenstrual or
persistent irregular bleeding,
infrequent heavy bleeding ( who are obese or have
polycystic ovary syndrome )
women taking tamoxifen
women for whom treatment for HMB has been unsuccessful.
 Investigation
• Saline infusion sonography
• MRI
• D&C
 management
• Women preferences
• Co morbidity
• presence or absence of fibroids (including
size, number and location), polyps,
• endometrial pathology or adenomyosis
• other symptoms such as pressure and pain.
 management
Provide information about all possible treatment options for HMB and
discuss these with the woman . Discussions should cover:

the benefits and risks of the various options

suitable treatments if she is trying to conceive

whether she wants to retain her fertility and/or her uterus

 Treatments for women with no identified pathology,
fibroids less than 3 cm in diameter or adenomyosis

Consider an LNG-IUS as the first treatment for

HMB in women with:
• no identified pathology or
• fibroids less than 3 cm in diameter, which are
not causing distortion of the uterine cavity or
• suspected or diagnosed adenomyosis.
 Treatments for women with no identified
pathology, fibroids less than 3 cm in diameter or
adenomyosis
If a woman with HMB declines an LNG-IUS or it is not
suitable, consider the
Non-hormonal:
tranexamic acid
NSAIDs (non-steroidal anti-inflammatory drugs)
Hormonal
combined hormonal contraception
cyclical oral progestogens
 Referral criteria
If treatment is unsuccessful, the woman declines
pharmacological treatment, or symptoms are severe,
consider referral to specialist care for:
Further investigation
alternative treatment –
pharmacological- not already tried
Surgical-
endometrial ablation
hysterectomy
hysteroscopic removal of submucous
fibroid
 For women with fibroids of 3 cm or
more in diameter
• For women with fibroids of 3 cm or more in
diameter, take into account the size, location
and number of fibroids, and the severity of
the symptoms and consider the following
treatments:
• pharmacological:
non-hormonal
tranexamic acid
NSAIDs
 For women with fibroids of 3 cm or
more in diameter (Cont)
• Hormonal
ulipristal acetate
LNG-IUS
combined hormonal contraception
cyclical oral progestogens
• uterine artery embolisation
• Surgical
myomectomy
hysterectomy
Pretreatment with a gonadotrophin-releasing hormone analogue or
ulipristal acetate before hysterectomy and myomectomy should be
considered if uterine fibroids are causing an enlarged or distorted
uterus.
 Medical Management of acute
abnormal uterine bleeding
drug dosage Drug schedule
Conjugated equine 25 mg I/V Every 4–6 hours for
estrogren 24 hours
Combined oral Monophasic Three times per day
contraceptives† combined oral for 7 days
contraceptive that
contains 35
micrograms of
ethinyl estradiol
Medroxypro- 20 mg orally Three times per
‡
gesterone acetate day for 7 days
§
Tranexamic acid 1.3 g orally Three times per day
or for 5 days (every 8
10 mg/kg IV hours )
(maximum 600
mg/dose)
 Surgical treatment
based on the clinical stability of the patient, the severity of
bleeding, contraindications to medical management, the
patient’s lack of response to medical management, and the
underlying medical condition of the patient.
Surgical options include
• dilation and curettage (D&C),
• endometrial ablation,
• uterine artery embolization,
• Hysterectomy.
• Specific treatments, such as hysteroscopy with D&C,
polypectomy, or myomectomy, may be required if
structural abnormalities are suspected as the cause of
acute AUB